Health Assessment, Examination Techniques, Cultural Competence, Pain, and Mental Health Assessment

A comprehensive vocabulary flashcard set covering nursing health assessment principles, examination techniques and equipment, cultural competence, pain assessment, and mental health assessment.

Health Assessment

A systematic method of collecting and analyzing data to plan patient-centered care, taking into account physical, psychological, and socioeconomic status.

Person-Centered Care

An approach defined by the World Health Organization as empowering people to take charge of their health rather than being passive recipients of services.

Signs

Objective data observed, felt, heard, or measured by the nurse, such as a rash, swelling, or enlarged lymph nodes.

Symptoms

Subjective data perceived and reported by the patient, such as pain, itching, or nausea.

Clinical Manifestation

A term used to describe the presenting signs and symptoms experienced by a patient.

Primary Source Data

Subjective health history data acquired directly from the patient.

Secondary Source Data

Health data acquired from an individual other than the patient, such as a family member or caregiver.

Problem-Oriented Health Record (POHR)

A documentation format organized around patient problems, including a health history, physical examination, problem list, plan of care, and progress notes.

Comprehensive Assessment

A detailed health history and physical examination performed at the onset of care in a primary care setting or on admission to a hospital or long-term care facility.

Problem-Based/Focused Assessment

A health history and physical examination limited in scope to a specific problem or complaint.

Episodic/Follow-Up Assessment

An assessment performed when a patient follows up with a healthcare provider for a previously identified problem.

Shift Assessment

An assessment conducted by nurses each shift on hospitalized patients to identify changes in condition from baseline.

Screening Assessment

A short examination focused on disease detection, such as blood pressure or glucose screening.

Context of Care

The circumstances related to healthcare delivery, including the setting, environment, patient situation, and nurse expertise.

Clinical Reasoning

The process nurses use to make sense of collected data through analysis and interpretation based on nursing knowledge and current evidence.

Clinical Judgment

The decision or conclusion reached by a nurse that drives action, encompassing the processes of noticing, interpreting, responding, and reflecting.

Noticing

The initial perceptual grasp of a situation based on a nurse's expectations, clinical experience, knowledge, and context.

Reflection-in-Action

A component of clinical judgment where the nurse reflects on past experiences while in the midst of a situation or evaluates ongoing outcomes of interventions.

Reflection-on-Action

Thinking about a clinical situation after it has occurred to gain a better understanding and learn for future encounters.

Primary Prevention

Protection to prevent the occurrence of disease through healthy lifestyle promotion, such as immunizations, exercise, and nutrition.

Secondary Prevention

Early identification of disease before it becomes symptomatic to halt pathologic progression, such as screening examinations.

Tertiary Prevention

Interventions directed toward minimizing severity and disability from established chronic disease or injury through appropriate therapy.

Health Promotion

Behavior motivated by the desire to increase well-being and actualize human health potential.

Health Protection

Behavior motivated by the desire to actively avoid illness, detect it early, or maintain functioning within constraints.

Normalizing

An interview technique where the nurse frames sensitive questions by stating that many people share or experience the issue, signaling it is safe to discuss.

Permission Giving

An interview technique in which the nurse asks consent from the patient before introducing personal or sensitive topics.

Open-Ended Questions

Broadly stated interview questions that encourage free-flowing, detailed responses of more than one or two words.

Directive Questions

Specific closed-ended questions requiring a one- or two-word answer to elicit precise details.

Active Listening

Concentrating purposefully on spoken words and nonverbal behaviors without making assumptions or prematurely formulating responses.

Clarification

An interview technique used when a nurse needs more information about conflicting, vague, or ambiguous patient statements.

Reflection

An interview technique where the nurse restates a phrase used by the patient in the form of a question to encourage elaboration.

Interpretation

An interview technique where the nurse shares conclusions drawn from collected data so the patient can confirm, deny, or revise them.

OLD CARTS

A mnemonic for symptom analysis representing Onset, Location, Duration, Characteristics, Aggravating factors, Related symptoms, Treatment, and Severity.

Pack-Years

A measurement of smoking history calculated by multiplying the number of cigarette packs smoked per day by the number of years smoked.

Genogram

A family-tree diagram depicting structure and health history of family members over at least three generations.

Review of Systems (ROS)

A systematic inquiry about past and present health, symptoms, and health promotion practices across each body system.

Standard Precautions

Primary infection control measures applied in all patient care settings to reduce infection transmission risks.

Transmission-Based Precautions

Infection control guidelines applied in addition to Standard Precautions for patients with known or suspected transmissible pathogens.

Tangential Lighting

Directing a light source at right angles to the target area to create shadows and highlight subtle contour variations during inspection.

Light Palpation

Pressing down to a depth of approximately $1\,\text{cm}$ using the palmar surfaces of fingers to assess skin, pulsations, and tenderness.

Deep Palpation

Pressing down to a depth of $4\,\text{cm}$ with one or two hands to determine the size and contour of internal organs.

Bimanual Palpation

A palpation technique using both hands (one anterior, one posterior) to entrap an organ or mass between fingertips.

Direct Percussion

An examination technique involving striking a finger or hand directly against the patient's body to evaluate underlying structures.

Indirect Percussion

An examination technique requiring both hands, where the dominant middle finger strikes the distal interphalangeal joint of the non-dominant middle finger resting on the skin.

Tympany

A loud, high-pitched, drumlike percussion tone normally heard over the stomach and gas-filled abdomen.

Resonance

A loud, low-pitched, hollow percussion tone normally heard over healthy lung tissue.

Hyperresonance

A very loud, very low-pitched, booming percussion tone heard over overinflated lungs, such as in emphysema.

Dullness

A medium, medium-high pitched, thudlike percussion tone heard over dense organs like the liver or viscera.

Flatness

A soft, high-pitched, extremely dull percussion tone heard over muscle or bone.

Stethoscope Diaphragm

The flat surface of a stethoscope head used to auscultate high-pitched sounds, such as breath, bowel, and normal heart sounds.

Stethoscope Bell

The concave surface of a stethoscope head used to auscultate soft, low-pitched sounds, such as extra heart sounds or vascular bruits.

Pulse Oximeter

An electronic device using LED light reflection to estimate arterial blood oxygen saturation and pulse rate.

Snellen Chart

A visual acuity chart consisting of 11 lines of letters of decreasing size used to screen distance vision at $20\,\text{ft}$.

Rosenbaum Chart

A chart used to evaluate near vision held $14\,\text{in}$ from the patient's face.

Ophthalmoscope

An instrument containing lenses, mirrors, and light apertures used to inspect internal eye structures.

Otoscope

An instrument with a light source, magnifying lens, and speculum used to inspect the external auditory canal and tympanic membrane.

Doppler

An ultrasonic device that amplifies subtle pitch changes of circulating blood flow to detect hard-to-hear vascular sounds or fetal heart tones.

Goniometer

A two-piece protractor-type measuring device used to measure the degree of joint flexion and extension.

Monofilament

A flexible wire device used to test lower extremity peripheral sensation by bending at $10\,\text{g}$ of linear pressure.

Transilluminator

A strong light source placed against skin to differentiate tissue, fluid, and air within a body cavity based on glowing light tones.

Culture

Knowledge, beliefs, art, morals, laws, customs, and habits acquired by an individual as a member of society.

Ethnicity

Characteristics shared by a group in combination, including geographic origin, language, religion, traditions, folklore, and food preferences.

Race

A social construct and unscientific categorization of genetically related people sharing physical characteristics.

Cultural Awareness

The process of self-examination regarding one's personal cultural background and mindfulness of biases toward other cultures.

Cultural Competence

The ongoing process in which a healthcare professional continuously strives to work effectively within the cultural context of a patient.

Gender Identity

A person's internal sense of self as male, female, a blend of both, or neither.

Gender Expression

How an individual presents gender within cultural and societal contexts through mannerisms, dress, speech, or behavior.

Sexual Orientation

The pattern of sexual or emotional attraction to persons of a different sex/gender, same sex/gender, or multiple sexes/genders.

A-delta Fibers

Large myelinated nerve fibers that carry pain impulses associated with sharp, pricking, acute, well-localized pain of short duration.

C Fibers

Small unmyelinated nerve fibers carrying pain impulses associated with dull, aching, throbbing, or burning diffuse pain with slow onset and longer duration.

Substantia Gelatinosa

The structure in the dorsal horn of the spinal cord that acts as a gate controlling sensory impulse transmission to sensory tracts.

Acute Pain

Pain with a recent onset ($< 6\,\text{months}$) resulting from tissue damage that is self-limiting and provokes a sympathetic stress response.

Persistent Pain

Pain lasting longer than $6\,\text{months}$ that may be intermittent or continuous, to which patients adapt without classic autonomic signs.

Somatic Pain

Nociceptive pain arising from nerve stimulation in bone, joint, muscle, skin, or connective tissue.

Visceral Pain

Nociceptive pain arising from nerve stimulation within thoracic, pelvic, or abdominal organs.

Referred Pain

Visceral pain felt in a body area distant from the site of tissue injury due to shared sensory segments in the spinal cord.

Neuropathic Pain

Pain caused by abnormal processing of sensory input by the central or peripheral nervous system.

Pain Threshold

The point at which a physical stimulus is perceived as pain.

Pain Tolerance

The duration or intensity of pain that a person endures or tolerates before responding outwardly.

Problem-Focused Coping

Pain coping strategies involving activity modification, exercise, or self-care behaviors such as medications or physical therapies.

Emotion-Focused Coping

Pain coping strategies aimed at managing emotional responses, including social support, religious coping, or stoicism.

Stoicism

A learned coping response characterized by bearing pain with dignity and courage without complaining outwardly.

Limbic System

The regional structure in the brain, also called the emotional brain, regulating memory, basic emotions, fear, anger, and sex drive.

HITS Tool

A four-item domestic violence screening tool assessing how often a partner Hurts, Insults, Threatens, or Screams at the patient.

AUDIT

A 10-item Alcohol Use Disorders Identification Test used to screen patients for dangerous drinking patterns and alcohol misuse.

Rapid Eye Test

An examination assessing pupil size, light reaction, nystagmus, convergence, and corneal reflex to detect acute drug intoxication.

Major Depression

A mood disorder characterized by a persistently depressed mood or loss of interest lasting at least 2 weeks accompanied by specified vegetative and cognitive symptoms.

Postpartum Depression (PPD)

Intense and persistent depression occurring in mothers or fathers during the postpartum period up to 1 year after childbirth.

Bipolar Disorder

A chronic mood disorder characterized by recurrent alternating episodes of depression and mania or hypomania.

Schizophrenia

A group of chronic psychotic disorders characterized by disruptions in thought processes, perception, affective response, and social interaction.

Generalized Anxiety Disorder (GAD)

An anxiety disorder characterized by persistent, excessive, and uncontrollable worry that impairs daily personal, occupational, or social functioning.

Obsessive-Compulsive Disorder (OCD)

An anxiety disorder characterized by persistent intrusive thoughts and repetitive ritualistic behaviors performed to reduce anxiety.

Posttraumatic Stress Disorder (PTSD)

A disorder developing after exposure to a traumatic event, marked by re-experiencing symptoms, avoidance behaviors, reactivity changes, and mood alterations.

Alcohol Withdrawal Syndrome (AWS)

A clinical condition resulting from abrupt cessation of alcohol intake in dependent individuals, progressing from minor tremors to severe delirium tremens.

Delirium

An acute, fluctuating disturbance in attention and environmental awareness, typically secondary to underlying medical conditions or substance toxicity.

Dementia

A chronic, progressive neurocognitive disorder characterized by failing memory, cognitive impairment, behavioral changes, and irreversible decline in function.