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

2. Competencies
Identify ethical and legal considerations for the health history and physical examination.
Identify the components of the complete health history and physical examination.
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3. Competencies
Conduct a complete health history and physical examination on a patient.
Document a complete health history and physical examination.

4. General Guidelines Develop skill with time and practice
Use a holistic perspective
Use critical thinking abilities
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5. General Guidelines Act unhurried Respect the patient
Act professionally
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6. General Guidelines Acknowledge emotional reactions to illness
Be sensitive to cultural and spiritual requirements

7. Tips for Fostering Patient Cooperation
Minimize waiting time
Greet patient
Proceed in an organized manner
Use terminology that is easy to understand
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8. Tips for Fostering Patient Cooperation
Encourage active participation by patient
Be honest
Avoid false reassurances or jumping to conclusions

9. Legal Considerations Careful, complete documentation
Respect patient privacy, confidentiality, and the right to refuse
Report diseases as required
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10. Legal Considerations
Adhere to agency and Nurse Practice Act regulations
Use professional judgment to guide actions

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

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

13. Physical Assessment General survey Physical presence
Psychological presence
Distress
Pain
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14. Physical Assessment
Neurological status
LOC
Mental status
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15. Physical Assessment Measurements Height Weight Temperature Pulse
Respirations
Blood pressure
Anthropometric measurements

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

17. Head-to-Toe Assessment
Head and face
Hair
Expression, shape, symmetry
Cranial nerves
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18. Head-to-Toe Assessment
Eyes
Visual acuity
Color vision
Extraocular muscles
Internal and external structures
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19. Head-to-Toe Assessment
Ears
Gross hearing
External ear structures
Otoscopic exam
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20. Head-to-Toe Assessment
Nose and sinuses
Nostril patency
Olfactory sense
Sinuses
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21. Head-to-Toe Assessment
Mouth and throat
Breath odor
Inspect internal and external structures
Cranial nerves
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22. Head-to-Toe Assessment
Neck
ROM
Musculature
Carotid arteries
Jugular veins
Lymph nodes
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23. Head-to-Toe Assessment
Upper extremities
Nailbeds
Muscle size and tone
Joints
ROM
Pulses
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24. 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
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25. Head-to-Toe Assessment
Heart
Auscultate cardiac landmarks
Aortic
Pulmonic
Mitral
Tricuspid
Erb’s point
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26. Head-to-Toe Assessment
Female breasts
Characteristics to assess: color, vascularity, thickening or edema, size, symmetry
Palpate lymph nodes
Teach breast self-examination
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27. Head-to-Toe Assessment
Male breasts
Gynecomastia
Jugular veins
Observe for distension
Patient position should be 45 degrees and supine
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28. Head-to-Toe Assessment
Abdomen
Contour, symmetry, pigmentation, color
Scars, striae, visible peristalsis, masses, pulsations
Bowel sounds
Palpate all quadrants and organs
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29. Head-to-Toe Assessment
Inguinal area
Lymph nodes
Inguinal hernias
Palpate femoral pulses
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30. 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
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31. Head-to-Toe Assessment
Neurological system
Cranial nerves
Reflexes
Balance
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32. Head-to-Toe Assessment
Musculoskeletal system
Mobility
ROM
Scoliosis
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33. Head-to-Toe Assessment
Female genitalia, anus, and rectum
External and internal genitalia
Vaginal exam
Rectovaginal exam
Occult blood testing
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34. Head-to-Toe Assessment
Male genitalia
Penis, urethral meatus, scrotum
Inguinal area
Teach testicular self-examination
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35. Head-to-Toe Assessment
Male anus, rectum, and prostate
Perineum, sacrococcygeal area, anal mucosa
Anus and rectum
Palpate the prostate