Health Assessment NSG 316 Exam #1
Study online at https://quizlet.com/_hxg367
1. General Survey -overall impression of the client when first encountered
-Begins immediately on meeting the client
-Uses objective data (what the nurse observes)
2. Genral survey four -Physical Appearance
major areas -Body Structure
-Mobility
-Behavior
3. Physical Appearance age, sex, level of consciousness, skin color, facial features, distress
4. Body Structure stature, nutrition, symmetry, posture, position, build, deformities
5. Mobility gait, foot placement, range of motion, involuntary movements
6. Behavior facial expression, mood/affect, speech, dress, hygiene
7. Health Assessment -systematic collection of information about a client's health
-Involves inspection, palpation, percussion, auscultation (IPPA)
-Used for baseline, diagnosis, and planningcare
8. Subjective Data what the client says (Symptoms), feelings, history)
the client says it
9. Objective Data what the nurse observes (signs), measurable findings)
you can measure it
10. Comprehensive Full health history + head-to-toe physical exam
(Complete) Used at initial visits, hospital admissions, new settings.
Assessment Establishes baseline for future comparisons
11. Focused (Prob- Concentrates on a specific concern (ex: chest pain, wound check)
lem-Oriented) As- Used in urgent or follow-up care
sessment
, Health Assessment NSG 316 Exam #1
Study online at https://quizlet.com/_hxg367
12. Follow-up database check progress of known problems
13. Emergency database rapid collection, life-threatening situations
14. First level priority emergent life threatening & immediate
problem
15. Second level priority next in urgency, requiring attention to avoid further deterioration
problem
16. Third level priority important to clients health but can be addressed after more urgent prob-
problem lems are addressed
17. Collaborative prob- approach to treatment involves multiple disciplines
lems
18. Safety & Privacy Maintain HIPAA & confidentiality
in Health History/As- Ensure informed consent for procedures
sessment Provide privacy (close door/curtain, drape patient)
Prevent interruptions, ensure professional boundaries
Use infection prevention (hand hygiene, clean equipment, PPE)
Apply "One&Only" principle: 1 needle, 1 syringe, 1 patient
19. Factors Affecting -Age - risk factors vary (e.g., immunizations in children, screenings in older
Health Promotion & adults)
Disease Prevention -Lifestyle - diet, exercise, tobacco, alcohol, drugs, sexual practices
-Environment - housing, workplace safety, pollution
-Genetics/family history - predisposition to chronic illnesses
-Access to care & socioeconomic status
-Cultural influences - beliefs about health, prevention, treatment
20. Key Components of -Health history
Health History -Biographical data
, Health Assessment NSG 316 Exam #1
Study online at https://quizlet.com/_hxg367
-Reason for seeking care
-History of Present Illness (HPI)
-Past history
-Family history
-Review of Systems (ROS)
21. Health history foundation of assessment
Must consider culture, age, gender, ethnicity, religion, spirituality
22. Biographical data name, DOB, source of info
23. Reason for seeking chief complaint
care
24. History of Present Ill- PQRSTU mnemonic
ness (HPI)
25. PQRSTU mnemonic P- provocation/ palliation
Q- quality/ quantity
R-region/ radiation
S-severity scale
T-timing
U-understanding
26. Past history illnesses, hospitalizations, surgeries, meds, immunizations, allergies
27. Family history genogram
28. Review of Systems head-to-toe symptom checklist
(ROS)
29. Primary purpose of subjective
the interview is to col-
lect __________ data
Study online at https://quizlet.com/_hxg367
1. General Survey -overall impression of the client when first encountered
-Begins immediately on meeting the client
-Uses objective data (what the nurse observes)
2. Genral survey four -Physical Appearance
major areas -Body Structure
-Mobility
-Behavior
3. Physical Appearance age, sex, level of consciousness, skin color, facial features, distress
4. Body Structure stature, nutrition, symmetry, posture, position, build, deformities
5. Mobility gait, foot placement, range of motion, involuntary movements
6. Behavior facial expression, mood/affect, speech, dress, hygiene
7. Health Assessment -systematic collection of information about a client's health
-Involves inspection, palpation, percussion, auscultation (IPPA)
-Used for baseline, diagnosis, and planningcare
8. Subjective Data what the client says (Symptoms), feelings, history)
the client says it
9. Objective Data what the nurse observes (signs), measurable findings)
you can measure it
10. Comprehensive Full health history + head-to-toe physical exam
(Complete) Used at initial visits, hospital admissions, new settings.
Assessment Establishes baseline for future comparisons
11. Focused (Prob- Concentrates on a specific concern (ex: chest pain, wound check)
lem-Oriented) As- Used in urgent or follow-up care
sessment
, Health Assessment NSG 316 Exam #1
Study online at https://quizlet.com/_hxg367
12. Follow-up database check progress of known problems
13. Emergency database rapid collection, life-threatening situations
14. First level priority emergent life threatening & immediate
problem
15. Second level priority next in urgency, requiring attention to avoid further deterioration
problem
16. Third level priority important to clients health but can be addressed after more urgent prob-
problem lems are addressed
17. Collaborative prob- approach to treatment involves multiple disciplines
lems
18. Safety & Privacy Maintain HIPAA & confidentiality
in Health History/As- Ensure informed consent for procedures
sessment Provide privacy (close door/curtain, drape patient)
Prevent interruptions, ensure professional boundaries
Use infection prevention (hand hygiene, clean equipment, PPE)
Apply "One&Only" principle: 1 needle, 1 syringe, 1 patient
19. Factors Affecting -Age - risk factors vary (e.g., immunizations in children, screenings in older
Health Promotion & adults)
Disease Prevention -Lifestyle - diet, exercise, tobacco, alcohol, drugs, sexual practices
-Environment - housing, workplace safety, pollution
-Genetics/family history - predisposition to chronic illnesses
-Access to care & socioeconomic status
-Cultural influences - beliefs about health, prevention, treatment
20. Key Components of -Health history
Health History -Biographical data
, Health Assessment NSG 316 Exam #1
Study online at https://quizlet.com/_hxg367
-Reason for seeking care
-History of Present Illness (HPI)
-Past history
-Family history
-Review of Systems (ROS)
21. Health history foundation of assessment
Must consider culture, age, gender, ethnicity, religion, spirituality
22. Biographical data name, DOB, source of info
23. Reason for seeking chief complaint
care
24. History of Present Ill- PQRSTU mnemonic
ness (HPI)
25. PQRSTU mnemonic P- provocation/ palliation
Q- quality/ quantity
R-region/ radiation
S-severity scale
T-timing
U-understanding
26. Past history illnesses, hospitalizations, surgeries, meds, immunizations, allergies
27. Family history genogram
28. Review of Systems head-to-toe symptom checklist
(ROS)
29. Primary purpose of subjective
the interview is to col-
lect __________ data
