Foundations of Care: Health and Physical Assessment

Comprehensive vocabulary flashcards covering health history, physical examination techniques, system-specific terminology, and neurological signs based on adult health assessment lecture notes.

SOAP Notes

A frequently used format for documenting client data, including Subjective, Objective, Assessment (or diagnosis), and Plan of care.

Complete Assessment

An assessment that includes a complete health history and physical examination to form a baseline database.

Focused Assessment

An assessment that focuses on a limited or short-term problem, such as the client’s specific complaint.

Episodic/Follow-up Assessment

An assessment that focuses on evaluating a client’s progress.

Emergency Assessment

The rapid collection of data, often conducted during the provision of lifesaving measures.

Inspection

The first assessment technique, which uses the senses of vision and smell while observing the client.

Palpation

The assessment technique using the sense of touch to identify tender areas, texture, temperature, moisture, organ location, and masses.

Percussion

Involves tapping the client’s skin to assess underlying structures and determine the presence of vibrations and sounds.

Auscultation

Involves listening with a stethoscope to sounds produced by the body, such as heart, lung, or bowel sounds.

Cyanosis

A mottled bluish coloration of the skin; in dark-skinned clients, it is checked in the lips and tongue for a gray color or nail beds for a blue color.

Erythema

Redness of the skin.

Pallor

A pale or whitish coloration of the skin.

Jaundice

A yellow coloration of the skin or eyes; checked in the oral mucous membranes or the sclera nearest the iris.

Skin Turgor

The ability of the skin to return to its place when released after being pinched; poor turgor occurs in severe dehydration or extreme weight loss.

ABCDE Mnemonic

A guide for self-examination of skin lesions: Asymmetry, Border irregularity, Color variance, Diameter greater than $6\,mm$, and Evolving size, shape, and color.

Pitting Edema Scale 1+

Slight pitting with no visible distortion that disappears rapidly.

Pitting Edema Scale 4+

Very deep pit that lasts as long as $2$ to $5\,minutes$, with the dependent extremity being grossly distorted.

Vertigo

A spinning sensation described by the client.

Ptosis

Drooping of the eyelids.

Exophthalmos

Protrusion of the eyeballs.

Enophthalmos

Recession of the eyeballs into the orbit, as seen in sunken eyes.

Visual Acuity $20/20$

A measurement where the numerator is the distance the client is standing from the chart ($20\,feet$) and the denominator is the distance at which a normal eye could read that particular line.

Nystagmus

An involuntary, rhythmic, rapid twitching of the eyeballs.

Ishihara Chart

A tool used to test for color vision, specifically sensitive for the diagnosis of red-green blindness.

PERRLA

Documentation indicating Pupils are Equal, Round, Reactive to light (direct and consensual), and reactive to Accommodation.

Conductive Hearing Loss

Hearing loss caused by any physical obstruction to the transmission of sound waves.

Sensorineural Hearing Loss

Hearing loss caused by a defect in the cochlea, eighth cranial nerve, or the brain itself.

Mixed Hearing Loss

A combination of conductive and sensorineural hearing loss resulting from problems in the inner and the outer or middle ear.

Romberg’s Sign

A positive sign is noted when a client exhibits significant swaying while standing erect with feet together and eyes closed.

Epistaxis

The medical term for a nosebleed.

Tonsil Grade 4+

Tonsils that are extending to the midline.

Fine Crackles

High-pitched crackling and popping noises heard during the end of inspiration that are not cleared by cough.

Wheeze

A high-pitched, musical sound similar to a squeak, commonly heard during expiration in narrowed airway diseases like asthma.

Rhonchi

Low-pitched, coarse, loud snoring or moaning tones heard primarily during expiration; may clear with coughing.

Pleural Friction Rub

A superficial, low-pitched, coarse rubbing or grating sound heard in individuals with pleurisy.

Bruit

A blowing, swishing, or buzzing sound heard during auscultation that indicates blood flow turbulence.

Pulse Force Grade 2+

A normal, easily palpable pulse.

Borborygmus

The term used for hyperactive bowel sounds.

Lordosis

An increased lumbar curvature, also known as swayback.

Kyphosis

An exaggeration of the posterior curvature of the thoracic spine, also known as hunchback.

Scoliosis

A lateral spinal curvature.

Kinesthesia

Position sense; the ability of the client to perceive the direction of passive movement of a finger or toe.

Stereognosis

The ability to recognize objects placed in the hand.

Graphesthesia

The ability to identify a number traced on the client’s hand.

Babinski’s Sign

An abnormal finding in anyone older than $2\,years$ characterized by dorsiflexion of the great toe and fanning of the other toes.

Brudzinski’s Sign

A positive sign of meningeal irritation where the client passively flexes the hip and knee in response to neck flexion.

Kernig’s Sign

A positive sign of meningeal irritation where the client flexes the legs at the hip and knee and complains of pain along the vertebral column when the leg is extended.

Cystocele

A condition in which a portion of the vaginal wall and bladder prolapse or fall into the vaginal orifice anteriorly.

Rectocele

A bulging of the posterior wall of the vagina caused by prolapse of the rectum.