1. The Complete Health History and Physical Examination
Chapter 25
The Complete Health History and Physical Examination
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2. 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.
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3. 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
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4. 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
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5. 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
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6. Copyright 2002, Delmar, A division of Thomson Learning
Ethical Principles
Autonomy
Beneficence
Nonmaleficence
Justice
Fidelity
Veracity
Utilitarianism
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7. Purpose of Health History
Dependent on patient’s reason for visit
Types of histories
Complete
Episodic
Interval
Emergency
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8. Copyright 2002, Delmar, A division of Thomson Learning
Physical Assessment
General survey
Physical presence
Psychological presence
Distress
Neurological status
Vital signs
Height, weight
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9. Copyright 2002, Delmar, A division of Thomson Learning
Skin Assessment
Head to toe
Characteristics
Color, bleeding, ecchymosis, vascularity, lesions
Moisture, temperature, texture, turgor, edema
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10. Head-to-Toe Assessment
Head and face
Symmetry
Cranial nerves
Hair
Eyes
Visual acuity
Color vision
Extraocular muscles
Internal and external structures
(continues)
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11. Head-to-Toe Assessment
Ears
Gross hearing
External ear structures
Otoscopic exam
(continues)
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12. 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)
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13. Head-to-Toe Assessment
Neck
ROM
Musculature
Carotid arteries
Jugular veins
Lymph nodes
(continues)
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14. Head-to-Toe Assessment
Upper extremities
Nailbeds
Joints
ROM
Pulses
(continues)
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15. Head-to-Toe Assessment
Back, posterior, and lateral thoraxes
Spine
Thoracic expansion
Tactile fremitus
Diaphragmatic excursion
Costovertebral angle tenderness
(continues)
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16. Head-to-Toe Assessment
Heart
Inspect/palpate for pulsations, thrills, heaves
Apical pulse
Cardiac landmarks
Aortic
Pulmonic
Mitral
Tricuspid
Erb’s point
(continues)
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17. Head-to-Toe Assessment
Female breasts
Characteristics to assess: color, vascularity, thickening/edema, size
Palpate lymph nodes
Teach breast self-examination
(continues)
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18. Head-to-Toe Assessment
Male breasts
Gynecomastia
Jugular veins
Observe for distension
Patient position: 45 degrees and supine
(continues)
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19. Head-to-Toe Assessment
Abdomen
Contour, symmetry, pigmentation, color
Scars, striae, visible peristalsis, masses, pulsations
Bowel sounds
Palpate all quadrants and internal organs
(continues)
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20. Head-to-Toe Assessment
Inguinal area
Lymph nodes
Inguinal hernias
Palpate femoral pulses
(continues)
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21. 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)
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22. Head-to-Toe Assessment
Neurological system
Cranial nerves
Reflexes
Balance
Musculoskeletal system
Mobility
ROM
(continues)
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23. Head-to-Toe Assessment
Female genitalia, anus, and rectum
External and internal genitalia
Vaginal exam
Rectovaginal exam
Occult blood testing
(continues)
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24. 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
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