NUR 203 Health Assessment EXAM 1 Flashcards

what is a database?

A collection of subjective and objective information used to understand a patient's health status.

what is diagnostic reasoning?

The process of analyzing assessment information to identify a patient's health problems.

what is clinical judgement?

Using knowledge, assessment findings, and reasoning to make decisions about patient care.

what is culture?

The learned beliefs, values, behaviors, and practices shared by a group.

what is cultural competence?

The ability to provide care that is respectful of a patient's cultural beliefs and practices.

what is cultural assessment?

Collecting information about a patient's cultural beliefs and practices that may affect health and healthcare.

how can culture affect health and illness?

Culture can influence how people understand health, illness, symptoms, treatments, and healthcare.

how is culture developed?

Culture is learned through family, community, experiences, traditions, and social interactions.

where should the health interview take place?

In a private, comfortable environment free from interruptions and distractions.

why is privacy important during an interview?

It promotes comfort, trust, and honest communication.

what should the nurse consider when communicating with different developmental stages?

Use communication appropriate for the patient's age, developmental level, special needs, and abilities.

what should the nurse consider when communicating with patients from different cultures?

Respect cultural practices, beliefs, language differences, and communication preferences.

what are the 10 traps of interviewing?

Using biased or judgmental questions, asking too many questions at once, using medical jargon, giving false reassurance, asking leading questions, interrupting, using inappropriate silence, asking “why” questions, talking too much, and failing to listen.

what communication techniques help gather data during the health history?

Use open-ended questions, closed-ended questions when appropriate, attentive listening, clarification, reflection, facilitation, silence, and summarization.

why are open-ended questions useful?

They allow the patient to describe their concerns in their own words.

what is an example of an open-ended interview question?

“What brings you in today?”

what is the purpose of the complete health history?

To provide a database of subjective information about the patient's past and present health.

what are the major categories of a health history?

Biographical data, reason for seeking care, present health, past history, medications, family history, review of systems, and functional assessment.

what is biographical data?

Basic information such as name, address, phone number, birthplace, race, gender, and primary language.

what is the reason for seeking care?

The patient's main reason for coming to healthcare.

how should the reason for seeking care be documented?

Use the patient's exact words in quotation marks.

what question can be used to determine the reason for seeking care?

“What is bringing you in today?”

what should the nurse focus on when documenting the reason for seeking care?

The most pressing concern, including the symptom or sign and its duration.

what is the present health or history of present illness?

Information about the patient's current health problem or concern.

what does PQRSTU stand for?

Provocative/Palliative, Quality/Quantity, Region/Radiation, Severity, Timing, and Understanding.

what does the P in PQRSTU mean?

Provocative or Palliative—what makes the symptom worse or better?

what does the Q in PQRSTU mean?

Quality or Quantity—what does the symptom feel, look, or sound like and how severe or intense is it?

what does the R in PQRSTU mean?

Region or Radiation—where is the symptom located and does it spread?

what does S in PQRSTU mean?

Severity—how severe is the symptom, usually rated from 0 to 10.

what does the T in PQRSTU mean?

Timing—when did it begin, how long does it last, and how often does it occur?

what does U in PQRSTU mean?

Understanding—what does the patient think the symptom means?

what is past medical history?

Information about previous illnesses, injuries, hospitalizations, surgeries, immunizations, allergies, and other past health events.

what should be included in past medical history?

Childhood illnesses, accidents/injuries, serious or chronic illnesses, hospitalizations, operations, obstetric history, immunizations, examinations, allergies, and medications.

what should be included when reviewing current medications?

Prescription medications, over-the-counter medications, herbs, dosage, and frequency.

what is a family history used to identify?

Diseases and health conditions that may occur within the patient's family.

what conditions should be included in family history?

Heart disease, hypertension, stroke, diabetes, blood disorders, cancer, sickle-cell anemia, arthritis, allergies, obesity, alcoholism, mental illness, seizure disorders, kidney disease, and tuberculosis.

which family members are commonly included in a family history?

Parents, grandparents, aunts, uncles, and cousins.

what information should be included about deceased family members?

Their age at death and the cause of death.

what is a review of systems?

A systematic review of the patient's body systems to identify symptoms or problems.

what body systems are included in the review of systems?

General health, skin, hair, head, eyes, ears, nose/sinuses, mouth/throat, neck, breast/axilla, respiratory, cardiovascular, peripheral vascular, gastrointestinal, urinary, genital, sexual health, musculoskeletal, neurologic, hematologic, and endocrine.

what is a functional assessment?

An assessment of how the patient functions in daily life.

what are activities of daily living (ADLs)?

activities necessary for everyday functioning and self-care

What areas are included in functional assessment?

ADLs, self-esteem/self-concept, activity/exercise, sleep/rest, nutrition, elimination, relationships, resources, coping/stress management, personal habits, substance use, environment, occupational health, and perception of health.

what is the difference between subjective and objective data?

subjective data are what the patient tells you; objective data are what you observe or obtain through examination.

what is an example of subjective data?

A patient stating, “I have a headache.”

what is an example of objective data?

A blood pressure reading of 140/90 mmHg.

what is a symptom?

A subjective sensation that the patient feels.

what is a sign?

An objective abnormality detected by the examiner or through laboratory results.

what is a genogram?

A diagram used to document family relationships and health history.

how many generations should be documented in a genogram?

Use multiple generations, including parents, grandparents, aunts, uncles, and cousins as appropriate.

what additional information should be included with a genogram according to the notes?

The family's country of origin

what is the general organization of a physical examination?

Perform the examination systematically, generally moving from head to toe.

what are the goals of organizing the physical examination?

Maximize comfort, avoid unnecessary position changes, and improve clinical efficiency.

what are standard precautions?

Infection-control practices used with all patients, including hand hygiene and gloves when contact with blood or body fluids is possible.

when should gloves be worn?

when contact with blood, body fluids, or other potentially contaminated material is expected

when should the nurse perform hand hygiene?

Before touching the patient, after contact with blood/body fluids, before an aseptic task, when moving from a contaminated to clean body site, after glove removal, and when entering and leaving the care area.

what position should the examiner use during a physical exam?

Examine the patient from the patient's right side whenever possible.

how can unnecessary position changes be decreased?

Organize the examination so related areas are assessed together and the patient does not repeatedly sit, lie down, or turn.

what are the four cardinal techniques of physical examination?

inspection, palpation, percussion, and auscultation

what is inspection?

Concentrated watching of the patient.

when does inspection begin?

Inspection begins the moment you meet the patient.

how should inspection be performed?

Use good lighting, adequate exposure, and careful observation.

what is palpation?

Using the sense of touch to assess the patient.

how should palpation be performed?

slowly, systematically, calmly, and gently with warm hands.

what area should be palpated last?

Tender or painful areas should be palpated last.

what is light palpation used for?

Assessing surface characteristics and detecting tenderness or superficial abnormalities.

what are fingertips best used for during palpation?

Fine tactile discrimination, such as skin texture, swelling, pulsations, and lumps.

what is the back of the hand best used for?

assessing temperature

what is the base of the fingers best used for?

assessing vibration

what is grasping vibration used for?

Determining the position, shape, and consistency of an organ or mass.

what is percussion?

Tapping the person's skin with short, sharp strokes to assess underlying structures.

what are the purposes of percussion?

To locate and estimate the size of organs, determine tissue density, and detect abnormal masses.

how deep into the body does percussion assess?

Approximately 4–6 cm.

what is the stationary hand during percussion?

The hand placed firmly against the patient's skin while the middle finger is struck.

what is the striking hand during percussion?

The dominant hand that uses the middle finger to strike the stationary finger.

what is auscultation?

Listening to sounds produced by the body.

which technique is always performed second?

auscultation

what does the diaphragm of the stethoscope hear best?

high pitched sounds

what does the bell of the stethoscope hear best?

low pitched sounds

what can cause artifact nose during auscultation?

Room noise, shivering, chest hair, clothing, breathing, bumping the tubing, necklaces, and earrings.

should you auscultate through clothing?

No. Never listen through clothing.

what is a resonant percussion note?

the normal sound heard over air-filled lung tissue.

what is hyperresonance?

an abnormally increased resonance caused by excess air, such as with emphysema

what is tympany?

a drumlike sound heard over an air-filled structure such as the stomach

what is dullness?

a softer, higher-pitched sound heard over dense organs such as the liver or spleen

what is flatness?

a very soft sound heard over dense areas such as bone, muscle or a tumor

what is the usual sequence of assessment techniques?

Inspection → palpation → percussion → auscultation, except auscultation is performed before palpation and percussion when assessing the abdomen.

what should be considered when assessing an infant?

Build trust, keep the caregiver nearby, use a warm environment, use a soft voice, make eye contact, and perform least-distressing steps first.

what should be consider when assessing a toddler?

Build trust, allow the child to sit with the caregiver, offer limited choices, use games, and perform distressing procedures last.

what should be considered when assessing a preschool child?

Use short explanations, allow participation, use play, provide reassurance, and take a slow approach.

what should be considered when assessing a school-age child?

Explain procedures, demonstrate equipment, respect modesty, and allow appropriate caregiver choices.

what should be considered when assessing an adolescent?

Respect developing independence, examine privately when appropriate, keep clothing on when possible, and focus on wellness teaching.

what should be considered when assessing an older adult?

Allow more time, minimize position changes, provide rest periods, adjust the pace, and do not mistake hearing or vision changes for confusion.

what should be considered when assessing a sick patient?

Adapt the position and examination to the patient's comfort and condition.

what position may help a patient with shortness of breath?

a sitting position

what position may help a patient who is faint or extremely fatigued?

a supine position

what four areas are assessed during the general surgery?

Physical appearance, body structure, mobility, and behavior.

what is assessed under physical appearance?

Age, gender, level of consciousness, skin color, facial features, and signs of distress.

what is assessed under body structure?

Stature, nutrition, symmetry, posture, position, body build, contour, and physical deformities.

what is assessed under motility?

Gait and range of motion.