Osu-OKC Unit 1.2 Physical Assessment

Vocabulary flashcards covering physical assessment fundamentals, techniques, communication, and patient history based on the lecture transcript.

Medical Diagnoses

Diagnoses made specifically by physicians to identify medical conditions.

Nursing Diagnoses

Diagnoses made specifically by nurses to identify patient responses to health conditions.

Comprehensive Assessment

The most thorough assessment performed during initial admission to establish a complete baseline.

Focused Assessment

A shorter, targeted physical assessment conducted during shift changes or routine check-ins.

Subjective Data

Information reported directly by the patient that cannot be directly observed or measured by the nurse.

Objective Data

Observable, measurable physical findings detected by the nurse through senses, vital signs, or standardized scales.

Pain Assessment

An assessment that contains both subjective (patient report) and objective (standardized rating scale) components.

Evidence-Based Practice in Nursing

The integration of research evidence, provider clinical expertise, and patient preferences or values.

Inspection

The assessment technique using sight, smell, and hearing to observe patient appearance and structures.

Palpation

The assessment technique using touch with hands and fingers to feel body structures.

Percussion

The physical assessment technique of tapping the skin surface with fingertips, primarily used by specialists.

Auscultation

The physical assessment technique of listening to body sounds using a stethoscope and ears.

Four Primary Senses Used in Assessment

Sight (inspection), hearing (auscultation), touch (palpation), and smell (olfaction).

Olfaction

The use of smell during assessment to detect distinct clinical indicators such as GI bleeds or infected wounds.

IPPA

The standard physical assessment sequence mnemonic: Inspection, Palpation, Percussion, Auscultation.

Abdomen Assessment Order

The modified assessment sequence of Inspection, Auscultation, Percussion, Palpation to prevent altering bowel sounds.

Head to Toe Method

A systematic assessment approach starting at the patient's head and moving downward to the feet.

Symmetry Assessment

Comparing bilateral body structures to identify normal alignment or pathological deviations.

General Survey

An initial visual assessment evaluating overall appearance, hygiene, affect, posture, gait, and dress.

Patient Identification

The process of verifying patient identity using their armband to prevent medical errors.

Allergy Assessment

Gathering detailed information on patient allergies to distinguish true allergic reactions from side effects or preferences.

Anaphylaxis

A severe, true allergic reaction that must be differentiated from routine medication side effects.

Side Effect

A secondary, predictable drug effect, such as nose itching from morphine, which is distinct from a true allergy.

Chief Complaint

The primary reason for the healthcare visit stated by the patient, framing assessment priorities.

Chronic Health Conditions

Long-term medical issues that patients may deny having unless prompted via specific question formats or medication reviews.

Occupational History

Documentation of current and past work environments to detect hazardous exposures causing clinical disease.

Medication History

A complete record of all ingested substances including prescriptions, OTC drugs, herbal supplements, and medical marijuana.

Substance Use History

Detailed documentation of past and present tobacco, alcohol, and illegal drug use timelines.

Vaccination Status

Assessment of preventive immunizations, including annual flu shots and pneumonia vaccines for patients over $55$.

Living Situation

Evaluation of home environment, safety, and support systems required for effective discharge planning.

Frequent Flyer Phenomenon

Patients who present frequently to healthcare, requiring nurses to maintain open clinical vigilance and avoid stereotyping.

Open-Ended Questions

Questions designed to elicit detailed narrative information from patients without suggesting expected answers.

Leading Questions

Questions structured to suggest a desired response, which often leads to inaccurate or unhelpful patient answers.

False Reassurance

Providing unwarranted comforting statements without certain knowledge, which damages patient trust.

Medical Jargon

Technical medical terminology that nurses must translate into patient-understandable language.

Active Listening

Paying close attention to patient statements and nonverbal cues to gather detailed clinical information.

Professional Body Language

Open posture and approachability used by the nurse to encourage open patient communication.

Cultural Competence

Adapting assessment and communication styles to respect patient cultural norms, values, and comfort levels.

Eye Contact Sensitivity

Understanding that eye contact norms vary by culture and avoiding forcing eye contact when culturally inappropriate.

Rapport

Building trust and therapeutic connection with a patient to encourage complete and honest communication.

Pen Light

A portable light tool used to examine body cavities such as the mouth and eyes.

Stethoscope

An essential diagnostic tool used during auscultation to listen to internal body sounds.

Light Palpation

Gentle initial application of pressure with fingers to assess superficial body structures.

Deep Palpation

Advanced palpation technique using deeper pressure following light palpation to examine underlying organs.

Timing of Painful Procedures

Performing painful assessment steps at the end of the exam to prevent artificially elevating baseline measurements.

Baseline Data

Initial normal data collected at first encounter used as a reference point for future reassessments.

Environmental Preparation

Ensuring proper lighting, privacy, quietness, and minimal distractions prior to physical assessment.

Psychological Preparation

Explaining procedures to the patient before performing them to reduce anxiety and build trust.

Physical Preparation

Properly positioning and selectively exposing body parts during an exam to maintain dignity and access.

Hand Hygiene

Essential hand-washing prior to patient contact to maintain strict infection control.