Health Assessment and Nursing Process Practice Flashcards

Vocabulary flashcards covering key concepts from nursing lecture notes, including dimensions of health, assessment types, nursing process steps, therapeutic interviewing techniques, vital signs, and pain classification.

Social Determinants of Health

Factors proven to affect a person's health that represent the effects of where people work, live, play, and learn, and are associated with health risks and outcomes.

Health

A relative state in which a person strives to meet their potential, including areas of wellness with the ultimate goal of improving health.

Tangential Lighting

Lighting that casts light across body surfaces to show contours, elevations, and depressions, optimal for inspecting structures such as the jugular venous pulse, the thyroid gland, and the apical impulse of the heart.

Social Dimension of Health

A dimension of health and wellness that includes a sense of inclusiveness, connection, and support systems.

Emotional Dimension of Health

The ability to handle life and its challenges, be resilient, and use coping mechanisms effectively, including maintaining strong relationships with others.

Physical Dimension of Health

A dimension of wellness involving activity level, exercise, proper nutrition, sleep, promoting healthy coping behaviors, and identifying nonhealthy behaviors.

Spiritual Dimension of Health

A person's sense of values and beliefs.

Environmental Dimension of Health

A patient's surroundings, neighborhood safety, or violence in the home.

Intellectual Dimension of Health

The ability to advance knowledge, which is unique and different for each person.

Financial Dimension of Health

Finances required for shelter, food, and health care.

Occupational Dimension of Health

Work and having a healthy work-life balance.

Neuropathic Pain

Pain resulting from injury to or abnormal functioning of peripheral or central nervous system (CNS) nerves, often described as burning, shooting, tingling, or electric-like.

Lethargic

The level of consciousness of a patient who drifts off to sleep during conversation.

Health History

A collection of subjective information that provides information about the patient's health status.

Physical Examination

The process of gathering objective data using a head-to-toe examination to identify changes or abnormal findings.

Subjective Data

Information gathered from symptoms, representing what the patient says.

Objective Data

Information gathered from the physical examination and laboratory tests, also known as signs.

Nursing Process

A five-step problem-solving process (Assessment, Analysis, Planning, Implementation, Evaluation) used by the nurse to identify patient problems, set goals, develop an action plan, implement the plan, and evaluate outcomes.

Assessment (Nursing Process)

The first step of the nursing process where the nurse gathers subjective and objective patient data via the health history and physical examination.

Analysis (Nursing Process)

The step of the nursing process with a nursing focus where the nurse uses clinical reasoning to formulate analyses based on assessment data and the patient's problem list.

Planning (Nursing Process)

The step of the nursing process that involves devising the best course of action to address patient analyses and setting goals.

Implementation (Nursing Process)

The step in the nursing process clearly related to the nursing analysis and planned goals, executed by the patient, family, or care team members.

Evaluation (Nursing Process)

A continuing process to determine if established goals have been attained and if the plan of care needs revision.

Motivational Interviewing

An evidence-based method of therapeutic communication that enhances the nurse-patient relationship and helps patients identify, create, and implement behavioral changes to maintain or improve health.

OARS

An acronym for motivational interviewing communication techniques: Open-ended questions, Affirmation, Reflective listening, and Summarize and teach back.

Pre-interview Phase

The interview phase focused on setting the stage, self-reflecting, reviewing patient records, setting goals, reviewing clinical behavior/appearance, and adjusting the environment.

Introduction Phase

The phase of the interview focused on putting the patient at ease, greeting them, establishing rapport, and setting the agenda.

Working Phase

The interview phase where the nurse obtains patient information, invites their story, clarifies details, responds to emotional cues, and negotiates a plan.

Termination Phase

The final phase of the interview process involving summarizing important points and discussing the plan of care.

OLDCART

A mnemonic for the seven attributes of a symptom: Onset, Location, Duration, Characteristic symptoms, Associated manifestations, Relieving/exacerbating factors, Treatment, and Severity.

Continuers

Words, gestures, or body language (such as nodding or asking 'Can you tell me more about your pain?') used to encourage the patient to keep talking.

Focused Assessment

An assessment conducted when an established patient presents with a specific problem, such as new onset shortness of breath.

Comprehensive Assessment

An assessment performed for a new patient establishing care, requiring a full health history and physical examination.

Emergent Assessment

An assessment performed when a patient presents for an emergent reason.

Follow-up Assessment

An assessment conducted when an established patient returns for evaluation following previous care.

Chief Complaint

The primary reason the patient is seeking health care.

History of Present Illness (HPI)

The component of the health history that elaborates on the chief complaint and describes how each symptom developed.

Review of Systems (ROS)

A section of the health history documenting the presence or absence of common symptoms related to each major body system.

Palpation

An examination technique using tactile pressure from palmar fingers to assess skin elevation, depression, warmth, tenderness, lymph nodes, pulses, and organ contours.

Percussion

An examination technique involving tapping body parts to produce sound waves to assess the density of underlying structures.

General Survey

The initial assessment of overall appearance, behavior, and cognition that begins the moment the nurse sees the patient.

Systole

The pressure exerted in the arteries when the left ventricle contracts.

Diastole

The blood pressure in the arteries when the heart muscle rests and refills with blood.

Auscultatory Gap

A silent interval that may be present between the systolic and diastolic blood pressure readings.

Korotkoff Sounds

Sounds heard through a stethoscope as the blood pressure cuff changes the flow of blood through an artery.

Pyrexia

The medical term for a fever.

Hypothermia

A condition characterized by a body temperature falling below $35^\text{C}$.

Nociceptive Pain

Pain caused by actual or potential tissue damage, usually felt in the skin, muscles, bones, or joints.

Psychogenic Pain

Pain that is strongly influenced by psychological factors, such as stress or emotional distress.

Idiopathic Pain

Pain that has no known or identifiable cause.

FIFE

A mnemonic representing the patient's perspective on illness: Feelings, Ideas, Effect on function, and Expectations.

Durable Power of Attorney for Health Care

A designated proxy appointed to make health care decisions when a patient is unable to do so.

Advance Directive

A legal document outlining a patient's health care wishes in the event they become unable to communicate them.