Physical Assessment Lecture Flashcards

A set of vocabulary flashcards covering the levels, techniques, and purposes of physical assessments based on Chapter 21 course notes.

Comprehensive health assessment

An in-depth assessment of the whole person—including physical, mental, emotional, cultural, and spiritual aspects—generally performed by the RN upon admission.

Initial head-to-toe shift assessment

A quick overall assessment performed at the beginning of the shift to establish a baseline against which later assessments can be compared.

Focused assessment

An examination and an interview regarding a specific body system.

Subjective Data

Information referred to as symptoms, reflecting the patient's personal perspective.

Objective Data

Information referred to as signs, which are observable or measurable findings.

Inspection

A visual observation of anything about the body that can be seen with the naked eye or with the assistance of other equipment.

Palpation

The application of hands to the external surfaces of the body to detect abnormalities of the skin or underlying tissues by touch or feel.

Percussion

The technique of striking body parts with the tips of the fingers.

Auscultation

The act of listening to the sounds produced by the body, often utilizing equipment like a bell or diaphragm.

Abnormal Finding Reassessment Timing

Abnormal findings should be reassessed within $4$ hours, or sooner depending on the severity of the finding.

Critical Fever Protocol

If a fever of $103^{\circ}\text{F}$ ($39.4^{\circ}\text{C}$) is assessed, immediate treatment is required and the temperature must be reassessed within $1$ hour.

Interviewing

A technique used to build rapport and collect data through therapeutic communication.

Language Barrier Protocol

If a language barrier exists, all efforts should be made to obtain an interpreter to avoid miscommunication or omission of data.

Documentation of Assessment Findings

Recording data as soon as possible after assessment, often using flow sheets, checklists, or narrative sections.

Purpose of Physical Assessment

To establish a baseline, identify potential problems, evaluate nursing intervention effectiveness, monitor body function changes, and detect systems needing further testing.