Patient Assessment and Physical Examination

Flashcards covering key terms and definitions related to patient assessment and physical examination from the lecture notes.

Assessment

A systematic method of collecting patient data.

Initial/Baseline Assessment

A type of assessment performed to gather foundational patient data.

Problem-Focused Assessment

A type of assessment centered on a specific patient problem.

Emergency Assessment

A rapid assessment performed in life-threatening situations.

Time-Lapsed Reassessment

A type of assessment conducted to compare current patient status to baseline data.

Subjective Data

Symptoms; what the patient states or feels.

Objective Data

Signs; what the nurse observes or measures.

Primary Data

Information obtained directly from the patient.

Secondary Data

Information obtained from sources other than the patient, such as family or medical records.

Nursing Health History

A comprehensive interview to collect subjective and objective data about the patient's health status.

Rapport

A close and harmonious relationship in which the people or groups concerned understand each other's feelings or ideas and communicate well.

Closed Questions

Questions that elicit short, direct answers, often 'yes' or 'no'.

Open-Ended Questions

Questions that invite a detailed personal response, encouraging the patient to elaborate.

Physical Assessment

The systematic examination of the patient's body for objective signs of health or illness.

Inspection

The act of visually examining a patient or body part.

Palpation

The use of touch to examine a patient's body part.

Percussion

The tapping of a patient's body part to elicit sounds or vibrations.

Auscultation

The act of listening to sounds from the heart, lungs, or other organs, typically with a stethoscope.

Abdominal Assessment Sequence

The specific order for examining the abdomen: Inspect, Auscultate, Percuss, Palpate.

Assessment in Infants

Focuses on height, weight, head circumference, and nutritional needs.

Assessment in Adolescents

Includes evaluation of puberty, peer involvement, sexual activity, relationships, and substance use.

Assessment in Older Adults

Focuses on functional status, activities of daily living (ADLs), and psychological adaptations.