The Health History and Functional Health Assessment Vocabulary

Vocabulary flashcards derived from lecture slides on patient health history components, assessment types, HPI characteristics, ADLs, IADLs, and functional evaluations.

Health Assessment

The first step in the nursing process that provides the data foundation informing clinical decisions, care planning, and professional nursing judgment.

Patient-Centered Interview

An interview conducted during the nursing history focused on the patient's story, concerns, and health goals to build rapport and gather baseline data.

Periodic Assessment

Ongoing evaluations conducted during subsequent encounters to monitor patient status and response to interventions.

Comprehensive Assessment

An in-depth, head-to-toe evaluation that includes a health history and physical exam to establish a baseline for future comparisons.

Problem-Focused Assessment

A quick, targeted assessment limited to a specific issue or complaint, commonly used in urgent, acute, or follow-up situations.

ABCDE Approach

A structured assessment framework for rapid emergency identification of life-threatening conditions: Airway, Breathing, Circulation, Disability, and Exposure.

Health History

A structured method of data collection combining skilled interviewing and critical thinking to build a comprehensive profile of past and present health status, coping mechanisms, and risk factors.

Primary Source

Information obtained directly from the patient themselves, providing a personal account of symptoms and health experiences.

Secondary Source

Information gathered from sources other than the patient, such as family caregivers, other healthcare professionals, or Electronic Health Records (EHR).

Biographic Data

Foundational personal information and demographics (such as age, gender identity, living situation, cultural factors, occupational history, and communication needs) that contextualize assessment findings.

Reason for Seeking Care

The chief complaint or concern that prompted the healthcare visit, documented verbatim in the patient's exact words with quotation marks and symptom duration.

History of Present Illness (HPI)

A detailed narrative account of the current health status or illness progression written by the nurse.

PQRST Symptom Analysis

A systematic method for thoroughly investigating symptoms, particularly pain: Provokes, Quality, Radiates, Severity, and Time.

Provokes (P)

The component of PQRST symptom analysis asking what triggers the symptom or what makes it better or worse.

Quality (Q)

The component of PQRST symptom analysis describing how a symptom feels, looks, or sounds (e.g., sharp, dull, burning, throbbing).

Radiates (R)

The component of PQRST symptom analysis identifying where the symptom is located and whether it moves to other anatomical areas.

Severity (S)

The component of PQRST symptom analysis evaluating symptom intensity, often measured on a 0 to 10 scale.

Time (T)

The component of PQRST symptom analysis identifying when symptoms began, their duration, and frequency of occurrence.

Genogram

A visual representation of family structure and health patterns across 3 generations used to uncover hereditary risks.

Review of Systems (ROS)

A systematic, head-to-toe inventory of subjective yes-or-no questions covering all major body systems to identify unmentioned symptoms.

Functional Health Assessment

An evaluation of a patient's capacity for self-care, daily routines, lifestyle factors, coping mechanisms, and environment to support holistic care planning.

Activities of Daily Living (ADLs)

Fundamental personal self-care tasks essential for basic functioning, including bathing, dressing, eating, toileting, and mobility.

Instrumental Activities of Daily Living (IADLs)

Complex tasks requiring higher cognitive function that support independent living, including managing finances, meal preparation, shopping, using transportation, managing medications, and housekeeping.

FICA Framework

A tool used to assess a patient's spiritual resources across four domains: Faith, Influence, Community, and Address.