Health Assesment exam 1

Complete (Total Health) Database

A full health history and physical examination, typically collected during a patient's first visit.

Episodic (Problem Focused) Database

Data focused on a specific problem or complaint, such as assessing a sore throat.

Follow-up Database

Data collected after treatment to evaluate whether interventions are effective.

Emergency Database

Rapid data collection in life-threatening situations, assessing essential signs like airway and circulation.

Active Listening

Paying full attention and acknowledging both verbal and non-verbal cues during an interview.

Cultural Competence

Awareness and sensitivity to different cultural backgrounds during patient interactions.

Therapeutic Interviewing

Uses techniques like active listening, open-ended questions, and empathy to create a supportive environment.

Nontherapeutic Interviewing

Uses techniques like interruptions, unsolicited advice, or medical jargon detrimental to effective communication.

Biographical Data

Information like a patient's name, age, and occupation collected in a health history.

Health History Purpose

To gather a comprehensive overview of the patient’s overall health, histories, and current concerns.

Symptoms

Subjective sensations reported by the patient, like pain or dizziness.

Signs

Objective findings that can be observed or measured, such as swelling or abnormal heart sounds.

Inspection

Visual examination of the body to notice abnormalities in features like skin color.

Palpation

Using hands to feel the body for tenderness, swelling, or abnormalities.

Percussion

Tapping on the body to assess underlying structures, like detecting fluid in the lungs.

Auscultaion

Listening to sounds produced by the body, most often the heart or lungs.

Erythema

Redness of the skin indicating increased blood flow or inflammation.

Jaundice

Yellowing of the skin or eyes due to excess bilirubin, often related to liver dysfunction.

Edema

Swelling caused by excess fluid trapped in the body’s tissues.

Nodule

A solid, elevated, and hard or soft growth that is larger than 1 cm.

Vesicle

A small, fluid-filled blister less than 1 cm in diameter.

Macule

A flat, colored spot less than 1 cm in diameter.

Assessment of Wounds

Evaluating and documenting size, depth, and drainage in pressure injuries.

Korotkoff Sounds

Sounds heard during blood pressure measurement, indicating systolic and diastolic pressures.

Functional Assessment Purpose

To determine how a person is managing day-to-day activities.

Color Alterations

Variations in skin tone that may indicate underlying health conditions.

Developmental Changes in Aging Adults

Age-related alterations in physical status recognized during assessments.

Cherne-Stokes Breathing

A pattern of alternating deep and shallow breaths with periods of apnea, often indicating severe distress.

Wheezes

High-pitched sound heard during expiration, indicative of narrowed airways.

Crepitus

A coarse, crackling sensation over the skin surface, indicating air leaking under the skin.

Tachypnea

Rapid breathing, typically more than 20 breaths per minute.

Bradycardia

Slow heart rate, generally defined as fewer than 60 beats per minute.

Hypoxia

Low oxygen saturation in the blood, often leading to respiratory distress.

Personal Hygiene

A reflection of an individual's cleanliness and grooming.

Health Traps in Interviewing

Common pitfalls such as providing false assurance or using authority that can hinder effective communication.

Self-Care for Lung Health

Encouragement of activities like smoking cessation and regular check-ups to maintain respiratory health.