ABSN Foundational Concepts - Health Assessment Week 1

Flashcards covering foundational health assessment concepts including health history, interview techniques, physical assessment skills, and documentation standards.

Biographic data

A component of the complete health history including the patient's name, date of birth, and address.

Chief complaint

The patient's primary reason for seeking care, documented in their own words.

History of Present Illness (HPI)

A deeper, structured exploration of the chief complaint, often using the OLDCARTS mnemonic to gather full detail.

Functional assessment

An evaluation of a patient's ability to perform activities of daily living ($ADLs$) such as sleep, eating, bathing, and independent ambulation.

Wellbeing (CDC definition)

Defined as more than the absence of illness; it encompasses physical, mental, and social dimensions of health.

Opening Phase (Interview)

The first phase of a therapeutic interview involving self-introduction, explaining the purpose, establishing rapport, and ensuring privacy.

Working Phase (Interview)

The second phase of a therapeutic interview focused on gathering complete data using active listening, open/closed questions, and validation.

Termination Phase (Interview)

The final phase of a therapeutic interview where the nurse summarizes findings, allows for patient questions, and explains next steps.

OLDCARTS

A mnemonic for pain and symptom assessment: Onset, Location, Duration, Characteristics, Aggravating/Relieving factors, Related symptoms, Timing, and Severity.

Open-ended questions

Questions that allow for free narrative and broad information; typically used to begin the patient interview.

Closed-ended questions

Questions used to obtain specific facts and clarification; helpful for anxious patients overwhelmed by open-ended prompts.

Reflection

A facilitative communication technique where the nurse mirrors the patient's words to encourage elaboration.

False reassurance

A communication barrier (e.g., 'Everything will be fine') that is harmful because it is dishonest and dismisses the patient's concerns.

RESPECT framework

A model for culturally sensitive interviewing standing for Rapport, Empathy, Support, Partnership, Explanations, Cultural Competence, and Trust.

Kleinman's Explanatory Model

A tool used to explore how patients understand their illness, its causes, and expected treatments to improve care adherence.

Clinical manifestation

Any sign or symptom of a disease or condition; it can be either subjective or objective.

Symptom

Subjective data reported by the patient, such as pain, nausea, dizziness, or fatigue.

Sign

Objective data observed or measured by the nurse, such as a rash, elevated blood pressure, or diaphoresis.

IPPA

The standard sequence of primary assessment techniques: Inspection, Palpation, Percussion, and Auscultation.

IAPP

The specific assessment sequence for the abdomen: Inspection, Auscultation, Percussion, and Palpation.

Inspection

A systematic visual examination of color, size, shape, symmetry, and movement that is always performed first.

Light palpation

The first level of palpation used to assess surface texture, temperature, tenderness, and skin turgor.

Deep palpation

The second level of palpation used to assess organ size, masses, and deeper tenderness.

Tympanic sound

A hollow, drum-like percussion sound heard over air-filled structures like an empty stomach or bowel.

Dull sound (Percussion)

A thud-like percussion sound heard over solid or fluid-filled organs such as the liver, spleen, or full bladder.

Resonant sound

A low-pitched, hollow percussion sound heard over normal lung tissue and intercostal spaces.

Diaphragm (Stethoscope)

The flat side of the stethoscope used for high-pitched sounds like breath, bowel, and $S_1/S_2$ heart sounds.

Bell (Stethoscope)

The cup-shaped side of the stethoscope used for low-pitched sounds such as heart murmurs, $S_3/S_4$, and vascular bruits.

Standard Precautions

CDC guidelines that apply specifically to exposure to blood and bodily fluids, including hand hygiene and appropriate PPE.

Airborne precautions

Requirements for tiny particles suspended in air (e.g., TB, measles); includes an $N95$ respirator and a negative pressure room.

Droplet precautions

Requirements for larger respiratory droplets traveling less than $3$ feet (e.g., influenza, COVID-19); includes a surgical mask.

Contact precautions

Requirements for direct or indirect environmental contact infections (e.g., MRSA, C. difficile); includes gloves and gown.

FACT

A mnemonic for nursing documentation: Factual, Accurate, Complete, and Timely.

SBAR

A communication tool for handoffs and provider calls sequence: Situation, Background, Assessment, and Recommendation.

ADPIE

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

NANDA nursing diagnosis

A diagnosis that addresses the human response to an illness or condition, within the nurse's scope to identify and treat.

Review of Systems (ROS)

A systematic series of questions covering each body system to identify symptoms the patient may not have volunteered.

Primary source

The patient themselves; considered the most reliable source of information when they are alert and oriented.

Secondary source

Information gathered from family members, caregivers, medical records, or previous providers when the patient cannot communicate.