The Complete Health History and Physical Examination Chapter 27 The Complete Health History and Physical Examination

Competencies Identify ethical and legal considerations for the health history and physical examination. Identify the components of the complete health history and physical examination. (continues)

Competencies Conduct a complete health history and physical examination on a patient. Document a complete health history and physical examination.

General Guidelines Develop skill with time and practice Use a holistic perspective Use critical thinking abilities (continues)

General Guidelines Act unhurried Respect the patient Act professionally (continues)

General Guidelines Acknowledge emotional reactions to illness Be sensitive to cultural and spiritual requirements

Tips for Fostering Patient Cooperation Minimize waiting time Greet patient Proceed in an organized manner Use terminology that is easy to understand (continues)

Tips for Fostering Patient Cooperation Encourage active participation by patient Be honest Avoid false reassurances or jumping to conclusions

Legal Considerations Careful, complete documentation Respect patient privacy, confidentiality, and the right to refuse Report diseases as required (continues)

Legal Considerations Adhere to agency and Nurse Practice Act regulations Use professional judgment to guide actions

Ethical Principles Use the following ethical principles to guide actions Autonomy, beneficence, nonmalificence, justice, fidelity, veracity, utilitarianism

Health History Depends on patient’s reason for visit Types of histories Complete Episodic Interval Emergency

Physical Assessment General survey Physical presence Psychological presence Distress Pain (continues)

Physical Assessment Neurological status LOC Mental status (continues)

Physical Assessment Measurements Height Weight Temperature Pulse Respirations Blood pressure Anthropometric measurements

Skin Assessment Head to toe Characteristics Inspect for color, bleeding, ecchymosis, vascularity, lesions Palpate for moisture, temperature, texture, turgor, edema

Head-to-Toe Assessment Head and face Hair Expression, shape, symmetry Cranial nerves (continues)

Head-to-Toe Assessment Eyes Visual acuity Color vision Extraocular muscles Internal and external structures (continues)

Head-to-Toe Assessment Ears Gross hearing External ear structures Otoscopic exam (continues)

Head-to-Toe Assessment Nose and sinuses Nostril patency Olfactory sense Sinuses (continues)

Head-to-Toe Assessment Mouth and throat Breath odor Inspect internal and external structures Cranial nerves (continues)

Head-to-Toe Assessment Neck ROM Musculature Carotid arteries Jugular veins Lymph nodes (continues)

Head-to-Toe Assessment Upper extremities Nailbeds Muscle size and tone Joints ROM Pulses (continues)

Head-to-Toe Assessment Back, posterior, and lateral thoraxes Spine Thoracic expansion Tactile fremitus Diaphragmatic excursion Costovertebral angle tenderness Anterior thorax Inspection, palpation, percussion, auscultation (continues)

Head-to-Toe Assessment Heart Auscultate cardiac landmarks Aortic Pulmonic Mitral Tricuspid Erb’s point (continues)

Head-to-Toe Assessment Female breasts Characteristics to assess: color, vascularity, thickening or edema, size, symmetry Palpate lymph nodes Teach breast self-examination (continues)

Head-to-Toe Assessment Male breasts Gynecomastia Jugular veins Observe for distension Patient position should be 45 degrees and supine (continues)

Head-to-Toe Assessment Abdomen Contour, symmetry, pigmentation, color Scars, striae, visible peristalsis, masses, pulsations Bowel sounds Palpate all quadrants and organs (continues)

Head-to-Toe Assessment Inguinal area Lymph nodes Inguinal hernias Palpate femoral pulses (continues)

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

Head-to-Toe Assessment Neurological system Cranial nerves Reflexes Balance (continues)

Head-to-Toe Assessment Musculoskeletal system Mobility ROM Scoliosis (continues)

Head-to-Toe Assessment Female genitalia, anus, and rectum External and internal genitalia Vaginal exam Rectovaginal exam Occult blood testing (continues)

Head-to-Toe Assessment Male genitalia Penis, urethral meatus, scrotum Inguinal area Teach testicular self-examination (continues)

Head-to-Toe Assessment Male anus, rectum, and prostate Perineum, sacrococcygeal area, anal mucosa Anus and rectum Palpate the prostate