Health Assessment & Clinical Physical Examination Flashcards

Vocabulary practice flashcards covering health assessment databases, interviewing techniques, assessment order, general survey, physical exam techniques, pain types and evaluation, and levels of consciousness.

Subjective Data

Information reported by the patient, such as feelings, perceptions, or self-reported symptoms like pain.

Objective Data

Observable and measurable findings obtained through physical examination, laboratory tests, diagnostic studies, or direct observation by the provider.

Complete (Total Health) Database

A baseline evaluation that includes a complete health history and full physical examination to establish a patient's overall health state.

Episodic (Problem-Centered) Database

A mini-database focused primarily on a short-term, acute problem or single body system.

Follow-Up Database

An assessment conducted at regular intervals to evaluate the status of previously identified problems.

Emergency Database

A rapid collection of crucial data gathered concurrently with lifesaving interventions.

Data Validation

The process of verifying that subjective reports match objective findings, confirming facts through corroborating sources or repeated assessments, and clearing up inconsistencies before making clinical judgments.

Open-Ended Questions

An interview technique asking for narrative information that allows the patient to express themselves fully.

Closed-Ended Questions

An interview technique asking for specific, targeted information that leads to a forced choice (e.g., 'yes' or 'no').

Facilitation

An interview technique that encourages the patient to say more or continue talking.

Silence (Interview Technique)

Directed attentiveness during an interview that gives the patient time to think and organize thoughts.

Clarification

An interview technique used when a patient's word choice is ambiguous or confusing to ask for confirmation or agreement.

Reflection

An interview technique that echoes or repeats part of what the patient just said to help them elaborate or clarify meaning.

Empathy (Interview Technique)

An interview communication technique that recognizes and names a feeling, allowing its expression.

Interpretation

An interview technique that links events, makes associations, or identifies causes based on inference.

Explanation

An interview communication technique that shares factual and objective information with the patient.

Summary (Interview Technique)

An interview technique providing a final review or conclusion of what was learned to signal the end of the interview.

Traps of Interviewing

Ten nonverbal/verbal pitfalls including false reassurance, unwanted advice, using authority, avoidance language, distancing, jargon, leading questions, talking too much, interrupting, and 'why' questions.

Verbal Communication

Words spoken, vocalizations, and the tone used in conversation.

Non-Verbal Communication

Unconscious or conscious body language, posture, gestures, facial expressions, eye contact, and physical touch; viewed as the truer reflection of feelings when in conflict with verbal messages.

Functional Assessment

Measures a person’s self-care ability in daily life (Activities of Daily Living or ADLs) and lifestyle factors including self-esteem, activity, sleep, nutrition, relationships, and coping.

Health Promotion Principles

Proactive questions integrated into the Review of Systems (ROS) or functional assessment to assess disease prevention and healthy behaviors.

General Survey

An objective evaluation of the patient as a whole upon first impression, encompassing physical appearance, body structure, mobility, and behavior.

Physical Appearance (General Survey)

A general survey parameter evaluating age, sex, level of consciousness, skin color, facial features, and overall appearance.

Body Structure (General Survey)

A general survey parameter evaluating stature, nutrition, symmetry, posture, position, and physical deformities.

Mobility (General Survey)

A general survey parameter evaluating gait, range of motion, and absence of involuntary movements.

Behavior (General Survey)

A general survey parameter evaluating facial expression, mood and affect, speech, dress, and personal hygiene.

Inspection

The first assessment technique, involving close, careful scrutiny of the patient as a whole and then of each individual body system.

Palpation

An assessment technique applying the sense of touch to evaluate texture, temperature, moisture, organ size, swelling, rigidity, masses, and tenderness.

Percussion

Tapping the skin with short, sharp strokes to assess underlying structures by evaluating sound density, location, and organ boundaries.

Auscultation

Listening to sounds produced by the body using a stethoscope.

Fingertips (Palpation)

The part of the hand best suited for fine tactile discrimination, such as skin texture, swelling, pulsation, and presence of lumps.

Fingers and Thumb (Palpation)

The part of the hand used for detecting position, shape, and consistency of an organ or mass.

Dorsa of Hands and Fingers

The back of the hands/fingers used for evaluating skin temperature because the skin is thinner there than on the palms.

Base of Fingers / Ulnar Surface

The region of the hand used primarily for detecting vibration.

Indications for Wearing Gloves

Standard Precautions requirement whenever there is potential for contact with blood, infectious materials, mucous membranes, non-intact skin, body fluids, or contaminated equipment.

Nosocomial Infections (HAIs)

Healthcare-associated infections acquired during hospital stays or medical treatment, where strict hand hygiene is the single most effective prevention measure.

Stethoscope

An instrument that transmits body sounds to the ear while blocking extraneous ambient noise without amplifying sound.

Stethoscope Diaphragm

The flat edge of a stethoscope used for high-pitched sounds like breath, bowel, and normal heart sounds.

Stethoscope Bell

The deep, cuplike shape of a stethoscope used for soft, low-pitched sounds like extra heart sounds, murmurs, and bruits.

PQRSTU Framework - P

Provocation/Palliation: Asks what makes the pain better or worse.

PQRSTU Framework - Q

Quality/Quantity: Asks what the pain feels like (e.g., burning, stabbing, aching).

PQRSTU Framework - R

Region/Radiation: Asks where the pain is located and whether it spreads.

PQRSTU Framework - S

Severity: Asks how bad the pain is on a 0 to 10 scale.

PQRSTU Framework - T

Timing: Evaluates onset, duration, and frequency of pain.

PQRSTU Framework - U

Understand Patient Perception: Asks how the pain affects daily living.

Gold Standard of Pain Assessment

Collecting self-report data directly from the patient first before reassessing following any intervention.

Standard Assessment Sequence

The standard order of physical assessment techniques: Inspection, Palpation, Percussion, Auscultation.

Abdominal Assessment Sequence

The specialized sequence for assessing the abdomen: Inspection, Auscultation, Percussion, Palpation (performed in this order so as not to alter natural bowel sounds).

Focused Mini-Database

An examination steps adaptation used for sick or distressed patients based on immediate comfort or clinical distress.

Acute Pain

Short-term, self-limiting pain that follows a predictable trajectory and dissipates after an injury heals.

Chronic (Persistent) Pain

Pain lasting 6 months or longer that does not stop when an injury heals and outlasts its protective purpose.

Visceral Pain

Pain originating from large interior organs, caused by stretching, ischemia, or distention.

Deep Somatic Pain

Pain originating from blood vessels, joints, tendons, muscles, and bones.

Cutaneous Pain

Pain derived from the skin surface and subcutaneous tissues.

Referred Pain

Pain felt at a particular site but originating from another location innervated by the same spinal nerve.

Neuropathic Pain

Pain caused by a lesion or disease affecting the somatosensory nervous system, resulting from abnormal processing of pain signals.

PAINAD Scale

A behavioral pain assessment scale evaluating breathing, vocalization, facial expression, body language, and consolability in patients with advanced dementia.

Alert

A level of consciousness where the patient is fully awake, oriented, aware of stimuli, and responds appropriately.

Lethargic (Somnolent)

A level of consciousness where the patient drifts off to sleep when not stimulated, but can be aroused when called in a normal voice.

Obtunded

A level of consciousness where the patient sleeps most of the time, is difficult to arouse, and acts confused when aroused.

Stupor (Semi-Coma)

A level of consciousness where the patient is spontaneously unconscious and responds only to persistent and vigorous shaking or painful stimuli.

Coma

A level of consciousness where the patient is completely unconscious with no response to pain or external stimuli.

Affect

A temporary, objective expression of feelings or state of mind observed through behavior and facial expressions.

ABCT Mental Status Exam

An acronym representing the core components of a mental status assessment: Appearance, Behavior, Cognitive functions, and Thought processes.