NRS 119 Health Assessment

These flashcards cover the key vocabulary related to health assessment, nursing processes, and patient care as discussed in the lecture for NRS 119.

Holistic Nursing Assessment

A method that collects both subjective and objective data to assess overall client functioning.

Physician Medical Assessment

Focuses primarily on the patient's physiologic status, with less regard for psychological and sociocultural factors.

Subjective Data

Information provided by the patient, including symptoms and personal perceptions.

Objective Data

Quantifiable and observable information obtained through measurement and observation.

Nursing Diagnosis

A clinical judgment about individual, family, or community responses to actual or potential health problems.

Collaborative Problems

Certain potential complications that nurses monitor and manage collaboratively with other healthcare professionals.

Validation of Data

The process of confirming that subjective and objective data are accurate and reliable.

Critical Thinking

A systematic way of thinking that enables nurses to make informed clinical judgments.

Acute Pain

Short-term pain that usually lasts less than 6 months.

Chronic Pain

Long-lasting pain that persists for more than 6 months.

General Survey

An overall assessment of the patient's appearance, behavior, and health state.

Self-Report

A patient’s verbal account of their personal experience and symptoms.

COLDSPA

A mnemonic used for pain assessment: Characteristics, Onset, Location, Duration, Severity, Pattern, Associations.

Vital Signs

Measurements that reflect physiological functions, including temperature, pulse, respiration, and blood pressure.

Holistic Model Assessment

An approach that considers the entire person, including their environment and lifestyle, during health assessment.

Documentation

The record-keeping of patient information, which is vital for continuity of care and legal purposes.

Auscultation

The act of listening to the sounds of the body, typically using a stethoscope.

Inspection

A visual examination of the patient to assess appearance and conditions.

Palpation

The technique of using touch to assess physical characteristics of the body.

Percussion

A technique that involves tapping the body to produce sound for assessment of underlying structures.

Gait

The manner or pattern of walking.

Mobility

The ability to move freely and independently.

Patient Record

Documentation that includes both subjective and objective patient data.

SBAR

A communication framework: Situation, Background, Assessment, Recommendation for clear reporting.

Cues

Pieces of information or signs that may indicate a problem or change in a patient's condition.

Diagnostic Hypothesis

A proposed explanation for signs and symptoms observed during assessment.

Lifestyle Factors

Personal habits and behaviors that can impact health and well-being.

Emergency Database

A rapid collection of data often compiled at the same time as lifesaving measures.

Episodic Database

A focused assessment of a specific problem or system.

Complete Health History

A comprehensive collection of information about a patient’s past and present health.

Patient Education

Information provided by the nurse to enhance patient understanding of health and self-care.

Cultural Health Rights

The recognition and respect of diverse cultural practices and beliefs in health care.