(Week 1) Health Assessment and Physical Exam

Vocabulary practice flashcards covering foundational concepts of health assessment, physical examination techniques, interviewing, and nursing documentation.

Health assessment

Gathering information about the health status of the patient, analyzing and synthesizing those data, making judgments about nursing interventions based on the findings and evaluating patient care outcomes (AACN, 2011).

Primary prevention

Intervention strategies aimed at preventing health problems before they occur.

Secondary prevention

Interventions focused on early diagnoses and prompt treatment of health issues.

Tertiary prevention

Interventions aimed at preventing complications of existing disease and promoting the highest level of health possible.

Emergency assessment

A rapid nursing assessment performed in a life-threatening or unstable situation.

Comprehensive assessment

A full health history and complete physical examination performed annually for outpatients or upon admission to a hospital or long-term care facility.

Focused assessment

An assessment performed in any setting that is smaller in scope than a comprehensive assessment but has increased depth for specific issues.

Genogram

A graphic family tree that uses symbols to depict gender, relationship, and age of immediate blood relatives across at least 3 generations.

Subjective data

Information reported directly by the patient regarding feelings, perceptions, or symptoms, such as pain or nausea.

Objective data

Measurable and verifiable information gathered by the nurse through physical examination, vital signs, and laboratory or diagnostic results.

Pre-interaction Phase

The phase of the therapeutic interview where existing data is compiled and the patient interview is prepared using existing medical records.

Beginning Phase

The interview phase where the nurse introduces themselves, explains the purpose, establishes rapport, and ensures privacy and comfort.

Working Phase

The interview phase spent gathering complete data, actively listening, asking open- and closed-ended questions, and clarifying or validating information.

Closing Phase

The final interview phase spent summarizing findings, allowing patient Q&A, explaining next steps, and expressing appreciation.

RESPECT Framework

A cross-cultural communication model developed by Berlin & Fowkes consisting of Rapport, Empathy, Support, Partnership, Explanations, Cultural Competence, and Trust.

Inspection

Systematic visual examination observing color, size, shape, symmetry, and movement that requires adequate lighting and is always performed first in a physical assessment.

Palpation

An assessment technique using the hands or fingertips to assess surface texture, tenderness, organ size, masses, temperature, and moisture.

Percussion

Tapping the body surface to produce sounds that assess the density of underlying tissue and locate organ borders.

Auscultation

Listening to internal body sounds (heart, lung, bowel, vascular) using a stethoscope.

Abdominal assessment sequence exception

The altered primary assessment order of Inspection → Auscultation → Percussion → Palpation, used specifically to avoid altering bowel sounds.

Standard Precautions

Infection prevention measures set by the CDC to prevent disease transmission during contact with non-intact skin, mucous membranes, body substances, and blood-borne contacts.

OASIS

Outcome and Assessment Information Set; a federally mandated assessment tool used for home care documentation.

RAI

Resident Assessment Instrument; a comprehensive assessment tool used for long-term care documentation.

Charting by Exception (CBE)

A documentation method where only findings outside normal limits require detailed narrative documentation.

SBAR model

A structured verbal and written communication tool consisting of Situation, Background, Assessment, and Recommendation.

FACT Principles of Documentation

Nursing documentation standards standing for Factual (objective findings), Accurate (correct terminology), Complete (all relevant data), and Timely (prompt entry).

ADPIE

The core steps of the nursing process: Assessment, Diagnosis, Planning, Implementation, Evaluation.