Fundamentals of Nursing: Health History & Physical Exam

Flashcards covering health history, physical assessment techniques, and system-specific examination findings based on Chapter 20.

Three phases of the patient interview

Orientation, working, and termination.

Subjective and objective data

The two types of information gathered during a health history.

Review of systems

An assessment that begins with general health status.

Inspection

Using vision and smell to examine characteristics of a whole person and individual body systems.

Palpation

Using touch to assess body organs and skin; includes deep and bimanual deep techniques.

Percussion

Tapping the skin to cause a vibration.

Auscultation

Listening to sounds made by body organs or systems.

General Survey

Includes age, race, sex/gender identity, sexual orientation, clothing, hygiene, affect, safety, substance use, speech, gait, vital signs, height, weight, and body mass index.

Skin color alterations

Includes absence of pigment, cyanosis, erythema, purpura, jaundice, pallor, and vitiligo.

ABCDE

The mnemonic used to evaluate skin malignancies.

Skin Turgor

Assessed during skin palpation along with texture and temperature.

Pitting edema

A condition characterized by swelling where and indentation remains after pressure is applied to the skin.

Capillary refill

A finding assessed during nail inspection and palpation.

Cataracts

Clouding of the lens of the eye affecting clarity.

Visual acuity assessment tools

The Snellen chart and the E chart.

Ophthalmoscope examination

Used to visualize the optic disc and retinal vasculature.

Otoscopic examination

A physical examination technique used for the ear to check for cerumen and discharge.

Hearing loss types

Sensorineural, conductive, and mixed.

Hearing and Equilibrium tests

The Weber, Rinne, and Romberg tests.

Tactile fremitus

A vibration felt during palpation of the chest.

Atelectasis

A condition of the lungs that may be identified during auscultation.

Adventitious breath sounds

Abnormal lung sounds heard during auscultation.

Cardiac murmurs

Heart sounds graded on a scale from Grade $1$ to Grade $6$.

Peripheral pulse intensity scale

$0$ (Absent), $1$ (Diminished), $2$ (Normal), and $3$ (Bounding).

Allen test

A test used during the assessment of radial pulses.

The Five Ps of arterial insufficiency

Pain, pallor, pulselessness, paresthesia, and paralysis.

Reflex response scale

$4+$ (Very brisk/hyperactive), $3+$ (Brisker than average), $2+$ (Average/normal), $1+$ (Sluggish), and $0$ (No response).

Cranial nerves

A total of $12$ nerves that are tested in numbered order during a neurologic assessment.

Dermatomes

Used during sensory nerve assessment to map sensation areas.

Borborygmi

Sounds heard during the auscultation of the abdomen.