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A collection of subjective information that provides information about the patient's health status.
A collection of objective data that provides information about changes in the patient's body systems.
A health history and complete physical examination is usually conducted when a patient first enters a health care setting, with information providing a baseline for comparing later assessments.
Assessment conducted at regular intervals during care of patient.
ongoing partial assessment
Conducted to assess a specific problem.
Rapid focused assessment conducted when addressing a life-threatening or unstable situation.
Eating, bathing, dressing, and toileting are examples of...
Activities of daily living
Process of performing deliberate, purposeful observations in a systematic manner. Closely observe visually but also use hearing and smell to gather data throughout the assessment. Assess details of the patients's appearance, behavior and movement.
Uses the sense of touch. The hands and fingers are sensitive tools that can assess skin temperature, turgor, texture, and moisture, as well as vibrations within the body and shape or structures within the body.
Act of striking one object against another to produce sound. The fingertips are used to tap the body over body tissues to produce vibrations and sound waves.
The act of listening with a stethoscope to sounds produced within the body.
Four characteristics of sound are assessed by auscultation.
1. ____ (ranging from high to low)
2. ____ (ranging from soft to loud)
3. ____ (e.g. gurgling or swishing)
4. ____ (short, medium, or long)
- 1. Pitch
- 2. loudness
- 3. quality
- 4. duration
Ration of weight to height. Used as an initial assessment of nutritional status, and is an indicator of obesity or malnutrition.
BMI: Body mass index
Bluish or grayish discoloration of the skin in response to inadequate oxygenation. Assessed as blue tinge in patients with white skin and as dullness in patients with dark skin tones.
Yellow color of the skin resulting from elevated amounts of bilirubin in the blood. Associated with liver and gallbladder disease, some types of anemia, and excessive hemolysis. Usually develops first in the sclera of the eyes.
Paleness of the skin, often results from a decrease in the amount of circulating blood or hemoglobin, causing inadequate oxygenation of the body tissues.
Collection of blood in the subcutaneous tissues, causing purplish discoloration.
Small hemorrhagic spots caused by capillary bleeding.
An excessive amount of perspiration, such as when the entire skin is moist.
The fullness or elasticity of the skin. Normal when skin fold returns to its usual shape when released. Dehydration may decrease level.
Characterized by swelling, with taut and shiny skin over the area. If area is palpated with the fingers, an indentation may remain after the pressure is released. Depth of indentation is measured in mm.
Abnormal "swooshing or blowing" sounds heard over a blood vessel, caused by blood that is swirling in the vessel, rather than normal smooth flow. May be heard in the presence of stenosis (narrowing) or occlusion of an artery.