Health Assessment: Clinical Judgment, Documentation, and Mental Status Assessment

Flashcards covering the fundamentals of health assessment, clinical judgment steps, documentation formats, vital sign norms, and mental status screening tools based on Weber & Kelly Chapters 4-6.

Subjective Data

Information that consists of symptoms described and described by the client.

Objective Data

The clinical impression that a health care provider sees, hears, touches, measures, or smells.

Step 1 of Clinical Judgment

Identify abnormal cues and supportive cues (client strengths) by comparing collected data with known norms.

Step 2 of Clinical Judgment

Cluster cues by identifying related strengths and abnormal findings.

Step 3 of Clinical Judgment

Draw inferences to propose or hypothesize possible clinical judgments, such as hunches or assumptions about cue clusters.

Step 4 of Clinical Judgment

Identify possible client concerns, which may include actual health concerns, risks for concerns, or opportunities for health promotion.

PIE Model

A documentation format consisting of Problem, Intervention, and Evaluation.

SOAP Note

A documentation format consisting of Subjective data, Objective data, Assessment (nursing diagnosis), and Plan.

Source-Oriented Medical Record

A traditional documentation format divided into specific sections such as history and physical, progress notes, and laboratory reports.

Focus Charting (DAR)

A documentation method centering on specific health problems or changes in condition using Data, Action, and Response.

Charting by Exception

A shorthand documentation model that focuses only on documenting unexpected or unusual findings.

FACT Acronym

A guideline for charting that stands for Factual, Accurate, Complete, and Timely.

Late Charting Entry

A documented entry that must be identified as 'late,' signed, dated, and linked to a specific previous event or note without leaving blank lines.

General Survey

The initial appraisal of a client's overall presentation, behaviors, and behaviors leading to focused assessments.

Obtundation

An unexpected level of consciousness finding where the client is minimally responsive.

Underweight BMI

A Body Mass Index of less than $18.5\,kg/m$.

Healthy Weight BMI

A Body Mass Index ranging from $18.5$ to $24.9\,kg/m$.

Overweight BMI

A Body Mass Index ranging from $25$ to $29.9\,kg/m$.

Obesity BMI

A Body Mass Index of $30\,kg/m$ and above.

Expected Oral Temperature

A range from $36^{\circ}$ to $38^{\circ}\,C$ ($96.8^{\circ}$ to $100.4^{\circ}\,F$) with an average of $37^{\circ}\,C$ ($98.6^{\circ}\,F$).

Expected Pulse Rate

A heart rate between $60$ and $100$ beats per minute.

Pulse Measurement +2

A normal, brisk pulse on the numerical measurement scale.

Pulse Measurement +1

A weak, thready, or diminished pulse on the numerical measurement scale.

Expected Oxygen Saturation (SpO2)

A measurement between $95-100\%$. An unexpected finding is less than $90\%$.

Expected Respiration Rate

A rate of $12-20$ breaths per minute.

Bradypnea

A respiratory rate of less than $12$ breaths per minute.

Tachypnea

A respiratory rate greater than $20$ breaths per minute.

Expected Blood Pressure

A reading of less than $120/80\,mmHg$.

Visceral Pain

Pain originating from internal organs.

Referred Pain

Pain felt in a location other than its origin.

Mini-Cog

A mental health screening tool that requires the client to draw the face of a clock showing a specific time.

CIWA Scale

A screening tool used for assessing alcohol withdrawal symptoms such as tremors and agitation.

Delirium

An acute condition characterized by sudden onset confusion, often seen in older adults.

SBAR

A communication technique for healthcare providers standing for Situation, Background, Assessment, and Recommendation.