Nursing Health Assessment Lecture Notes

A comprehensive set of vocabulary flashcards covering basic health assessment techniques, terminology, vital sign ranges, and specialized screening tools used in nursing.

Holistic Health Assessment

An assessment that takes into account mental and social factors rather than just the physical symptoms of a disease to evaluate the whole person.

Initial Assessment

Assessment performed during the first encounter with a patient to identify problems and establish a baseline for future comparison.

Ongoing Assessment

Also known as reassessment, this is done to compare current data with previous data to identify trends in a patient's condition.

Problem Focused Assessment

An assessment used to determine the status of a specific problem, such as a neurological check for a patient admitted with a stroke.

Emergency Assessment

An assessment focused on identifying new or life-threatening problems, specifically prioritizing ABC (Airway, Breathing, Circulation).

Subjective Data

Information gathered from the patient's point of view, including their sensations, feelings, values, beliefs, and perceptions.

Objective Data

Measurable aspects of a patient's condition that can be seen, measured, or validated, such as vital signs and diagnostic tests.

Activities of Daily Living (ADLs)

Basic self-care abilities including eating, bathing, dressing, toileting, transferring (walking), and continence.

Instrumental Activities of Daily Living (IADLs)

Complex self-care tasks such as housework, meal preparation, taking medications, managing money, shopping, and transportation.

Morse Fall Scale

A risk assessment tool consisting of six items: history of falling, secondary diagnosis, ambulatory aid, IV/heparin lock, gait, and mental status.

Columbia Suicide Severity Rating Score (CSSRS)

A screening assessment conducted on all patients during initial assessment to identify suicidal ideation or intent.

Inspection

The use of visual examination in a deliberate, purposeful, and systematic manner, using either the naked eye or lighted instruments.

Palpation

The act of using touch to determine characteristics such as texture, temperature, vibration, position, distention, pulsation, or pain.

Percussion

The act of striking the body surface to elicit sounds, categorized as flatness, dullness, resonance, hyper-resonance, or tympany.

Auscultation

The process of listening to sounds within the body, such as breath or heart sounds, using a stethoscope.

Bradycardia

A medical term describing a low pulse rate, typically below $60\,bpm$ in an adult.

Tachycardia

A medical term describing an elevated pulse rate, typically above $100\,bpm$ in an adult.

Hypotension

A condition of low blood pressure, generally considered as a systolic blood pressure (SBP) less than $90\,mmHg$.

Hypertension

A condition of high blood pressure, generally defined as systolic blood pressure (SBP) over $140\,mmHg$ or diastolic blood pressure (DBP) over $90\,mmHg$.

PQRST Pain Assessment

A mnemonic for pain characteristics: P (Provocation), Q (Quality), R (Region/Radiation), S (Severity), T (Timing).

PERRLA

An acronym used to document normal eye assessment findings: Pupils Equal, Round, Reactive to Light and Accommodation.

Paresthesia

An abnormal sensation such as tingling, tickling, pricking, numbness, or burning.

Normocephalic

A term used to describe a head of normal size and shape.

Ptosis

The medical term for the drooping of the upper eyelid.

Exophthalmos

Abnormal protrusion of the eyeball, frequently seen in Graves Disease.

Cheilitis

Inflammation of the lips, typically causing peeling, cracking, and soreness.

Jugular Vein Distension (JVD)

Visible bulging of the jugular veins, often a sign of right-sided heart failure or fluid volume overload.

Jaundice

Yellowish discoloration of the skin, mucous membranes, and sclera caused by elevated levels of bilirubin in the blood.

Turgor

The elasticity of the skin; skin that stays tented or moves back slowly after being pinched indicates dehydration.

S1 (Lub)

The heart sound occurring when the valves between the atrium and ventricles (Tricuspid and Mitral) close.

S2 (Dub)

The heart sound occurring when the pulmonic and aortic valves close.

Kyphosis

A deformity in the normal posterior shape of the spine, producing a humpback appearance.

Scoliosis

A sideways curvature of the spine.

Barrel Chest

An increased anterior-posterior chest diameter frequently seen in patients with COPD, emphysema, or chronic bronchitis.

Dysuria

The medical term for painful urination.

Hematuria

The medical term for the presence of blood in the urine.

Romberg Test

An assessment of balance where the patient stands with feet together and arms at sides, first with eyes open and then closed.