Week 1: Health Assessment Concise Set

Flashcards covering key concepts from Week 1 of NUR 3066, focusing on health assessment and interviewing techniques.

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.

What are the steps of the Nursing Process (NP)?

Assessment, Diagnosis, Planning, Implementation, Evaluation.

What are the steps of the Clinical Judgment Model (CJM)?

Recognize Cues, Analyze Cues, Prioritize Hypotheses, Take Action, Evaluate Outcomes.

What is first-level priority in care?

Urgent, life-threatening issues.

What is second-level priority?

Requires prompt attention to prevent worsening.

What is third-level priority?

Important but can be addressed after more urgent issues.

What are the four components of evidence-based practice?

Best research evidence, clinical expertise, patient preferences, and physical exam/assessment.

What are the 4 types of patient data?

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

What is holistic health?

The view that mind, body, and spirit function as an integrated whole in the context of environment.

What is the significance of Social Determinants of Health (SDoH)?

Nonmedical factors influencing health outcomes, like socioeconomic status and environment.

What is the purpose of the health interview?

To gather subjective data, build trust, teach, and establish a therapeutic relationship.

What does the interview contract include?

Time, place, purpose, duration, roles, confidentiality, and cost info.

Internal factors influencing communication?

Liking others, empathy, active listening, self-awareness.

External factors influencing communication?

Privacy, minimal interruptions, appropriate physical setting, appearance, note-taking, EHR use.

What is the working phase of an interview?

Data-gathering phase using open- and closed-ended questions.

What are open-ended questions used for?

To elicit narrative responses; useful for starting interviews or exploring new topics.

What are closed-ended questions used for?

To get specific facts; elicit short responses like 'yes' or 'no'.

10 traps of interviewing?

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

How to communicate with hearing-impaired patients?

Use signing, lip reading, or writing.

How to approach acutely ill or intoxicated patients?

Be clear, direct, and nonthreatening.

How to handle sexually aggressive behavior during interview?

Set verbal boundaries and remain professional.

What is health literacy?

A person's ability to understand, navigate, and communicate in the healthcare system.

Strategies to improve health literacy?

Oral teaching, simple written materials, Teach-Back method.

How to communicate with other healthcare professionals (SBAR)?

Situation, Background, Assessment, Recommendation.

What is biographic data in health history?

Name, age, gender, contact info, source of history, etc.

What is the reason for seeking care?

Patient's own words describing the reason for the visit; includes symptoms, not diagnoses.

What are symptoms vs. signs?

Symptoms are subjective; signs are objective.

What are the 8 critical characteristics of HPI?

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

What is medication reconciliation?

Comparing current meds with previous list to ensure accuracy and safety.

What is the purpose of family history in health assessment?

Identifies genetic risks; often presented in a pedigree/genogram.

What is the review of systems (ROS)?

Systematic head-to-toe review of subjective symptoms.

What is the functional assessment?

Evaluates ability to perform ADLs/iADLs and aspects like nutrition, environment, and coping.

What are the four physical examination techniques?

Inspection, Palpation, Percussion, Auscultation.

What is inspection?

Concentrated watching; first technique used in physical exam.

What is palpation?

Using hands to assess texture, temperature, moisture, organ location and size, swelling, vibration, etc.

What is percussion?

Tapping to produce sound waves for underlying structure density.

What is auscultation?

Listening to body sounds, usually with a stethoscope.

What does the bell of the stethoscope detect?

Low-pitched, soft sounds (e.g., murmurs).

What does the diaphragm of the stethoscope detect?

High-pitched sounds (e.g., breath and bowel sounds).

How should the exam setting be prepared?

Warm, quiet, private, well lit, with all equipment organized and accessible.

What's important about stethoscope use?

Always listen on skin, earpieces point forward, rotate the head to activate bell/diaphragm.