TERMS TO KNOW
CHAPTER 1
• Sign: objective; what we see"
• Objective: physical examination “signs”; height/BP/temp/HR"
• Symptom: subjective; reported by the patient"
• Subjective: health history; info about patients state of health, meds,
previous illnesses; primary (direct); secondary (other source)"
• Clinical manifestation: symptoms and sign"
• AD-O-PIE: assessment, diagnosis, observation/outcome, planning,
implementation, evaluate"
• Comprehensive assessment: detailed history and physical
assessment"
• Problem-based focus assessment: history and physical exam
limited to a specific problem"
• Episodic assessment: when a pt is following up with a health care
provider for a previous problem"
• Shift assessment: individuals are hospitalized and nurses conduct
assessment on each shift"
• Screening assessment: short exam focused on disease detection "
• Primary prevention: protection to prevent occurrence of disease "
• Secondary prevention: early/identification of disease before it
becomes symptomatic to halt the progression "
• Tertiary prevention: minimize severity and disability from disease
thru appropriate therapy for chronic disease "
,CHAPTER 2
• Open ended question: the aim is for the client to answer with more
than 2-3 words; broadly stated questions "
• Directive question: closed ended questions; more specific for
precise details (one or two words)"
• Biographic data: collected at first visit updated as changes occur
(name, gender/identity, address, birth date, race)"
• Reason for seeking care: a brief statement of the patients reason for
requesting the services of a HCP and is recorded in direct quotes "
• History of present illness: when a patient seeks health care for a
specific illness/problem, the nurse investigates it hurting using
symptom analysis (collecting data) "
• Present health status: patient’s current health conditions, meds, and
allergies"
• Past health history: past medical history, can have effect on
patients current health needs/problems"
• Family history: history of patients blood relatives, spouse, and
children is obtained to identify illnesses of genetic, familial , or
environmental nature that may effect the patients current/future
health"
• Personal/physchosocial history: explores a variety of topics that
effects/reflects the patients health "
• Review of systems: conducted to inquire about the past; present
health of each of the patient’s body systems"
,• OLDCART: onset (when did it begin?); location (where?); duration
(how long does it last?); characteristics (describe?); aggravating
factors (what makes it worse?); related symptoms (other symptom
present?); treatment (alleviate) "
CHAPTER 3
• Standard precautions: gloves, masks, gowns"
• Gloves: blood/bodily fluid or when handing equipment that is
contaminated "
• Masks/ eye protection/face shields: during procedures that may
result in splashes, sprays of blood, bodily fluid, and secretion"
• Gowns: protect arms to prevent contamination of clothing with
blood or other fluids"
• Resonant: heard over normal lung tissue"
• Hyper-resonance: heard in overinflated lungs, as in emphysema"
• Flat: heard over bones and muscle"
• Tympanic: loud, high-pitched sound heard over abdomen"
• Dullness: heard over liver"
• Supine: laying straight on back"
• Dorsal recumbant: laying on back with knees up (best position to
assess abdomen)"
• Lateral recumbant: laying on the side "
• Prone: laying on stomach"
• Sinus"
• SIMS position: laying on stomach with knee out to the side"
, CHAPTER 4"
• Rate: number of pulsations felt in one minute"
• Rhythm: regularity of the pulse "
• Tachycardia: fast heart rate (pulse) (greater than 100 BPM)"
• Bradycardia: slow heart rate (pulse) (less than 60 BPM)"
• Tachypnea: breathing that is abnormally rapid; shallow (lungs)"
• Bradypnea: breathing that is abnormally slow (lungs)"
• Korotkoff sound: 5 phases; auscultation sounds when doing BP"
$ 1. Sharp thumb (140)"
$ 2. Blowing/whoosh (120)$"
$ 3. Softer thump (110)"
$ 4. Softer blowing (100-90)"
$ 5. Silence (80)"
• Eupnea: normal relaxed breathing"
• Percussion tones: flat, tympanic, resonant"
• Resonant: lungs, loud/long, hollow"
• Flat: bone, muscle, soft/short, extremely dull"
• Tympanic: stomach/abdominal, gas bubbles, drum-like "
CHAPTER 5
• Ethnicity: refers to the character that a group may share in some combination "
• Culture: knowledge, belief, art, morals, laws"
• Race: genetic in origin and includes physical characteristics (skin color, blood
type, eye color)"
• Spirituality: 4 themes — as a religious systems of beliefs and values, as life
meaning, purpose, connection with others"
• Religion: organized system of beliefs, rituals "
• Sex: female or male"
• Gender: society’s perception of a person’s sex"
CHAPTER 1
• Sign: objective; what we see"
• Objective: physical examination “signs”; height/BP/temp/HR"
• Symptom: subjective; reported by the patient"
• Subjective: health history; info about patients state of health, meds,
previous illnesses; primary (direct); secondary (other source)"
• Clinical manifestation: symptoms and sign"
• AD-O-PIE: assessment, diagnosis, observation/outcome, planning,
implementation, evaluate"
• Comprehensive assessment: detailed history and physical
assessment"
• Problem-based focus assessment: history and physical exam
limited to a specific problem"
• Episodic assessment: when a pt is following up with a health care
provider for a previous problem"
• Shift assessment: individuals are hospitalized and nurses conduct
assessment on each shift"
• Screening assessment: short exam focused on disease detection "
• Primary prevention: protection to prevent occurrence of disease "
• Secondary prevention: early/identification of disease before it
becomes symptomatic to halt the progression "
• Tertiary prevention: minimize severity and disability from disease
thru appropriate therapy for chronic disease "
,CHAPTER 2
• Open ended question: the aim is for the client to answer with more
than 2-3 words; broadly stated questions "
• Directive question: closed ended questions; more specific for
precise details (one or two words)"
• Biographic data: collected at first visit updated as changes occur
(name, gender/identity, address, birth date, race)"
• Reason for seeking care: a brief statement of the patients reason for
requesting the services of a HCP and is recorded in direct quotes "
• History of present illness: when a patient seeks health care for a
specific illness/problem, the nurse investigates it hurting using
symptom analysis (collecting data) "
• Present health status: patient’s current health conditions, meds, and
allergies"
• Past health history: past medical history, can have effect on
patients current health needs/problems"
• Family history: history of patients blood relatives, spouse, and
children is obtained to identify illnesses of genetic, familial , or
environmental nature that may effect the patients current/future
health"
• Personal/physchosocial history: explores a variety of topics that
effects/reflects the patients health "
• Review of systems: conducted to inquire about the past; present
health of each of the patient’s body systems"
,• OLDCART: onset (when did it begin?); location (where?); duration
(how long does it last?); characteristics (describe?); aggravating
factors (what makes it worse?); related symptoms (other symptom
present?); treatment (alleviate) "
CHAPTER 3
• Standard precautions: gloves, masks, gowns"
• Gloves: blood/bodily fluid or when handing equipment that is
contaminated "
• Masks/ eye protection/face shields: during procedures that may
result in splashes, sprays of blood, bodily fluid, and secretion"
• Gowns: protect arms to prevent contamination of clothing with
blood or other fluids"
• Resonant: heard over normal lung tissue"
• Hyper-resonance: heard in overinflated lungs, as in emphysema"
• Flat: heard over bones and muscle"
• Tympanic: loud, high-pitched sound heard over abdomen"
• Dullness: heard over liver"
• Supine: laying straight on back"
• Dorsal recumbant: laying on back with knees up (best position to
assess abdomen)"
• Lateral recumbant: laying on the side "
• Prone: laying on stomach"
• Sinus"
• SIMS position: laying on stomach with knee out to the side"
, CHAPTER 4"
• Rate: number of pulsations felt in one minute"
• Rhythm: regularity of the pulse "
• Tachycardia: fast heart rate (pulse) (greater than 100 BPM)"
• Bradycardia: slow heart rate (pulse) (less than 60 BPM)"
• Tachypnea: breathing that is abnormally rapid; shallow (lungs)"
• Bradypnea: breathing that is abnormally slow (lungs)"
• Korotkoff sound: 5 phases; auscultation sounds when doing BP"
$ 1. Sharp thumb (140)"
$ 2. Blowing/whoosh (120)$"
$ 3. Softer thump (110)"
$ 4. Softer blowing (100-90)"
$ 5. Silence (80)"
• Eupnea: normal relaxed breathing"
• Percussion tones: flat, tympanic, resonant"
• Resonant: lungs, loud/long, hollow"
• Flat: bone, muscle, soft/short, extremely dull"
• Tympanic: stomach/abdominal, gas bubbles, drum-like "
CHAPTER 5
• Ethnicity: refers to the character that a group may share in some combination "
• Culture: knowledge, belief, art, morals, laws"
• Race: genetic in origin and includes physical characteristics (skin color, blood
type, eye color)"
• Spirituality: 4 themes — as a religious systems of beliefs and values, as life
meaning, purpose, connection with others"
• Religion: organized system of beliefs, rituals "
• Sex: female or male"
• Gender: society’s perception of a person’s sex"
