Week 1: Health Assessment Extended Set

Extended set of flashcards based on Week 1 PowerPoint

What is assessment in nursing?

The collection of data about an individual’s health state to make a judgment or diagnosis.

What is subjective data?

Information the patient says about themselves or their condition.

What is objective data?

Information observed by the healthcare provider using senses (sight, sound, smell, touch).

What is a database in health assessment?

The complete patient record, including history, physical exam, and lab results.

What is diagnostic reasoning?

Analyzing health data and drawing conclusions to identify diagnoses.

What is critical thinking in nursing?

The process of evaluating and modifying thinking to make sound clinical decisions.

What is clinical judgment?

The ability to make evidence-based decisions for patient care.

Steps of the Nursing Process

Assessment, Diagnosis, Planning, Implementation, Evaluation.

Steps of the Clinical Judgment Model

Recognize cues, analyze cues, prioritize hypotheses, take action, evaluate outcomes.

What is a first-level priority problem?

Life-threatening and urgent condition requiring immediate attention.

What is a second-level priority problem?

Requires prompt intervention to prevent deterioration.

What is a third-level priority problem?

Important but can be addressed after higher priority problems.

Four components of evidence-based practice

Best evidence, clinician experience, patient preferences, physical assessment.

Four types of patient data

Complete, Focused/problem-centered, Follow-up, Emergency.

What is holistic health?

Considers mind, body, and spirit as interdependent functioning together within environment.

What are Social Determinants of Health (SDoH)?

Nonmedical factors influencing health outcomes, such as socioeconomic status or environment

Purpose of the health interview

To gather subjective data, establish rapport, teach, and promote health/disease prevention.

What is the interview contract?

An agreement that outlines time, place, purpose, roles, and confidentiality during the interview

Internal factors influencing communication

Liking others, empathy, listening, self-awareness.

External factors influencing communication

Privacy, physical setting, dress, note-taking, EHR use

What is the working phase of an interview?

The data-gathering phase using open- and closed-ended questions.

When to use open-ended questions

To start interviews, introduce topics, and encourage detailed patient responses

When to use closed-ended questions

To obtain specific facts or yes/no responses.

Examples of closed-ended questions

Do you smoke? Are you in pain?

Examples of open-ended questions

Tell me about your pain. What brings you in today?

10 traps of interviewing

False reassurance, unwanted advice, authority, avoidance, distancing, jargon, bias, talking too much, interrupting, 'why' questions

What is nonverbal communication?

Communication using body language, facial expressions, gestures, and eye contact.

Techniques for interviewing hearing-impaired patients

Use sign language, lip reading, or written communication.

Approach for acutely ill patients

Prioritize urgent needs and communicate clearly and concisely.

Approach for intoxicated patients

Use simple, direct language and remain non-threatening.

How to respond to crying patients

Acknowledge the emotion and give time to express sadness.

How to respond to angry patients

Stay calm, listen actively, and de-escalate the situation.

What is health literacy?

The ability to understand, navigate, and communicate within the healthcare system.

Tools to improve health literacy

Oral teaching, simple written materials, teach-back method.

How to communicate with healthcare professionals

Use SBAR format—Situation, Background, Assessment, Recommendation.

What is biographic data?

Demographic details such as name, age, contact info, language, and relationship status.

Difference between signs and symptoms

Signs are objective (measurable); symptoms are subjective (patient-reported).

Eight critical characteristics of a symptom

Location, Quality, Severity, Timing, Setting, Aggravating/Relieving factors, Associated factors, Patient perception

What is medication reconciliation?

Comparing current medications with past lists to prevent errors.

What is a genogram?

A graphic family tree used to assess familial patterns and health risks.

Purpose of the review of systems (ROS)

To evaluate past and present health of each body system.

What are ADLs?

Activities of daily living: bathing, dressing, eating, toileting, etc.

What are iADLs?

Instrumental activities of daily living: shopping, cooking, housekeeping, finances.

What is inspection in physical exam?

Concentrated visual observation of the patient.

What is palpation?

Using hands to assess temperature, moisture, texture, swelling, and more.

What is percussion?

Tapping on the body surface to assess underlying structure and density.

What is auscultation?

Listening to sounds produced by the body using a stethoscope.

What part of stethoscope for low-pitched sounds?

Bell of the stethoscope.

What part of stethoscope for high-pitched sounds?

Diaphragm of the stethoscope.

Why listen to sounds directly on the skin?

Clothing can distort or block accurate sound transmission.

What are appropriate interview closing questions?

Is there anything else you’d like to mention? What would you like to accomplish today?

Definition of functional assessment

Measures a person's ability to perform tasks and live independently.

What is Teach-Back?

A method where patients repeat information to confirm understanding.

Example of empathy in interviewing

‘That sounds very difficult. I’m here to help you through this.'

What is the best way to build rapport in an interview?

Allow the patient to speak about their concerns early on.

Importance of self-awareness in communication

Recognize your biases to avoid influencing patient care.

What is an interpreter’s role?

Facilitates accurate communication; must be trained, not a family member.

What is therapeutic communication?

Use of verbal and nonverbal strategies to support patient emotional well-being.

Why avoid medical jargon with patients?

To prevent confusion and promote understanding.

Cultural considerations in interviewing

Respect beliefs, norms, and preferences, including gender roles and examination boundaries.

What does SGM stand for?

Sexual and Gender Minority—includes LGBTQ+ and individuals with nontraditional identities.

What is a high-quality interview setting?

Private, quiet, comfortable, well-lit, and free from interruptions.

What is SOAP documentation?

Subjective, Objective, Assessment, Plan – method for organizing clinical notes.

What is the difference between open and closed posture?

Open: relaxed, facing the patient. Closed: crossed arms, facing away.

Importance of listening in communication

Demonstrates respect, builds trust, and ensures understanding.

How should a nurse introduce themselves?

By name, role, and explaining the purpose of the encounter.

Why assess health promotion behaviors?

To identify opportunities for education and disease prevention.

What is considered the first step of physical assessment?

Inspection.

Example of a leading question

'You don’t smoke, do you?'

How can anxiety affect the interview?

May lead to incomplete or inaccurate responses; requires reassurance and patience.

What is the purpose of the health history?

To gather a complete picture of past and present health.

What is a functional health pattern?

Framework to organize health data based on behaviors and functions.

When is an emergency database collected?

Rapid collection during life-threatening situations.

What is a focused/problem-centered database?

For a limited or short-term problem – one specific concern.

What is the best indicator of return of GI motility?

Return of flatus and first bowel movement.

What influences the accuracy of subjective data?

The patient's memory, emotional state, and willingness to disclose.

How does environment impact assessment?

Affects comfort, privacy, and reliability of data collection.

Why is trust important in interviews?

Encourages honest, open communication.

Definition of therapeutic silence

Intentional pause to allow patient to think and respond.

When to use gloves in an exam?

When there's a risk of contact with blood, mucosa, or body fluids

Purpose of alcohol wipes in physical exam

Disinfect equipment like stethoscopes between patients.

Why document source of history?

To assess reliability of information and any potential bias.

What should you do if you can’t pronounce a patient’s name?

Politely ask the patient how to pronounce it.

Why is lighting important in physical exam?

Essential for accurate inspection and identification of abnormalities.

Best response to patient who’s crying?

Acknowledge emotion, allow expression, provide support.

What is considered a complete health history?

Includes biographic data, reason for seeking care, present illness, past history, meds, family history, ROS, and functional assessment.

Why review immunization history?

To ensure compliance with preventive care and public health protocols.

What is an example of a functional concern in the elderly?

Inability to prepare meals or manage medications independently.