226 Nursing process- focus on assessment

subjective data

Information reported by the patient (e.g., pain, nausea). (assessment/recognize cues)

objective data

Observable or measurable data (e.g., vital signs, lab results).  (assessment/recognize cues)

primary source

The patient themselves (the best source of information). (assessment/recognize cues)

secondary source

Information from family, records, or other healthcare providers. (assessment/recognize cues)

health history

A record of past and present health conditions, surgeries, and treatments. (assessment/recognize cues)

review of systems

Systematic questioning about each body system. (assessment/recognize cues)

physical examination

Inspection, palpation, percussion, and auscultation to assess body systems. (assessment/recognize cues)

general apperance

The overall impression of a patient’s health, including posture, grooming, and facial expressions. (general survey technology)

level of consiousness

A measure of a patient's alertness and awareness. Levels include alert, lethargic, obtunded, stuporous, and comatose. (general survey technology)

affect

The observable expression of emotion (e.g., flat, appropriate, labile). (general survey technology)

posture

The way a person holds their body when sitting or standing. (general survey technology)

gait

The manner or style of walking. (general survey technology)

mobility

The ability to move freely and easily. (general survey technology)

hygiene and grooming

Personal cleanliness and neatness in appearance. (general survey technology)

speech

Includes rate, rhythm, volume, and clarity of spoken language. (general survey technology)

signs of distress

Indications of physical or emotional discomfort (e.g., labored breathing, grimacing). (general survey technology)

obtunded

The patient has a decreased level of alertness. They are drowsy and difficult to arouse but will respond slowly to stimuli. Interaction may be limited and confused (general survey technology)

stuporus

The patient is in a deep sleep-like state. They can only be aroused with vigorous and repeated stimuli (e.g., pain), and responses are minimal or incomprehensible. (general survey technology)

catamose

The patient is unresponsive to all external stimuli, including pain. There is no purposeful movement or response; they are in a coma. (general survey technology) 

alert

The patient is fully awake and responsive. They are aware of their surroundings and can respond appropriately to questions and stimuli. (general survey technology)

flat affect

A severe reduction or complete absence of emotional expressiveness. The patient shows little or no facial expression or voice inflection. (general survey technology)

appropriate affect

The patient's emotional expression matches the content of speech or situation. For example, they may smile when talking about something pleasant. (general survey technology)

labile

Rapid and exaggerated changes in emotion or mood, often inappropriate to the context. The patient may laugh, cry, or become angry very quickly without a clear cause. (general survey technology)

lethargic

The patient is sluggish, drowsy, and has reduced alertness. They are slower to respond to stimuli but can be aroused with minimal effort. Often used interchangeably with "obtunded," but lethargy typically suggests a milder impairment of consciousness. (general survey technology)

subjective data

Information reported by the patient (e.g., pain, nausea). (assessment)

objective data

Observable or measurable data (e.g., vital signs, lab results). (assessment)

primary source

The patient themselves (the best source of information). (assessment)

secondary source

Information from family, records, or other healthcare providers. (assessment)

health history

A record of past and present health conditions, surgeries, and treatments. (assessment)

review of systems

Systematic questioning about each body system. (assessment)

physical examination

Inspection, palpation, percussion, and auscultation to assess body systems. (assessment)

baseline data

Initial data used for comparison during care. (assessment)

vital signs

Clinical measurements: temperature, pulse, respiration rate, blood pressure, and oxygen saturation. (health assessment terminology)

BMI

A measure of body fat based on height and weight. (health assessment terminology)

inspection

Visual examination of the body. (health assessment terminology)

palpatation

Using hands to feel body parts for abnormalities (e.g., lumps, temperature). (health assessment terminology)

percussion

Tapping the body to hear sounds that indicate underlying structures.(health assessment terminology) 

ausculatation

Listening to internal body sounds using a stethoscope. (health assessment terminology)

cyanosis

Bluish discoloration of the skin due to lack of oxygen. (health assessment terminology)

pallor

Unnatural paleness, often due to anemia or shock. (health assessment terminology)

jaundice

Yellowing of the skin or eyes, typically indicating liver dysfunction. (health assessment terminology)

clubbing

Rounding and enlargement of the fingers or toes, often related to hypoxia. (health assessment terminology)

edema

Swelling caused by fluid accumulation in tissues. (health assessment terminology)

turgor

Skin elasticity; used to assess hydration status. (health assessment terminology)

orientation

Awareness of person, place, time, and situation (often referred to as Alert & Oriented (A&O )x4). (health assessment terminology)

pain scale

A tool (often 0–10) used to measure a patient's level of pain. (health assessment terminology)