Comprehensive Health Assessment Final Exam Flashcards

A set of 224 vocabulary flashcards covering health assessment concepts including interviewing, cardiac, respiratory, cultural, HEENT, neuro, GI, GU, musculoskeletal, and integumentary systems.

Sign

Objective information observed, felt, heard, or measured by the nurse during examination.

Symptom

Subjective information reported by the patient.

Subjective Data

Information gathered during assessment that reflects what the patient says about themselves.

Objective Data

Information gathered during physical assessment that the nurse directly observes or measures.

Purpose of Health History

Describes current and past health state to form a baseline for future changes, yield initial nursing diagnoses, and build therapeutic rapport.

Complete Database

Full health history and physical examination performed to establish a comprehensive baseline and identify past/present health issues.

Focused / Problem-Centered Database

A mini database designed for one limited or short-term problem, cue complex, or specific body system.

Follow-Up Database

Database used to reassess a previously identified problem over time to evaluate progress, changes, and patient coping.

Emergency Database

Rapid collection of crucial data focused on airway, breathing, circulation, LOC, and disability, gathered while stabilizing the patient.

Past Medical History (PMHx)

Component of health history capturing childhood illnesses, accidents, chronic illnesses, hospitalizations, surgeries, immunizations, allergies, and medications.

Allergy Documentation Requirement

Requires recording the specific allergen and patient reaction, while clearly distinguishing a true allergy from a side effect.

Purpose of Family Medical History

Identifies genetic or hereditary diseases the patient may be at higher risk for, guiding early screening and lifestyle modifications.

Family Medical History Scope

Covers 3 generations: parents, grandparents, siblings, aunts, uncles, nieces, nephews, and cousins.

Documented Family History Details

Records gender (symbols), relationship, age, and health conditions of blood relatives.

Common Family History Conditions

Heart disease, hypertension, stroke, diabetes, cancer, sickle cell anemia, mental illness, seizure disorders, kidney disease, and tuberculosis.

False Reassurance

A communication trap that minimizes patient feelings, offers unfounded hope, and blocks honest dialogue.

Giving Unwanted Advice

A communication trap that shifts control away from the patient and impedes therapeutic decision-making.

Using Authority

A communication trap ('I know best') that creates a power imbalance and discourages patient autonomy.

Avoidance Language

A communication trap using vague terms instead of direct naming, increasing patient anxiety.

Distancing / Impersonal Speech

A communication trap referring to 'the patient in room 4' instead of their name, reducing trust.

Professional Jargon

A communication trap using technical medical terms the patient does not understand, causing confusion and fear.

Interrupting

A communication trap that breaks rapport and prevents the patient from fully expressing symptom details.

Biased or Leading Questions

A communication trap that pushes the patient toward a desired response rather than an objective answer.

'Why' Questions

A communication trap that feels judgmental and places the patient on the defensive.

Making Assumptions

A communication trap assuming lifestyle, behavior, or understanding without direct assessment.

Reflection

An interviewing technique where the nurse repeats a key phrase said by the patient to show listening and encourage expansion.

Open-Ended Questions

Questions allowing narrative answers; ideal for beginning interviews, introducing new sections, or exploring general topics.

Closed-Ended Questions

Questions requiring short, specific answers; useful for obtaining details, completing ROS, or expediting the interview.

Inspection

Physical assessment technique using vision and other senses to observe patient size, color, shape, symmetry, and abnormalities.

Palpation

Physical assessment technique using hands and fingers to feel body characteristics (light for surface, deep for internal structures).

Percussion

Physical assessment technique involving tapping the body to produce sounds that indicate air, fluid, or solid tissue density.

Auscultation

Physical assessment technique using a stethoscope to evaluate internal sounds produced by the heart, lungs, and bowels.

Chief Complaint

A brief statement in the patient's own words describing why they seek care, including 1-2 symptoms and duration.

History of Present Illness (HPI)

Detailed, chronological description of current problem from onset tracing location, quality, severity, timing, factors, and patient perception.

HPI Location Component

Determines the exact anatomical site of the patient's complaint.

HPI Character / Quality Component

Describes the specific sensory nature of the symptom (e.g., sharp, dull, burning, throbbing).

HPI Quantity / Severity Component

Quantifies the intensity or extent of the symptom (e.g., pain scale score, impact on activity).

HPI Timing / Onset Component

Establishes when the symptom started, its frequency, and whether it is constant or intermittent.

HPI Aggravating / Relieving Factors

Identifies triggers that worsen the symptom and interventions that alleviate it.

HPI Patient's Perception Component

Gathers what the patient believes is happening or causing their condition.

General Survey Timing

Initiates at the very first encounter with the patient to form an overall impression.

General Survey Components

Systematic collection of baseline objective observations: physical appearance, body structure, mobility, and behavior.

Raynaud Phenomenon

Vasospastic disorder where cold or stress triggers small artery constriction in digits causing sequential color changes and sensory alterations.

Raynaud Phenomenon Triggers

Exposure to cold, emotional stress, mechanical vibration, smoking, and caffeine.

Raynaud Phenomenon Triphasic Color Changes

Sequential color changes: white (ischemia), blue (cyanosis), and red (reperfusion).

Primary vs Secondary Raynaud Phenomenon

Primary is idiopathic, common, and milder; Secondary is severe and associated with autoimmune diseases like scleroderma or lupus.

Raynaud Phenomenon Nursing Care

Keep extremities warm, avoid triggers, and inspect skin regularly for breakdown or ulcers.

Lymphedema Pathophysiology

Accumulation of protein-rich fluid in interstitial spaces due to damaged/removed lymph nodes, raising local oncotic pressure and drawing fluid.

Lymphedema Presentation

Unilateral limb swelling featuring non-pitting brawny edema with indurated, hardened skin overlay.

Lymphedema Key Action

Always obtain baseline presurgical arm measurements prior to axillary lymph node surgery.

Pulse Deficit Calculation

Calculated using the formula: $\text{Apical Heart Rate} - \text{Radial Pulse Rate} = \text{Pulse Deficit}$.

Pulse Deficit Significance

Indicates weak ventricular contractions failing to propel peripheral perfusion; frequently encountered in atrial fibrillation.

Pulse Grading 3+

Increased, full, bounding pulse characteristic of hyperkinetic states.

Pulse Grading 2+

Normal, expected arterial pulse quality.

Pulse Grading 1+

Weak, thready pulse associated with shock or peripheral artery disease (PAD).

Femoral Pulse Location

Located just below the inguinal ligament in the groin area.

Popliteal Pulse Location

Palpated by curling fingers deep into the popliteal fossa behind the knee joint.

Posterior Tibial Pulse Location

Located in the groove behind and slightly below the medial malleolus of the ankle.

Dorsalis Pedis Pulse Location

Located on the dorsum of the foot, lateral and parallel to the extensor tendon of the big toe.

Heart Sound S1

First heart sound produced by closure of the AV valves (mitral and tricuspid) at the start of systole; loudest at apex.

Heart Sound S2

Second heart sound produced by closure of SL valves (aortic and pulmonic) at the end of systole; loudest at base.

Heart Sound S3

Early diastolic sound caused by blood colliding against a dilated, overfilled ventricular wall.

Heart Sound S4

Late diastolic sound (just before S1) caused by atrial contraction pushing blood into a stiff, hypertrophic, or noncompliant ventricle.

Point of Maximum Impulse (PMI)

Located at the 5th ICS midclavicular line; site of strongest apical pulse caused by left ventricular contraction during systole.

Radial Pulse Location

Palpated on the thumb side of the wrist, just distal to the radius on the palmar forearm.

Brachial Pulse Location

Located in the antecubital fossa on the inner upper arm between biceps and triceps muscles.

Cardiac Murmurs

Gentle, swooshing sounds created by turbulent blood flow, best evaluated overall at Erb's point.

SPAMS Acronym

Mnemonic for murmur causes: Stenosis, Partial Obstruction, Aneurysms, Mitral Regurgitation, Septal Defect.

Bruits Auscultation Technique

Auditory assessment using the bell of the stethoscope placed lightly over major arteries like the carotid.

Carotid Bruit Significance

A whooshing arterial sound indicating turbulent flow from structural narrowing (stenosis) or partial vascular occlusion.

Palpating Thrills

Palpation technique using the palmar surface of the fingers flat over cardiac valve areas on the precordium.

Thrill Significance

A tactile vibration felt on the chest wall denoting turbulent blood flow from severe cardiac murmurs or defects.

Edema Assessment Technique

Apply firm finger pressure to swollen skin for exactly 5 seconds, release, and evaluate indentation depth and rebound.

1+ Pitting Edema

Mild pitting present with no perceptible swelling of the extremity.

2+ Pitting Edema

Moderate pitting depth where the skin indentation subsides rapidly.

3+ Pitting Edema

Deep pitting indentation where the extremity visibly looks swollen.

4+ Pitting Edema

Very deep pitting indentation that persists for a prolonged period.

Edema Documentation Requirements

Must state anatomical location, pitting depth grade (1+ to 4+), and whether edema is bilateral or unilateral.

Bilateral vs Unilateral Edema Significance

Bilateral swelling reflects systemic fluid overload (e.g. heart failure); unilateral swelling reflects local vascular/lymphatic obstruction (e.g. DVT).

Venous Stasis Ulcers

Ulcers caused by incompetent valves and blood pooling; located at medial malleolus/tibia; feature shallow, weepy, irregular edges with brawny edema.

Arterial Ischemic Ulcers

Ulcers caused by arterial occlusion starving tissue of oxygen; located on toes/heels/ankle; feature pale base, punched-out edges, and shiny cool skin.

Neuropathic Diabetic Ulcers

Ulcers caused by sensory nerve dysfunction; located on plantar pressure points; feature surrounding calluses and absence of local pain.

7 P's: Pain

Severe, disproportionate pain resulting from acute cellular tissue ischemia.

7 P's: Pallor

Pale or cold skin reflecting inadequate arterial perfusion to the extremity.

7 P's: Pulselessness

Diminished or absent peripheral pulse indicating critical arterial compromise.

7 P's: Paresthesia

Numbness, prickling, or tingling sensations caused by nerve ischemia.

7 P's: Paralysis

Loss of motor function; late and ominous sign of severe muscle and nerve tissue damage.

7 P's: Poikilothermia

Inability of the ischemic limb to regulate temperature, causing it to match cold environmental surroundings.

7 P's: Pressure

Elevated intracompartmental pressure causing the limb skin to feel tense and firm.

Aortic Auscultation Site

2nd right intercostal space; evaluated using the stethoscope diaphragm.

Pulmonic Auscultation Site

2nd left intercostal space; evaluated using the stethoscope diaphragm.

Erb's Point Auscultation Site

3rd intercostal space at left sternal border; assessed with bell of stethoscope.

Tricuspid Auscultation Site

4th intercostal space at lower left sternal border; evaluated using diaphragm.

Mitral Auscultation Site

5th intercostal space at left midclavicular line; evaluated using diaphragm.

Bronchial Breath Sounds

Loud, high-pitched, hollow breath sounds normally heard directly over the trachea.

Bronchovesicular Breath Sounds

Medium-pitched breath sounds of moderate intensity heard over major bronchial tree areas.

Vesicular Breath Sounds

Soft, low-pitched breath sounds heard over peripheral lung fields, louder during inspiration.

Asthma Assessment Findings

Bronchoconstriction and airway inflammation presenting with wheezing, prolonged expiration, dyspnea, tachycardia, accessory muscle use, and diminished breath sounds.

Pneumonia Assessment Findings

Infection of bronchioles and alveoli presenting with fever, malaise, pleuritic chest pain, and crackles.

Closed Pneumothorax

Air accumulation in pleural space causing dyspnea, pain, tachypnea, cyanosis, distant breath sounds, and decreased chest movement.