Health Assessment & Clinical Judgment Flashcards

Vocabulary practice flashcards covering health assessment methodologies, diagnostic reasoning, data collection types, cultural/spiritual considerations, mental status exams, and domestic violence screening tools.

Subjective Data

Information verbalized by the patient while sharing their story or complaint during a health assessment.

Objective Data

Information observed by the clinician during an examination through inspection, percussion, palpation, and auscultation.

Database

The complete collection formed by combining the patient's record, laboratory studies, and subjective and objective clinical data.

Diagnostic Reasoning

The process of analyzing health data and drawing conclusions to identify clinical diagnoses.

Nursing Process

A 6-phase critical thinking framework consisting of Assessment, Diagnosis, Outcome identification, Planning, Implementation, and Evaluation (ADPIE).

First-Level Priority Problems

Immediate, life-threatening clinical issues that require emergent action, such as establishing an airway or supporting breathing.

Second-Level Priority Problems

Issues requiring prompt intervention to prevent further deterioration, such as mental status changes, acute pain, or abnormal lab values.

Third-Level Priority Problems

Health problems that are important to patient care but can be addressed after urgent issues, requiring long-term interventions.

Evidence-Based Practice (EBP)

A clinical approach integrating research evidence, clinical expertise, physical assessment data, and patient values and preferences.

Complete (Total Health) Database

A baseline database comprising a full health history and physical examination, usually collected in primary care settings.

Focused (Problem-Centered) Database

A mini or targeted database collected for a limited or short-term problem, primarily concerning one body system or issue.

Follow-Up Database

A database used to evaluate previously identified problems at regular intervals to determine if conditions have improved or worsened.

Emergency Database

An urgent and rapid collection of crucial information compiled concurrently with lifesaving measures.

Holistic Health

A health perspective viewing the mind, body, and spirit as interdependent and functioning as a whole within the environment.

Acculturation

The process of adopting the culture and behavior of the majority culture.

Biculturalism

The practice of combining the cultures of one's country of origin with those of a new country.

Acculturative Stress

Stress resulting from adjusting to a new system of beliefs, routines, social roles, and cultural expectations.

FICA Tool

A spiritual assessment framework evaluating Faith, Importance and Influence, Community, and Address in Care.

Chief Complaint

A brief, spontaneous statement in the patient's own words describing the reason for seeking health care.

PQRSTU Mnemonic

A pain assessment system: Provocative or Palliative, Quality or Quantity, Region or Radiation, Severity Scale, Timing, and Understanding Patient Perception.

Activities of Daily Living (ADLs)

Basic self-care tasks required for daily function, including bathing, dressing, toileting, eating, and walking.

Instrumental Activities of Daily Living (IADLs)

Functional tasks required for independent living, such as housekeeping, shopping, cooking, laundry, managing finances, and using a telephone.

CAGE Questionnaire

An alcoholism screening tool assessing Cut down, Annoyed, Guilty, and Eye-opener responses, where two or more positive answers suggest abuse.

HEEADSSS

An adolescent assessment framework examining Home environment, Education/Employment, Eating, Activities, Drugs, Sexuality, Suicide/Depression, and Safety.

ABCD Components

The four main areas evaluated during a mental status examination: Appearance, Behavior, Cognition, and Thought processes.

Dysphonia

An abnormality in voice pitch or volume during speech production.

Dysarthria

Distorted speech articulation caused by difficulty forming or misusing words.

Four Unrelated Word Test

A sensitive memory test assessing a patient's ability to retain new learning by recalling four words at 5, 10, and 30-minute intervals.

Aphasia

The loss of the ability to speak or write coherently, typically caused by stroke or brain injury.

Anhedonia

A symptom characterized by a lack of interest or pleasure in doing activities, routinely assessed using screening tools like the PHQ-2.

Denver II Screening

A developmental screening tool designed to detect delays in infants and preschoolers across gross motor, language, fine motor, and personal-social domains.

Mini-Cog

A brief cognitive assessment tool for older adults consisting of a three-word recall test and a clock-drawing task.

Fetal Alcohol Spectrum Disorder

A group of physical, learning, and behavioral problems in a child resulting from maternal alcohol intake during pregnancy.

Withdrawal Delirium

A severe form of alcohol withdrawal occurring within 1 week of cessation, characterized by tremors, autonomic hyperactivity, vivid hallucinations, and agitation.

HITS Tool

An intimate partner violence screening tool assessing how often a partner Hurts, Insults, Threatens, or Screams at the patient.

Elder Abuse Suspicion Index (EASI)

A 6-question tool consisting of five patient-directed questions and one clinician observation question to screen for elder abuse.

Danger Assessment (DA)

An instrument designed to evaluate the frequency and severity of intimate partner violence over the past year to determine homicide risk.

Hematoma

A localized collection of blood outside the blood vessels, often caused by blunt-force trauma.