The Complete Health History and Physical Examination Chapter 25 The Complete Health History and Physical Examination Copyright 2002, Delmar, A division of Thomson Learning

Copyright 2002, Delmar, A division of Thomson Learning Competencies Identify the components of a complete health history and physical examination. Conduct a complete health history and physical examination on a patient. Document a complete health history and physical examination. Copyright 2002, Delmar, A division of Thomson Learning

Copyright 2002, Delmar, A division of Thomson Learning General Guidelines Utilize a holistic perspective Use critical thinking abilities Respect the patient Demonstrate self-awareness Act professionally Acknowledge emotional reactions to illness Be sensitive to cultural and spiritual requirements Copyright 2002, Delmar, A division of Thomson Learning

Tips for Fostering Patient Cooperation Minimize waiting time Greet the patient Proceed in an organized manner Use terminology that is easy to understand Encourage active participation from the patient Express honesty Copyright 2002, Delmar, A division of Thomson Learning

Copyright 2002, Delmar, A division of Thomson Learning Legal Considerations Careful, complete documentation Respect patient privacy, confidentiality, and the right to refuse Adhere to agency and Nurse Practice Act regulations Report required diseases Use common sense Copyright 2002, Delmar, A division of Thomson Learning

Copyright 2002, Delmar, A division of Thomson Learning Ethical Principles Autonomy Beneficence Nonmaleficence Justice Fidelity Veracity Utilitarianism Copyright 2002, Delmar, A division of Thomson Learning

Purpose of Health History Dependent on patient’s reason for visit Types of histories Complete Episodic Interval Emergency Copyright 2002, Delmar, A division of Thomson Learning

Copyright 2002, Delmar, A division of Thomson Learning Physical Assessment General survey Physical presence Psychological presence Distress Neurological status Vital signs Height, weight Copyright 2002, Delmar, A division of Thomson Learning

Copyright 2002, Delmar, A division of Thomson Learning Skin Assessment Head to toe Characteristics Color, bleeding, ecchymosis, vascularity, lesions Moisture, temperature, texture, turgor, edema Copyright 2002, Delmar, A division of Thomson Learning

Head-to-Toe Assessment Head and face Symmetry Cranial nerves Hair Eyes Visual acuity Color vision Extraocular muscles Internal and external structures (continues) Copyright 2002, Delmar, A division of Thomson Learning

Head-to-Toe Assessment Ears Gross hearing External ear structures Otoscopic exam (continues) Copyright 2002, Delmar, A division of Thomson Learning

Head-to-Toe Assessment Nose and sinuses Nostril patency Olfactory sense Sinuses Mouth and throat Breath odor Inspect internal and external structures Cranial nerves (continues) Copyright 2002, Delmar, A division of Thomson Learning

Head-to-Toe Assessment Neck ROM Musculature Carotid arteries Jugular veins Lymph nodes (continues) Copyright 2002, Delmar, A division of Thomson Learning

Head-to-Toe Assessment Upper extremities Nailbeds Joints ROM Pulses (continues) Copyright 2002, Delmar, A division of Thomson Learning

Head-to-Toe Assessment Back, posterior, and lateral thoraxes Spine Thoracic expansion Tactile fremitus Diaphragmatic excursion Costovertebral angle tenderness (continues) Copyright 2002, Delmar, A division of Thomson Learning

Head-to-Toe Assessment Heart Inspect/palpate for pulsations, thrills, heaves Apical pulse Cardiac landmarks Aortic Pulmonic Mitral Tricuspid Erb’s point (continues) Copyright 2002, Delmar, A division of Thomson Learning

Head-to-Toe Assessment Female breasts Characteristics to assess: color, vascularity, thickening/edema, size Palpate lymph nodes Teach breast self-examination (continues) Copyright 2002, Delmar, A division of Thomson Learning

Head-to-Toe Assessment Male breasts Gynecomastia Jugular veins Observe for distension Patient position: 45 degrees and supine (continues) Copyright 2002, Delmar, A division of Thomson Learning

Head-to-Toe Assessment Abdomen Contour, symmetry, pigmentation, color Scars, striae, visible peristalsis, masses, pulsations Bowel sounds Palpate all quadrants and internal organs (continues) Copyright 2002, Delmar, A division of Thomson Learning

Head-to-Toe Assessment Inguinal area Lymph nodes Inguinal hernias Palpate femoral pulses (continues) Copyright 2002, Delmar, A division of Thomson Learning

Head-to-Toe Assessment Lower extremities Color, capillary refill, edema, ulcerations, hair distribution, varicose veins Popliteal, dorsalis pedis, posterior tibial pulses ROM Muscle size, tone Temperature, edema, texture (continues) Copyright 2002, Delmar, A division of Thomson Learning

Head-to-Toe Assessment Neurological system Cranial nerves Reflexes Balance Musculoskeletal system Mobility ROM (continues) Copyright 2002, Delmar, A division of Thomson Learning

Head-to-Toe Assessment Female genitalia, anus, and rectum External and internal genitalia Vaginal exam Rectovaginal exam Occult blood testing (continues) Copyright 2002, Delmar, A division of Thomson Learning

Head-to-Toe Assessment Male genitalia Penis, urethral meatus, scrotum Inguinal area Teach testicular self-exam Male anus, rectum, and prostate Perineum, sacrococcygeal area, anal mucosa Anus and rectum Palpate the prostate Copyright 2002, Delmar, A division of Thomson Learning