Nursing Health Assessment

Flashcard set containing 60 vocabulary terms and definitions covering nursing health assessment, history taking, data classification, and physical exam techniques.

Nursing Process

Assessment > Diagnosis > Outcome Identification > Planning > Implementation > Evaluation

Nursing Assessment

An accurate assessment needed in order to supply high-quality nursing care. It is achieved by data such as collect data, validate data, and organize data.

Collect Data

The act of compiling detailed health information about the patient during an assessment.

Validate Data

The process of confirming the accuracy and truthfulness of collected assessment data.

Organize Data

Using an established nursing framework to arrange and categorize collected assessment information.

Comprehensive Health Assessment

An evaluation encompassing physical, psychological, social, and spiritual aspects to establish a patient baseline database.

Admission Assessment

Initial evaluation performed within a specified timeframe after admission to establish normal function, functional status, and reference baselines.

Focus Assessment

Ongoing status determination integrated into nursing care, occurring a few minutes to a few hours between assessments, to evaluate a specific problem identified during a previous assessment.

Time-Lapse Reassessment

An assessment conducted after an extended period (such as 3, 6, or 9 months) to compare current status with previously recorded baselines.

Emergency Assessment

Rapid evaluation carried out during a physiologic, psychological, or emotional crisis to identify life-threatening conditions.

Cues

Recognized pieces of information or clinical signs and symptoms that offer insight into a patient's health status.

General Survey

An overall assessment of a patient's health status, including physical appearance, behavior, and vital signs, used to identify any immediate health issues.

Subjective Data

Information reported directly by the patient regarding their internal feelings, perceptions, or symptoms that cannot be directly measured by the nurse.

Objective Data

Observable and measurable clinical evidence (signs) obtained by the nurse through physical assessment, measurement, and sensory observations.

Interviewing

A structured communication process used by the nurse to obtain subjective data for the patient's health history. Includes broad opening statements and open-ended questions.

Physical Examination

Systematic collection of objective data using observation, sensory evaluation, equipment, and diagnostic measurements (tests/labs).

Physical Assessment

An initial general inspection of the patient. Includes the assessment of neurologic systems, musculoskeletal system, respiratory system, cardiovascular system, peripheral vascular system, gastrointestinal system, genitourinary system, integumentary system, and reproductive system to evaluate overall health.

Functional Health Framework

An assessment structure based on Gordon's 11 functional health patterns that evaluates the effects of the mind, body, and environment in relation to person’s ability to perform daily living tasks.

Head-to-Toe Framework

A systematic physical examination approach where data is gathered sequentially starting from the head and proceeding down to the feet.

Body Systems Framework

An assessment approach organized around pathophysiology and specific anatomical body systems.

Activity-Exercise

A functional health pattern that focuses on the respiratory, cardiovascular, and musculoskeletal body systems. Includes upper and lower extremities (pulses and circulation), precordium and anterior thorax, and posterior thorax.

Nutrition-Metabolism

A functional health pattern that focuses on the gastrointestinal, integumentary, and endocrine body systems. Includes hair, scalp, oral cavity, thyroid, nails, and abdomen.

Elimination

A functional health pattern that focuses on the genitourinary and gastrointestinal body systems. Includes the abdomen, pelvis, anus, and rectum.

Cognition-Perception

A functional health pattern that focuses on the sensory and neurologic body systems. Includes the eyes, ears, and cranial nerves.

Self Perception-Self Concept

A functional health pattern that focuses on the psychosocial body system. Includes roles, coping, and values.

Roles-Relationships

A functional health pattern that focuses on the psychosocial body system. Includes mental health.

Coping-Stress Tolerance

A functional health pattern that focuses on the psychosocial body system. Includes mental health.

Sexuality-Reproduction

A functional health pattern that focuses on the endocrine and reproductive body systems. Includes breasts, testicles, pelvic exam, and genitalia.

Values-Beliefs

A functional health pattern that focuses on the psychosocial body system. Includes mental health.

Environment Preparation

Establishing a warm, quiet, private, and well-lit setting equipped with functional assessment tools.

Patient Preparation

Preparing the individual for an exam by making introductions, ensuring confidentiality, offering restroom access, and assessing comfort.

Primary Data Source

The patient, who is considered the primary and most direct source of subjective health information when reliable.

Secondary Data Source

Sources of information other than the patient, including family members, medical records, or other healthcare professionals.

Biographical Data

Factual demographic details about a patient, such as name, address, phone number, birth date, occupation, race, and language requirements.

Chief Concern

The primary reason why the patient is seeking medical care, recorded verbatim in the patient's own words.

Eight Critical Characteristics

A method used in health assessments to gather specific information about a patient's symptoms, including location, character/quality, quantity/severity, timing, setting, aggravating and relieving factors, associated factors, and patients perception.

PQRSTU Framework

A mnemonic structure used for detailed symptom and pain analysis: Provocative/Palliative, Quality/Quantity, Region/Radiation, Severity Scale, Timing, and Understanding patients' perception.

Provocative or Palliative Factors

The components of symptom evaluation that identify what triggers, worsens, or alleviates the pain or symptom.

Quality or Quantity

The characteristic description of a symptom's nature (e.g., heavy pressure) or its degree of severity and functional limitation.

Region or Radiation

The precise body location of a symptom and any pathways where the discomfort spreads.

Severity Scale

A measurement scale (e.g., 0 to 10 numerical rating) used to quantify symptom intensity.

Timing

The evaluation of a symptom's exact onset, duration, and frequency over time.

Patient's Perception

The patient's personal view, belief, or understanding of what is causing their health problem and its impact on them.

Pain Goal

The specific numerical or descriptive level of pain that a patient considers acceptable.

Functional Goal

The specific physical activity or daily task a patient wishes to accomplish once pain is adequately controlled.

Wong-Baker FACES Scale

A visual rating scale utilizing facial expressions corresponding to pain levels from 0 ("NO HURT") to 10 ("HURTS WORST").

Past Health History

A comprehensive summary of past childhood illnesses, chronic diseases, surgeries, hospitalizations, immunizations, last examination, allergies, and medications.

Family Health History

A record of health conditions within blood relatives used to identify genetic risks for conditions such as heart disease, diabetes, cancer, mental illness, blood disorders, allergies, obesity, seizure disorder, kidney disease, asthma, arthritis, alcoholism, and tuberculosis.

Review of Systems

A systematic interrogation of each anatomical body system to evaluate past/present health and health promotion practices, double-check data, and identify normal function and risk of dysfunction.

Self-Care Level 0

A classification on the self-care abilities scale indicating complete independence in performing self-care activities.

Self-Care Level I

A classification on the self-care scale where the patient requires equipment or devices to perform self-care tasks.

Self-Care Level II

A classification on the self-care scale where the patient requires personal supervision to complete self-care tasks.

Self-Care Level III

A classification on the self-care scale where the patient requires both equipment/devices and supervision for self-care.

Self-Care Level IV

A classification on the self-care scale where the patient is totally dependent and unable to perform self-care tasks.

Inspection

The deliberate, methodical visual examination of physical characteristics, behaviors, and anatomical features.

Palpation

The physical examination technique of using hands and fingers to assess structure position, texture, size, consistency, masses, and fluid.

Light Palpation

Pressing the skin surface $1\text{–}2\,\text{cm}$ to evaluate superficial structures, pulse points, or tenderness.

Deep Palpation

Pressing the body surface $2\text{–}4\,\text{cm}$ to examine deeper abdominal organs and identify masses.

Bimanual Palpation

A palpation technique utilizing both hands to trap or enclose an internal organ or tissue (e.g., breast, kidney, or pelvic exam).

Percussion

Tapping the body surface with fingers or hands to produce audible sound waves that reflect the density of underlying tissue.

Tympany

A high-pitched, loud, musical drum-like percussion sound produced over air-filled spaces such as the stomach.

Hyperresonance

A very low-pitched, very loud, booming percussion sound characteristic of hyperinflated or emphysematous lungs.

Resonance

A low-pitched, loud, hollow percussion sound elicited over healthy, normal lung tissue.

Dullness

A medium-pitched, medium-intensity, thud-like percussion sound produced over solid organs like the liver or diaphragm.

Flatness

A high-pitched, soft, extremely dull percussion sound heard over dense tissue such as the sternum or thigh.

Auscultation

The clinical technique of listening to internal body sounds (such as heart, breath, and bowel sounds) using a stethoscope.

Stethoscope Diaphragm

The flat, wide side of a stethoscope chestpiece designed to transmit high-pitched sounds like normal heart, lung, and bowel sounds.

Stethoscope Bell

The deep, cupped side of a stethoscope chestpiece best suited for detecting soft, low-pitched sounds such as heart murmurs.

Draping

Covering the patient during a physical exam to maintain warmth, preserve modesty, and expose only the specific area under examination.

Concluding the Assessment

The final stage of assessment where findings are summarized with the patient, priority problems are validated, the patient is asked to volunteer new or additional information as changes occur, and documentation is done.

Adult and Older Adult Assessment Considerations

May be apprehensive about physical examinations from past experiences.

Older Adult Assessment Considerations

Tailoring examinations to accommodate sensory impairment, fatigue from lengthy examinations, cold intolerance, or decreased mobility due to chronic conditions or pain.