Health Assessment and Nursing Process Vocabulary

Vocabulary flashcards covering core concepts of health assessment, data collection types, prioritization levels, patient interview phases, and therapeutic communication techniques.

Assessment

The collection of data about an individual's health state, forming the starting point of diagnostic reasoning.

Subjective Data

Information reported by the patient during history taking, including symptoms, perceptions, and feelings.

Objective Data

Measurable health data observed by the professional during physical examination via inspection, palpation, percussion, and auscultation.

Sign

Objective evidence of a disease or condition that can be observed or measured by someone other than the patient.

Symptom

Subjective evidence of a disease or condition that is perceived only by the patient.

Nursing Process

A systematic, patient-centered, goal-oriented method of providing nursing care consisting of assessment, diagnosis, planning, implementation, and evaluation.

Person-Centered Care

Care focusing on the individual within multiple complicated contexts, including family and important others.

Validation

The process of comparing collected data with another source to ensure accuracy.

Clinical Judgment

The observed outcome of critical thinking and decision-making in nursing that enables precise patient care.

First-Level Priority

Emergent, life-threatening, and immediate health problems, such as airway, breathing, and circulation issues.

Second-Level Priority

Health issues next in urgency that require prompt intervention to prevent further deterioration, such as acute pain or risk of infection.

Third-Level Priority

Health issues important to patient health but addressed after more urgent problems, often involving long-term interventions.

Complete (Total Health) Database

A comprehensive health history and full physical examination that establishes a baseline for all future health changes.

Focused (Problem-Centered) Database

A mini database targeting a specific, limited, or short-term problem, cue complex, or body system.

Follow-Up Database

A database used to evaluate the status of identified problems at regular intervals to assess changes and effectiveness of interventions.

Emergency Database

Rapid collection of crucial information, often gathered concurrently with lifesaving measures in life-threatening situations.

Orientation Phase

The interview phase where the nurse introduces themselves, explains the purpose, sets the agenda, and establishes rapport.

Working Phase

The interview phase dedicated to collecting comprehensive assessment data using structured interview techniques.

Termination Phase

The interview phase where the nurse summarizes findings, verifies information, and explains next steps.

Open-Ended Questions

Questions that encourage narrative responses and allow patients to tell their story in their own words.

Closed-Ended Questions

Questions seeking specific information with yes/no or short answers, useful for clarifying specific details.

Probing

An interviewing technique encouraging patients to elaborate on responses to gather more detailed information.

Facilitation

A therapeutic communication technique that encourages the patient to continue speaking, such as saying 'Go on…' or 'I'm listening…'.

Reflection

A therapeutic communication technique where the nurse repeats the patient's words to encourage elaboration.

Empathy

A therapeutic communication technique that acknowledges a patient's feelings (e.g., 'That must be difficult for you.').

Backchannelling

Providing brief, non-committal verbal or nonverbal responses (such as 'Uh-huh', nodding, eye contact) to show active listening.

Teach-Back Method

A communication strategy where the nurse asks patients to explain in their own words what they need to know or do to confirm understanding.