Health Assessment Across The Life Span

Subjective Data

Information reported by the patient, including symptoms, feelings, and concerns.

Objective Data

Information observed or measured by the healthcare professional, including physical findings and vital signs.

Patient Record Data

Includes past medical history, medications, previous diagnoses, and previous assessment findings.

Diagnostic Studies Data

Includes laboratory results, imaging, and other diagnostic tests.

Internal Communication Factors

Factors coming from the patient or nurse such as pain, anxiety, fear, fatigue, personal beliefs, and knowledge level.

External Communication Factors

Factors coming from the environment such as noise, poor privacy, interruptions, time pressure, and room temperature.

Open-Ended Questions

Questions that encourage narrative information and allow patients to explain concerns in detail.

Closed Questions

Questions that obtain specific information and usually require short answers.

Therapeutic Communication Techniques

Includes active listening, clarification, reflection, restatement, summarization, silence, and empathy.

Older Adult Assessment Considerations

Show respect, allow additional time, speak clearly, reduce distractions, and check hearing and vision needs.

Acutely Ill Patient Priority

Prioritize life-threatening problems, perform a focused interview, and obtain essential information initially.

Violent or Aggressive Patient Priority

Safety comes first, remain calm, maintain personal space, avoid arguing, and identify an exit route.

Complete Database

Provides a comprehensive health history, establishes a baseline, and is used for new patients.

Episodic / Problem-Centered Database

Focuses on a specific problem and collects information related to the current concern.

Follow-Up Database

Reassesses a known problem, evaluates treatment response, and identifies changes since the previous visit.

Emergency Database

Rapid assessment used during urgent situations to collect essential information quickly and focus on immediate threats.

Symptoms vs. Signs

Symptoms are subjective and experienced by the patient; signs are objective and detected by the healthcare professional.

OLDCARTS Pain Assessment

Onset, Location, Duration, Character, Aggravating/Alleviating, Radiation, Timing, Severity.

PQRST Pain Assessment

Provoking/Palliating, Quality, Region/Radiation, Severity, Time.

SOCRATES Pain Assessment

Site, Onset, Character, Radiation, Associated symptoms, Time, Exacerbating/Relieving, Severity.

GTPAL Acronym

Gravida, Term births, Preterm births, Abortions/losses, Living children.

Review of Systems (ROS)

Head-to-toe review of past and present symptoms evaluated across major body systems.

Mental Status Assessment Components

Assesses Appearance, Behavior, Cognition, and Thought process.

A&O × 4 (Orientation)

Orientation to Person, Place, Time, and Situation.

Mood vs. Affect

Mood is what the patient says they feel; affect is the emotional expression observed by the nurse.

Physical Assessment Techniques (IPPA)

Inspection, Palpation, Percussion, Auscultation.

Abdominal Assessment Technique (IAPP)

Inspection, Auscultation, Percussion, Palpation (auscultation comes before palpation and percussion).

AIDET Communication Framework

Acknowledge, Introduce, Duration, Explanation, Thank You.

EHR Documentation Principles

Documentation should be accurate, objective, timely, complete, clear, relevant, and patient-centered.