Clinical Assessment Study Guide
Subjective Data - Answer-Information that the patient/ caregiver provides
Objective Data - Answer-what the nurse observes by inspecting, palpating,
percussing, and auscultating during the physical examination
Types of Databases - Answer-complete/total, focused/problem centered, follow-
up, emergency
Priority Levels - Answer-first, second, third, collaborative
First Level Priority - Answer-emergent, life-threatening, and immediate
Second Level Priority - Answer-Next in urgency, requiring attention so as to avoid
further deterioration
Third Level Priority - Answer-Important to patient's health but can be addressed
after more urgent problems are addressed
Collaborative Problems - Answer-approach to treatment involves multiple
disciplines
,A grasping action of the fingers and thumb—To detect the position, shape, and
consistency of an organ or mass
-The dorsa (backs) of hands and fingers—Best for determining temperature
because the skin is thinner than on the palms
-Base of fingers (metacarpophalangeal joints) or ulnar surface of the hand—Best
for vibration
percussion - Answer-tapping the person's skin with short, sharp strokes to assess
underlying structures. The strokes yield an audible vibration and a characteristic
sound that depicts the location, size, and density of the underlying organ.
nociceptive pain - Answer-develops when functioning and intact nerve fibers in
the periphery and the CNS are stimulated. It is triggered by events outside the
nervous system from actual or potential tissue damage
nociception phases - Answer-1. transduction
2. transmission
3. perception
4. modulation
neuropathic pain - Answer-pain that does not adhere to the typical and rather
predictable phases in nociceptive pain. It is pain due to a lesion or disease in the
somatosensory nervous system.
types of pain - Answer-Acute
Breakthrough
, Chronic
acute pain - Answer-short term, often follows a predictable trajectory. (ex:
surgery, trauma, kidney stones)
chronic pain - Answer-diagnosed when pain continues for 6 months or longer. the
pain does not stop when the injury heals. divides into malignant and
nonmalignant as well.
breakthrough pain - Answer-a transient spike in pain level, moderate to severe in
intensity, in an otherwise controlled pain syndrome
sources of pain - Answer-visceral, somatic (deep somatic), cutaneous pain,
referred pain
visceral pain - Answer-originates from the larger internal organs (i.e., stomach,
intestine, gallbladder, pancreas)
somatic pain - Answer-originates from musculoskeletal tissues or the body surface
deep somatic pain - Answer-originates from sources such as the blood vessels,
joints, tendons, muscles, and bone. Pain may result from pressure, trauma, or
ischemia
cutaneous pain - Answer-originates from skin surface and subcutaneous tissues.
may be superficial, sharp, or burning