Health Assessment (27)

Activities of Daily Living (ADLs)

• the basic self-care tasks a person needs to perform every day to live independently

• Includes bathing, dressing, eating, toileting, transferring (moving), and continence.

Adventitious breath sounds

• abnormal lung sounds

• crackles, wheezes, or rhonchi

• indicates possible respiratory problems.

Auscultation

• listening to the sounds of the body

• usually with a stethoscope

• to assess organs like the heart, lungs, and bowel.

Body Mass Index (BMI)

• a measure of body fat based on a person’s weight in relation to their height.

Bronchial Breath Sounds

• loud, high-pitched lung sounds normally heard over the trachea

• Hearing them over the lung fields can signal abnormal lung consolidation.

bronchovesicular breath sounds

• medium-pitched, moderate-intensity lung sounds heard over the major bronchi

• where airflow is less harsh than bronchial sounds and louder than vesicular sounds.

comprehensive health assessment

• a thorough, head-to-toe evaluation of a patient’s physical, psychological, social, and health history to get a complete picture of their overall health status.

Cyanosis

• bluish or purplish discoloration of the skin or mucous membranes

• caused by low oxygen levels in the blood.

Data

• information collected about a patient’s health

• such as observations, measurements, symptoms, and history

• used to guide care and decision-making.

Diaphoresis

• excessive sweating

• often due to pain, fever, stress, or medical conditions.

Ecchymosis

• a large, flat bruise

• caused by bleeding under the skin.

Edema

• swelling

• caused by excess fluid in the tissues.

Emergency health assessment

• A rapid, focused evaluation of a patient in a life-threatening situation to identify immediate problems.

Erythema

• Redness of the skin

• caused by increased blood flow

• often from inflammation or infection.

Follow-up assessment

• Ongoing evaluation of a patient’s condition to monitor progress or response to treatment.

Health history

• Collection of information about a patient’s past and current health, lifestyle, and risk factors.

Inspection

• Careful visual examination of the body for signs of health or illness.

Instrumental Activities of Daily Living (IADLs)

• Complex daily tasks are needed for independent living

• such as cooking, managing finances, shopping, and using transportation.

Jaundice

• Yellowing of the skin, eyes, or mucous membranes

• due to high bilirubin levels.

Ongoing or partial health assessment

• Focused evaluation performed after the initial assessment to monitor specific health problems or changes.

Pallor

• Paleness of the skin or mucous membranes

• often due to anemia or poor blood flow.

Palpation

• Using hands to feel the body to assess texture, temperature, swelling, or tenderness.

Percussion

• Tapping the body to evaluate underlying structures by the sounds produced.

Petechiae

• Small, pinpoint red or purple spots on the skin caused by bleeding under the skin.

Physical assessment

• Systematic examination of the body to evaluate a patient’s health status.

Precordium

• Area of the chest over the heart.

Review of systems (ROS)

• Structured series of questions about each body system to identify health problems.

Turgor

• Skin’s elasticity used to assess hydration status.

Vesicular breath sounds

• soft, low-pitched lung sounds heard over most of the lungs

• especially the peripheral areas, during normal breathing.

Waist Circumference

• the measurement around the smallest part of the waist

• used to assess abdominal fat and risk for health problems.