System Specific Assessment Flashcards

Vocabulary flashcards for reviewing NRS 100 System Specific Assessment lecture concepts.

Subjective Data

Information provided directly by the client describing what is experienced, gathered during the health history through therapeutic communication.

Objective Data

Measurable and observable findings elicited through physical assessment examination techniques such as inspection, palpation, percussion, and auscultation.

Inspection

The systematic visual, auditory, and olfactory examination of the client that begins upon initial contact and continues throughout the general survey.

Palpation

An assessment technique using the sense of touch (palmar surface for pulses/texture, dorsum for temperature) to feel body structures and detect tender areas.

Percussion

An advanced assessment technique involving striking fingers or a rubber hammer against the body surface to elicit sounds that indicate tissue density.

Auscultation

The process of listening to internal body sounds (heart, lungs, bowel) using a stethoscope to evaluate pitch, loudness, quality, and duration.

Stethoscope Diaphragm

The flat side of the stethoscope chestpiece, applied firmly against the skin to hear high-pitched sounds such as bowel and breath sounds.

Stethoscope Bell

The cup-shaped side of the stethoscope chestpiece, applied with light pressure to detect low-pitched sounds like abnormal heart murmurs and vascular sounds.

Skin Turgor

A physical measure of skin elasticity used to assess a client's hydration status.

ABCDE Rule

A mnemonic for evaluating suspicious skin lesions: Asymmetry, Border irregularity, Color variation, Diameter greater than $6\,mm$, and Expert evaluation or change.

Erythema

Abnormal redness of the skin caused by capillary congestion or inflammation.

Ecchymosis

A collection of extravasated blood in the subcutaneous tissue visible as a purplish or dark discoloration (bruise).

Petechiae

Tiny, pinpoint red or purple spots on the skin caused by minor hemorrhaging from capillaries.

Purpura

Reddish-purple skin discolorations caused by bleeding underneath the skin, larger than petechiae.

Nail Clubbing

A bulbous enlargement of the fingertips with a loss of the normal $160^\circ$ nail base angle ($180^\circ$ in early clubbing, $>180^\circ$ in late clubbing), often associated with chronic hypoxia.

Pitting Edema Scale

A numeric rating scale assessing tissue swelling depth and recovery: $1+$ ($2\,mm$ mild depression), $2+$ ($4\,mm$ moderate), $3+$ ($6\,mm$ moderately severe), and $4+$ ($8\,mm$ severe).

PERRLA

An acronym describing normal pupillary assessment findings: Pupils Equal, Round, Reactive to Light and Accommodation.

Arcus Senilis

A normal age-related white, gray, or blue opaque ring surrounding the corneal margin caused by lipid deposits.

Entropion and Ectropion

Ocular eyelid abnormalities where Entropion is the inward turning of the eyelid margin, and Ectropion is the outward turning and sagging of the lower eyelid.

Bronchial Breath Sounds

High-pitched, loud, hollow breath sounds heard over the larynx and trachea, where expiration is longer, lower, and higher-pitched than inspiration.

Bronchovesicular Breath Sounds

Medium-pitched, moderate-intensity blowing breath sounds heard over the first and second intercostal spaces anteriorly, where inspiration and expiration durations are equal.

Vesicular Breath Sounds

Soft, low-pitched, whispering breath sounds heard over most outer lung fields, where inspiration is longer and louder than expiration.

Fremitus

Palpable vibrations felt across the chest wall using the palmar surface of the hands while the patient repeats phrases such as 'ninety-nine'.

Cardiac Auscultation Landmarks (APETM)

The five anatomical precordial areas for listening to heart sounds: Aortic, Pulmonic, Erb's point, Tricuspid, and Mitral (apical).

S1 and S2

The two normal heart sounds: S1 ('lub') produced by closure of the AV valves, and S2 ('dub') produced by closure of the semilunar valves.

Pulse Amplitude Scale

A standardized numerical rating system for peripheral pulse force: $0$ (absent), $1+$ (weak), $2+$ (normal), $3+$ (increased), and $4+$ (bounding).

Tail of Spence

The superior lateral corner of breast tissue that extends upward and outward into the axilla.

Abdominal Assessment Sequence

The unique ordering of physical assessment techniques for the abdomen—Inspection, Auscultation, Percussion, and Palpation—to avoid altering bowel sounds before listening.

Expressive Aphasia

A neurological language impairment characterized by the inability to speak or write effectively to communicate thoughts.

Receptive Aphasia

A neurological language impairment characterized by the inability to comprehend spoken or written words.

Glasgow Coma Scale (GCS)

A standardized neurological tool evaluating eye opening, verbal, and motor responses; scores range from $3$ (totally unresponsive) to $15$ (best response), with $\le 8$ indicating coma.

Fulmer SPICES Assessment

An assessment tool for hospitalized older adults screening six marker conditions: Sleep disorders, Problems with eating/feeding, Incontinence, Confusion, Evidence of falls, and Skin breakdown.