Comprehensive Health Assessment and Nursing Fundamentals Flashcards

Vocabulary-style flashcards covering medical equipment, nursing frameworks, vital signs, physical assessment techniques, and diagnostic lab markers as presented in the lecture notes.

Sphygmomanometer

An instrument used for measuring blood pressure; it utilizes an inflatable rubber cuff and a graduated scale to determine systolic and diastolic values. Key parts include the cuff, gauge holder, range/index marks, artery indicator, aneroid manometer gauge, inflation bulb, air release valve, and bladder hose.

Stethoscope

A medical device used for auscultation (listening to internal body sounds) featuring a resonator (chest-piece with diaphragm and bell) connected via tubing to earpieces.

Anthropometric Assessment

The use of tools like tape measures and weighing scales to evaluate body composition parameters such as height, weight, girths (waist, hip, thigh), and skinfold thickness.

Tongue Depressor

A multi-use clinical tool used to clear the view of the mouth and throat during examinations, apply ointments, or stir medications.

Ophthalmoscope

A medical device that enables a practitioner to see inside the eye to examine the retina, optic nerve, blood vessels, and other deep ocular structures.

Otoscope

A tool composed of a head and a handle used specifically for examining the ear canal and the tympanic membrane (eardrum).

Nasal Speculum

A tool used to facilitate the inspection of nasal passages during anterior rhinoscopy, allowing visualization of the septum, turbinates, and mucous membranes.

Vaginal Speculum

A device designed to hold the vaginal walls open during pelvic examinations to enable visual inspection of the cervix for procedures like Pap smears.

Tuning Fork

An aluminum U-shaped tool with a handle (stem) and two prongs that vibrates at a specific frequency to assess hearing (air and bone conduction), vibratory sensation, and balance.

Reflex Hammer

A clinical tool used to test deep tendon reflexes like the patellar and ankle reflexes; types include the Taylor Hammer, Queens Square Hammer, and Babinski Telescoping Hammer.

Concept Map

A visual framework used in nursing education to distill complex clinical information into digestible elements, help establish nursing diagnoses, and configure patient care plans.

Nursing Care Plan (NCP)

A formal systematic process that identifies a client's existing healthcare needs and potential risks; it serves as a roadmap for communication and begins at the moment of admission.

Subjective Data

Information within the assessment phase of an NCP that consists of what the patient states (e.g., symptoms, personal health perceptions).

Objective Data

Findings within the assessment phase of an NCP that are directly observed or measured by the nurse (e.g., vital signs, physical exam results).

Rationale (NCP)

The scientific or evidence-based reason that justifies the specific nursing interventions chosen for a care plan.

Comprehensive Health History

A complex clinical duty restricted to Registered Nurses (RNs) that screens demographic data, reason for care, medical history, family history, functional health (ADLs), and body systems (ROS).

Pyrexia (Fever)

A body temperature range between $38^{\circ}\text{C}$ and $40^{\circ}\text{C}$ ($100.4^{\circ}\text{F} \text{--} 104.0^{\circ}\text{F}$).

Oral Temperature Rule

The nurse must wait $20\text{--}30\,min$ before measurement if the patient has recently smoked or consumed hot or cold fluids.

Pulse Formula (Cardiac Output)

The relationship defined as $\text{Cardiac Output} = \text{Stroke Volume} \times \text{Heart Rate}$, which is approximately $5\,\text{L/min}$ in an adult.

Apical Pulse Location

Located at the $5\text{th}$ intercostal space (ICS) at the midclavicular line for adults, and the $4\text{th}$ ICS for children under $4$ years old.

Eupnea

The term for normal, unlabored breathing.

Orthostatic Hypotension Protocol

A procedure involving measuring BP after $10\,min$ supine, then at $1\,min$ and $3\,min$ after sitting/standing; positive if systolic drops $> 20\,mmHg$ or diastolic drops $> 10\,mmHg$.

BP Cuff Sizing ($40/20$ Rule)

Standard where bladder width is $40\%$ of arm circumference and bladder length is $80\%$ of arm circumference (or $20\%$ wider than arm diameter).

Korotkoff Sounds (Diastolic)

Phase $4$ (muffled sound) indicates diastolic in children/pregnant women; Phase $5$ (disappearance of sound) indicates diastolic in adults.

Functional Health Patterns

A structured assessment framework developed by Marjory Gordon in $1987$ that views health as the ability to function effectively in life across $11$ patterns.

Health Perception-Health Management Pattern

Examines how a patient perceives their overall well-being and manages daily health activities, including adherence to treatments and safety precautions.

Nutritional-Metabolic Pattern

Investigates fluid and nutrient consumption, skin integrity, and physical recovery markers like height, weight, and condition of hair/nails.

Elimination Pattern

Evaluates excretory functions including bowel and bladder habits, stool/urine consistency, and sweat production.

Cognitive-Perceptual Pattern

Focuses on sensory information processing (five senses), pain management, memory, orientation, and decision-making abilities.

Role-Relationship Pattern

Assesses a patient's social roles and responsibilities within their family and community, and how health issues affect those roles.

Value-Belief Pattern

Investigates spiritual goals and religious affiliations that guide a patient's choices, including those that might conflict with medical treatments like blood transfusions.

Osteoblasts vs. Osteoclasts

Osteoblasts are cells responsible for bone tissue formation/deposition; osteoclasts are responsible for bone tissue breakdown and resorption.

Synovial Joints

Freely movable joints lubricated by synovial fluid, contained within a capsule, stabilized by ligaments, and cushioned by bursae.

Crepitation

A dry, crackling, or grating sensation heard or felt during musculoskeletal palpation, indicating friction between bone or damaged cartilage.

Muscle Strength Grade $3$

Defined as 'Fair' status; the patient shows complete Range of Motion (ROM) against gravity only, with no resistance.

Phalen's Test

A maneuver where dorsal sides of hands are pressed together at $90^{\circ}$ for $60\,sec$; positive for Carpal Tunnel if numbness or tingling occurs in thumb and first two fingers.

Bulge Test

A knee assessment where the nurse strokes the medial knee upward and taps the lateral side; a positive wave or bulge indicates fluid effusion.

Kyphosis

An exaggerated thoracic 'humpback' spinal curvature common in osteoporosis.

Barlow and Ortolani Maneuvers

Specialized infant assessments used to detect congenital hip dysplasia via specific 'clicks' or 'clunks' during hip movement.

CN II (Optic Nerve)

The cranial nerve responsible for central and peripheral visual acuity and visual fields.

Snellen Chart

A tool for distance visual acuity where the patient stands $20\,ft$ away; interpretation uses a fraction where a higher denominator means poorer vision.

PERRLA

Acronym for: Pupils Equal, Round, Reactive to Light (Direct/Consensual), and Accommodation.

Presbyopia

Age-related loss of lens elasticity, making it difficult to focus on close objects; common in adults over $40$.

Whisper Test

Auditory screening where the nurse stands $1\text{--}2\,ft$ behind the patient and whispers a combination of $3$ letters/numbers.

Weber Test

A hearing assessment using a tuning fork on the midline of the skull; normal finding is sound heard equally in both ears.

Rinne Test

Comparison of Air Conduction (AC) and Bone Conduction (BC); normal finding is $AC > BC$ (AC heard twice as long as BC).

Anosmia

The clinical term for loss of smell, associated with CN I (Olfactory Nerve) dysfunction.

Romberg Test

A balance assessment where the patient stands with eyes closed for $20\,sec$; significant swaying or loss of balance is a 'Positive Romberg' result.

S1 (Lub)

The heart sound caused by atrioventricular (AV) valve closure; heard loudest at the apex.

Bruit

A turbulent 'swishing' sound detected via the bell of the stethoscope over an artery (e.g., carotid, abdominal aorta), indicating vascular narrowing or hypervascularity.

Abdominal Assessment Sequence

The strict order of Inspection, then Auscultation, then Percussion, then Palpation (I-A-P-P) to avoid altering bowel sounds.

Blumberg's Sign

Also known as rebound tenderness; sharp, stabbing pain upon the sudden release of deep abdominal pressure, indicating peritoneal inflammation.

Murphy's Sign

An 'Inspiratory Arrest' test; sharp pain occurring when an inflamed gallbladder touches the nurse's fingers during deep inspiration, suggesting cholecystitis.

Primary Skin Lesions

Eruptions arising from previously healthy skin, including Macules ($< 1\,cm$, flat), Papules ($< 0.5\,cm$, elevated), and Vesicles ($< 0.5\,cm$, fluid-filled).

Braden Scale

A clinical tool with six sub-categories (Sensory Perception, Moisture, Activity, Mobility, Nutrition, Friction/Shear) used to predict pressure ulcer risk.

Creatinine

A blood chemistry marker that is a highly sensitive indicator of glomerular filtration rate (GFR) and overall renal function.

Culture and Sensitivity (C&S)

Diagnostic testing where a 'Culture' identifies the specific pathogen and 'Sensitivity' determines which antibiotics effectively inhibit its growth.