Ch 3,4,58 Health Assessment, Health History, Mental Status, and Physical Examination

Comprehensive vocabulary flashcards generated from health assessment lecture notes, covering interview techniques, complete health history components, mental status examination terms, levels of consciousness, mood/affect abnormalities, and physical assessment methods.

Subjective Data

Information gathered during the health interview that includes primary sensations directly stated by the patient or secondary information provided by someone other than the patient.

Objective Data

Measurable clinical information and physical cues detectable on physical examination (such as vital signs or visual appearance) or in laboratory reports.

Therapeutic Communication

A communication approach in nursing centered on care, empathy, and self-awareness to build a supportive nurse-patient relationship.

Intimate Zone

A physical space distance of $0$ to $1\frac{1}{2}\text{ ft}$ where visual distortion occurs and which is best suited for assessing breath and body odors.

Personal Distance

A physical space distance of $1\frac{1}{2}$ to $4\text{ ft}$ perceived as an extension of the self, where voice is moderate and much of the physical assessment occurs.

Social Distance

A physical space distance of $4$ to $12\text{ ft}$ used for impersonal business transactions and where much of the patient interview occurs.

Public Distance

A physical space distance of $12+\text{ ft}$ where interactions are impersonal, the speaker's voice must be projected, and subtle facial expressions are imperceptible.

Symptom

A subjective cue representing a physical or emotional sensation experienced directly by the patient.

Sign

An objective cue representing measurable information detectable by an examiner on physical exam or in laboratory reports.

Genogram

A graphic family tree diagram depicting the age, health status, and cause of death of blood relatives across generations.

Emergency Assessment

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

Comprehensive Assessment

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

Focused Assessment

A targeted nursing assessment performed in any clinical setting that is smaller in scope than a comprehensive assessment but has increased depth regarding specific issue(s).

Mini-Mental State Examination (MMSE)

A 11-question screening tool administered in 5 to 10 minutes that concentrates on cognitive functioning including memory, orientation, reading, writing, and visual-spatial copying.

Aphasia

The loss of the ability to speak or write coherently or to understand speech or writing as a result of stroke or brain damage.

Agraphia

The inability to communicate through writing, often occurring in patients with aphasia.

Alert

A normal level of consciousness where the person is awake, readily aroused, oriented, fully aware of external/internal stimuli, and responds appropriately.

Lethargic (Somnolent)

A level of consciousness where the person is not fully alert, drifts off to sleep when not stimulated, can be aroused when called by name in a normal voice, but thinking seems slow and fuzzy.

Obtunded

A level of consciousness where the person sleeps most of the time, is difficult to arouse requiring a loud shout or vigorous shake, acts confused when aroused, and converses in monosyllables.

Stupor (Semi-coma)

A level of consciousness where the person is spontaneously unconscious, responds only to persistent and vigorous shake or pain, and exhibits appropriate motor withdrawal or groaning.

Coma

A level of consciousness characterized by complete unconsciousness with no purposeful movement or response to pain or any external or internal stimuli.

Acute Confusion State (Delirium)

A medical emergency characterized by clouding of consciousness, dulled cognition, impaired alertness, agitation, visual hallucinations, and disorientation that worsens at night.

Flat Affect (Blunted Affect)

An abnormality of mood and affect defined by a lack of emotional response, no expression of feelings, a monotonous voice, and an immobile face.

Depersonalization

An abnormality of mood and affect involving a loss of identity where the individual feels estranged and perplexed about their own identity and meaning of existence.

Euphoria

An excessive sense of well-being and unusual cheerfulness or elation that is inappropriate considering the physical and mental condition, implying a pathologic mood state.

Anxiety

A state of feeling worried, uneasy, and apprehensive from the anticipation of a danger whose source is unknown.

Fear

A state of feeling worried, uneasy, and apprehensive where the external danger is known and identified.

Lability

An affect abnormality characterized by a rapid shift of emotions in quick succession.

Inappropriate Affect

An affect that is clearly discordant with the content of the person's speech, such as laughing while discussing a serious medical procedure.

Inspection

The physical assessment technique of concentrated, unhurried watching, comparing the patient's right side with their left side under good lighting.

Palpation

The physical assessment technique using touch to confirm inspection findings and evaluate skin texture, temperature, moisture, organ location, swelling, and tenderness.

Percussion

The physical assessment technique of tapping the patient's skin with short, sharp strokes to produce sound waves that reveal the location, size, and density of underlying tissue.

Auscultation

The physical assessment technique of listening to internal body sounds (such as heart, lung, and bowel sounds) using a stethoscope.

Unilateral Neglect

Total inattention to one side of the body, which can occur following a stroke.

Anisocoria

Unequal pupil size, which can be the result of a brain tumor or recent drug use.