NUR 2030 Week 1: Health Assessment and Physical Examination

Vocabulary flashcards covering health assessment principles, sources of data, health history components, ROS, functional assessment, HEEADSSS adolescent interview, assessment types, and physical exam techniques.

Health Assessment

Collection of health data using many different methods to establish baselines, create care plans, exercise clinical judgment, and ensure patient safety.

Major Data Sources

The main categories of assessment data, comprising health history/chief complaint (subjective), physical assessment (objective), and diagnostic/laboratory data (objective).

ORR Assessment Technique

An observation toolkit method involving Observing depth and pattern of breathing, Recording/counting breaths, and knowing normal rates according to age.

Biographical Data

A health history component consisting of name, address, DOB, birthplace, phone number, pronouns, race/ethnicity, relationship status, occupation, and language.

Reason for Seeking Care

A health history section documented in the patient's exact words, providing subjective and objective context for the visit.

OPQRSTU

An acronym used in the History of Present Illness (HPI) to explore complaints: Onset, Provokes/Palliates, Quality/Quantity, Region/Radiates, Severity, Timing, and Understanding.

Associated S/S and Pertinent Negatives

Questions regarding symptoms or their absence, similar to a Review of Systems (ROS), asked to help determine the specific cause of a patient's problem.

Immigrant Health Assessment

Additional health history details required for new immigrants, including country of origin, date of entrance to USA, religion/spiritual resources, past health immunizations, health perception, and nutritional taboo foods/combinations.

Review of Systems (ROS)

Purely subjective data obtained through a verbal review of body systems conducted prior to the physical examination.

Functional Assessment

An evaluation of lifestyle and daily living across 12 components: ADLs, self-esteem/self-concept, activity/exercise, sleep/rest, nutrition/elimination, interpersonal relationships/resources, coping/stress management, personal habits, drug use, environment/work hazards, relationship/partner violence, and occupational health.

HEEADSSS Psychosocial Interview

A psychosocial assessment framework conducted with adolescents alone, covering Home environment, Education & employment, Eating, Activities with peers, Drugs, Sexuality, Suicide/depression, and Safety.

Comprehensive Assessment

A complete evaluation performed during yearly physicals in PCP offices or outpatient settings to identify risks and early stages of disease processes.

Episodic Assessment

An assessment conducted at a PCP office in response to new patient complaints or issues.

Progress/Interval Assessment

Re-checks performed after treatment to evaluate healing and prevent disease recurrence.

Developmental Assessment

An assessment used to track and evaluate developmental milestones in children.

Hospital Assessment

A quick, head-to-toe inpatient assessment performed on admitted patients.

Emergency Assessment

Initial critical assessments performed within the RN scope of practice to detect immediate life-threatening problems ('what will kill you').

Palpation Guidelines

A physical examination technique inserting fingers $\frac{1}{2}\text{ to }\frac{3}{4}\text{ inches}$ into skin with gloves, monitoring patient reaction and sensory findings, and stopping if a mass is felt.

Resonant Percussion Sound

A medium-loud sound with a lower pitch, clear-hollow quality, and moderate duration, characteristic of normal lung tissue.

Hyperresonant Percussion Sound

A louder, lower-pitched booming sound with longer moderate duration; normal over children's lungs, but abnormal in adults, indicating an increased amount of air in lungs such as in emphysema or COPD.