Health History, General Survey, Mental Status, and Functional Assessment

Practice vocabulary flashcards covering health history, general survey, mental status exam, functional assessment, levels of prevention, physical exam techniques, and therapeutic communication.

Database

The combination of subjective data collected during the health history and objective data collected during physical assessment, used to make clinical judgements and form diagnoses.

Subjective Data

Information provided directly by the patient or caregiver during the assessment, including health history, complaints, sensations, and feelings.

Objective Data

Observable and measurable clinical information gathered by the nurse through physical examination, vital sign measurements, laboratory values, and diagnostic test results.

PQRST

A structured method of symptom analysis, standing for Provocation/Palliative factors, Quality/Quantity, Region/Radiation, Severity scale, and Timing.

Mental Status Examination

A systematic assessment of emotional state and cognitive functioning that can be conducted during the general survey and physical examination.

Four Components of Mental Status Assessment

The essential categories evaluated in a mental status exam: Appearance, Behavior, Cognitive functions, and Thought processes (ABCT).

Mini-Mental State Evaluation (MMSE)

A thorough cognitive assessment tool that evaluates memory, language, calculations, visual-spatial orientation, and speech, with a maximum total score of $30$ points.

Mini-Cog

A quick and sensitive cognitive evaluation instrument consisting of a 3-word recall test and a clock-drawing test, designed to screen for dementia and friendly for diverse populations.

PHQ-2 and PHQ-9

Validated screening questionnaires used to evaluate patients for depressive symptoms and monitor depression severity.

Geriatric Depression Scale

A validated depression screening tool specifically designed to identify depressive symptoms in older adult populations.

General Survey

An initial objective study of the whole person observing physical appearance, body structure, mobility, behavior, and basic body measurements upon first contact.

Functional Ability

An individual's capability to carry out activities necessary to live independently in modern society.

Functional Status

A person's ability to perform self-care tasks; it is dynamic, and older adults may continuously shift through varying levels of independence and disability.

Activities of Daily Living (ADLs)

Basic self-care tasks essential for fundamental everyday survival, including bathing, dressing, grooming, eating, toileting, and transferring.

Instrumental Activities of Daily Living (IADLs)

Higher-level functional tasks necessary for independent community living, including shopping, meal preparation, housekeeping, laundry, managing finances, and taking medications.

Katz Index of Independence

An ADL assessment tool that uses dichotomous scoring to evaluate whether a patient is independent or dependent in six basic self-care activities.

Lawton Instrumental Activities of Daily Living Scale

A self-report assessment instrument used to evaluate higher-level independent living skills to determine the most suitable living situation for an older adult.

Primary Social Domain

A small group of tight, long-lasting, direct, and intimate relationships, such as immediate family members.

Secondary Social Domain

Groups gathered to achieve a specific goal or share a common interest and a sense of belonging.

Caregiver Burnout

A state of physical exhaustion, social withdrawal, neglect of self-care, emotional fatigue, and cognitive impairment resulting from prolonged caregiving demands.

Wong-Baker FACES Pain Rating Scale

An age-appropriate visual pain assessment tool utilizing facial expressions to help patients quantify pain intensity.

Yin and Yang

A traditional Chinese medicine concept that views health as a balance between opposing natural forces, with illness resulting from an imbalance.

FICA Spiritual Assessment Tool

An acronym-based spiritual assessment framework evaluating Faith, Importance/influence, Community, and Address/action in healthcare decisions.

Healthy People 2030

A national initiative managed by the Office of Disease Prevention and Health Promotion (ODPHP) that sets data-driven national goals to improve health and well-being.

U.S. Preventive Services Task Force (USPSTF)

An independent, volunteer panel of national experts that evaluates clinical preventive services and issues evidence-based recommendations for screenings, counseling, and preventive medications.

Primary Prevention

Strategies designed to prevent disease onset before it occurs by modifying or removing risk factors (e.g., bike helmets, tobacco cessation, vaccinations).

Secondary Prevention

Interventions aimed at early detection and treatment of asymptomatic disease to prevent disease progression and complications (e.g., mammograms, newborn screening, blood pressure screening).

Tertiary Prevention

Healthcare measures focused on reducing complications and managing existing chronic diseases to improve function and quality of life (e.g., post-stroke rehabilitation, physical therapy).

Inspection

The first assessment technique of the physical examination, involving close, careful scrutiny of the individual as a whole and then of each body system under adequate lighting.

Palpation

The physical exam technique that applies the sense of touch to evaluate texture, temperature, moisture, organ size and position, swelling, rigidity, crepitation, masses, and tenderness.

Percussion

Tapping the skin with short, sharp strokes to produce vibrations penetrating approximately $5\,\text{cm}$ deep, used to map organ location, size, density, and tenderness.

Auscultation

The technique of listening to internal body sounds produced by cardiovascular, respiratory, and gastrointestinal systems using a stethoscope directly on skin.

Evidence-Based Practice (EBP)

A systematic clinical decision-making approach integrating best research evidence, clinical expertise, physical assessment findings, and patient preferences and values.

Nursing Process

A five-step clinical decision-making framework consisting of Assessment, Diagnosis, Planning, Implementation, and Evaluation.

Traps of Interviewing

Non-therapeutic communication barriers to avoid during patient interviews, including false reassurance, unwanted advice, using authority, avoidance language, medical jargon, leading questions, and 'why' questions.