Health Assessment Exam 1 Focus Points

The purpose of assessment is to make a judgment or diagnosis.

The process of collecting data about an individual's health status.

Subjective data comes from the patient's perspective and is what the patient tells you, while objective data is obtained through observation and examination, such as vital signs and physical exam findings.

The nursing process is a systematic approach to patient care, involving assessment, diagnosis, planning, implementation, and evaluation.

Social determinants of health are the non-medical factors that shape an individual's health status, such as poverty, education, and access to healthcare services.

The Clinical Judgment Model is a framework used to enhance clinical judgment skills by moving through different levels of expertise, from novice to expert.

Priority setting in assessment prioritizes patient needs based on urgency and severity. Level 1 involves life-threatening issues, Level 2 includes urgent but non-life-threatening concerns, and Level 3 focuses on important but less urgent problems.

A complete database includes a comprehensive history and physical examination, while a focused database is targeted to a specific problem. Follow-up databases track previous problems, and emergency databases are rapid collections of critical information.

The conditions that influence a person's health and well-being throughout their life.

A structured process of gathering and analyzing data about a person's culture, beliefs, and values related to health.

The learned and shared beliefs, attitudes, values, norms, and behaviors of a group of people.

The ability to understand and respect cultural differences and provide care that is consistent with a patient's beliefs and values.

A social construct reflecting self-identification based on shared physical characteristics.

A social group with shared geographic origin, religion, language, traditions, and values.

A personal connection to something larger than oneself, often involving a belief in transcendence.

An organized system of beliefs about the universe's cause, nature, and purpose. It typically includes religious services and practices.

Information that a patient tells you about their health.

Information that you observe or measure about a patient's health.

A communication technique that helps build rapport by acknowledging the patient, introducing yourself, explaining the duration of the interaction, providing explanations, and expressing gratitude.

Questions that allow for open-ended responses, providing a wider range of information.

Specific questions that require brief answers, often just yes or no.

Nonverbal communication, such as facial expressions, gestures, posture, and eye contact, that reveals feelings and emotions.

A comprehensive record of a patient's health history, including their past and present health status.

A detailed account of the patient's symptoms, from the onset to the present, including their severity, frequency, and any associated factors.

A systematic assessment of each body system to identify any past or present health issues, including any health promotion practices.

Activities of Daily Living (ADLs) are basic self-care tasks like bathing, dressing, toileting, eating, and walking. Instrumental ADLs (IADLs) are complex tasks required for independent living, such as housekeeping, shopping, and managing finances.

A structured interview method used for adolescents, focusing on Home Environment, Education, Eating, Activities, Drugs, Sexuality, Suicide/Depression, and Safety.

The excessive and harmful use of alcohol, often leading to physical, psychological, and social problems.

The use of illegal drugs, including marijuana, cocaine, heroin, hallucinogens, inhalants, methamphetamine, and psychotherapeutics.

A public health crisis characterized by widespread misuse of prescription opioid pain relievers, often leading to heroin addiction.

Addiction is a complex condition influenced by a combination of genetic predispositions, environmental factors, and developmental stages.

Alcohol consumption during pregnancy can lead to fetal alcohol syndrome, causing physical, learning, and behavioral problems in the developing fetus.

A standardized questionnaire used to screen for alcohol use disorders. It assesses alcohol consumption, drinking behavior, and adverse consequences.

A brief screening tool for alcohol abuse, asking about attempts to Cut down, Annoyance by others' comments, Guilt about drinking, and Eye-openers.

A test that measures the amount of alcohol present in a person's breath, providing a way to assess recent alcohol consumption.

A validated tool used to assess alcohol withdrawal symptoms, including nausea, tremors, sweating, anxiety, and sensory disturbances.

A broad term encompassing different forms of violence, including intimate partner violence, child abuse and neglect, elder abuse and neglect, and human trafficking.

Includes acts like hitting, kicking, slapping, punching, choking, or using weapons to cause physical harm.

Any unwanted sexual activity, including unwanted touching, forced penetration, or sexual coercion.

Repeated and unwanted behaviors like following, harassing, watching, or threatening someone.

Using words, actions, or gestures to intimidate, belittle, or control someone.

Failing to provide basic needs like food, shelter, clothing, or medical care to a child.

Involves physical harm inflicted on a child, like hitting, shaking, or burning.

Any sexual activity involving a child, including sexual contact, exploitation, or abuse.

Acts that cause emotional distress or harm to a child, like yelling, insulting, or threatening.

A form of abuse against older individuals involving physical harm, sexual abuse, psychological abuse, neglect, or financial exploitation.

Failure to provide essential care like food, water, hygiene, medical attention, or safe living conditions for an elderly person.

Misusing or taking advantage of an elderly person's finances or assets for personal gain.

Using force or coercion to control or exploit a person for labor or sexual services.

Asking about a patient's feelings about their safety at home is a crucial question.

A screening tool to assess intimate partner violence by asking about physical harm, insults, threats, and yelling.

Observing physical signs of abuse during a head-to-toe examination.

The force of blood against artery walls during systole (heart contraction).

The force of blood against artery walls between heartbeats (diastole).

The difference between systolic and diastolic pressure, reflecting the volume of blood pumped with each heartbeat.

The average pressure pushing blood into tissues throughout the cardiac cycle.

A heart rate below 60 beats per minute.

A heart rate above 100 beats per minute.

A rapid respiratory rate, above 25 breaths per minute.

A decreased respiratory rate, below 12 breaths per minute.

High blood pressure, with systolic pressure over 140 mmHg, or diastolic over 90 mmHg, or both.

A set of precautions used to prevent the spread of infections from patients with known or suspected infections.

Precautions used for patients with infections spread through direct contact with the patient or their environment.

Precautions used for patients with infections spread through respiratory droplets produced when the patient coughs, sneezes, talks, or even breathes.

Precautions used for patients with infections spread through airborne agents that may remain suspended in the air for extended periods.

A comprehensive assessment of a patient's overall health status, covering physical appearance, body structure, mobility, and behavior.

The assessment of a patient's body structure, including stature, nutrition, symmetry, posture, and any obvious deformities.

The assessment of a patient's mobility, including gait and range of motion.

The assessment of a patient's behavior, including facial expression, mood, speech, dress, and personal hygiene.

The process of obtaining objective data about a patient's weight, height, and other relevant measurements.

The measurement of a patient's weight, typically obtained using a scale.

The measurement of a patient's height, typically obtained using a stadiometer or measured against a wall.

The examination of an infant patient, which should be conducted in a calm and comfortable environment.

The examination of a toddler patient, which requires patience, understanding, and a playful approach.

The examination of a preschool patient, which involves using simple explanations and addressing their fears regarding body injury.

The examination of a school-age patient, which involves understanding their desire for approval and their increasing interest in body function.

Fluid retention can cause unexplained weight gain.

BMI is a practical indicator of healthy weight for height, and can also help indicate obesity or malnutrition.

Excessive abdominal fat increases the risk of heart disease and type 2 diabetes.

The weight of an infant is measured using a platform scale, ensuring their safety.

Head circumference is measured in newborns through 6 years old using a plastic tape aligned with the eyebrows and the widest span of the occipital bone.

After 2 years, chest circumference is greater than head circumference. It is measured at the nipple line with a tape.

Physical growth in children is a strong indicator of their overall health.

Social factors like poverty, nutrition, and environment play a role in a child's growth and development.

Weight naturally declines in aging adults, along with muscle mass.

Many aging adults become shorter due to thinning vertebral discs, kyphosis, and changes in knee and hip flexion.

Deficiency of growth hormone in childhood leads to stunted growth.

Excess growth hormone secretion in adulthood leads to overgrowth of bones in the face, hands, and feet, but no change in height.

A genetic disorder affecting cartilage-to-bone conversion, leading to normal trunk size but short limbs and stature.

A mental health disorder characterized by episodes of binge eating followed by purging.

A mental health disorder characterized by severe and life-threatening weight loss in an otherwise healthy person.