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30 Health Assessment 30 Health Assessment LEARNING OUTCOMES After completing this chapter, you will be able to: 1. Identify the purposes of the physical examination. l. Assessing the heart and central vessels. 2. Explain the four techniques used in physical examination: m. Assessing the peripheral vascular system. inspection, palpation, percussion, and auscultation. n. Assessing the breasts and axillae. 3. Identify expected findings during health assessment. o. Assessing the abdomen. p. Assessing the musculoskeletal system. 4. Verbalize the steps used in performing selected examination q. Assessing the neurologic system. procedures: r. Assessing the female genitals and inguinal area. a. Assessing appearance and mental status. s. Assessing the male genitals and inguinal area. b. Assessing the skin. t. Assessing the anus. c. Assessing the hair. d. Assessing the nails. 5. Describe suggested sequencing to conduct a physical health e. Assessing the skull and face. examination in an orderly fashion. f. Assessing the eye structures and visual acuity. 6. Discuss variations in examination techniques appropriate for g. Assessing the ears and hearing. clients of different ages. h. Assessing the nose and sinuses. 7. Recognize when it is appropriate to delegate assessment i. Assessing the mouth and oropharynx. skills to unlicensed assistive personnel. j. Assessing the neck. 8. Demonstrate appropriate documentation and reporting of k. Assessing the thorax and lungs. health assessment. KEY TERMS adventitious breath sounds, 555 external auditory meatus, 539 mydriasis, 534 resting tremor, 577 alopecia, 528 extinction, 582 myopia, 533 S1, 561 angle of Louis, 553 fasciculation, 577 normocephalic, 531 S2, 561 antihelix, 539 flatness, 519 nystagmus, 536 semicircular canals, 540 aphasia, 580 fremitus, 557 one-point discrimination, 582 sensorineural hearing loss, 540 astigmatism, 533 gingivitis, 546 ossicles, 540 sordes, 546 auricle, 539 glaucoma, 533 otoscope, 539 stapes, 540 auscultation, 519 glossitis, 546 pallor, 523 stereognosis, 582 blanch test, 530 goniometer, 579 palpation, 517 sternum, 554 bruit, 562 helix, 539 parotitis, 546 strabismus, 536 caries, 546 hernia, 593 percussion, 518 systole, 561 cataracts, 533 hordeolum (sty), 533 perfusion, 566 tartar, 546 cerumen, 539 hyperopia, 533 periodontal disease, 546 thrill, 562 clubbing, 530 hyperresonance, 519 PERRLA, 537 tragus, 539 cochlea, 540 incus, 540 pinna, 539 tremor, 577 conductive hearing loss, 540 inspection, 517 pitch, 519 triangular fossa, 539 conjunctivitis, 533 intensity, 519 plaque, 546 two-point discrimination, 582 cyanosis, 523 intention tremor, 577 pleximeter, 518 tympanic membrane, 539 dacryocystitis, 533 jaundice, 523 plexor, 518 tympany, 519 diastole, 561 lift, 560 precordium, 560 vestibule, 540 dullness, 519 lobule, 539 presbyopia, 533 visual acuity, 533 duration, 519 malleus, 540 proprioceptors, 581 visual fields, 533 edema, 523 manubrium, 554 pyorrhea, 546 vitiligo, 523 erythema, 523 mastoid, 539 quality, 519 eustachian tube, 540 miosis, 534 reflex, 581 exophthalmos, 532 mixed hearing loss, 540 resonance, 519 513 # 153613 Cust: Pearson Au: Berman Pg. No. 513 C/M/Y/K DESIGN SERVICES OF M30_BERM4362_10_SE_CH30.indd 513 S4CARLISLE 04/12/14 11:00 AM Title: Kozier & Erb’s Fundamentals of Nursing 10e Short / Normal Publishing Services 514 Unit 7 Assessing Health INTRODUCTION the location of the examination, and the agency’s priorities and pro- Assessing a client’s health status is a major component of nursing cedures. The order of head-to-toe assessment is given in Box 30–1. care and has two aspects: (1) the nursing health history discussed in Regardless of the procedure used, the client’s energy and time need Chapter 11 and (2) the physical examination discussed in this to be considered. The health assessment is therefore conducted in chapter. A physical examination can be any of three types: (1) a a systematic and efficient manner that results in the fewest position complete assessment (e.g., when a client is admitted to a health care changes for the client. agency), (2) examination of a body system (e.g., the cardiovascular Frequently, nurses assess a specific body area instead of the entire system), or (3) examination of a body area (e.g., the lungs, when dif- body. These specific assessments are made in relation to client com- ficulty with breathing is observed). Note: Some nurses consider as- plaints, the nurse’s own observation of problems, the client’s present- sessment to be the broad term used in applying the nursing process to ing problem, nursing interventions provided, and medical therapies. health data and examination to be the physical process used to gather Examples of these situations and assessments are provided in Table 30–1. the data. In this text, the terms assessment and examination are some- These are some of the purposes of the physical examination: times used interchangeably—both referring to a critical investigation • To obtain baseline data about the client’s functional abilities. and evaluation of client status. • To supplement, confirm, or refute data obtained in the nursing history. • To obtain data that will help establish nursing diagnoses and plans PHYSICAL HEALTH ASSESSMENT of care. A complete health assessment may be conducted starting at the head • To evaluate the physiological outcomes of health care and thus the and proceeding in a systematic manner downward (head-to-toe as- progress of a client’s health problem. sessment). However, the procedure can vary according to the age of • To make clinical judgments about a client’s health status. the individual, the severity of the illness, the preferences of the nurse, • To identify areas for health promotion and disease prevention. BOX 30–1 Head-to-Toe Framework • General survey • Chest and back • Vital signs • Skin • Head • Thorax shape and size • Hair, scalp, face • Lungs • Eyes and vision • Heart • Ears and hearing • Spinal column • Nose • Breasts and axillae • Mouth and oropharynx • Abdomen • Neck • Skin • Muscles • Abdominal sounds • Lymph nodes • Femoral pulses • Trachea • External genitals • Thyroid gland • Anus • Carotid arteries • Lower extremities • Neck veins • Skin and toenails • Upper extremities • Gait and balance • Skin and nails • Joint range of motion • Muscle strength and tone • Popliteal, posterior tibial, and dorsalis pedis pulses • Joint range of motion • Brachial and radial pulses • Sensation TABLE 30–1 Nursing Assessments Addressing Selected Client Situations Situation Physical Assessment Client complains of abdominal pain. Inspect, auscultate, percuss, and palpate the abdomen; assess vital signs. Client is admitted with a head injury. Assess level of consciousness using Glasgow Coma Scale (see Table 30–10 later in this chapter); assess pupils for reaction to light and accommodation; assess vital signs. The nurse prepares to administer a cardiotonic drug to Assess apical pulse and compare with baseline data. a client. The client has just had a cast applied to the lower leg. Assess peripheral perfusion of toes, capillary blanch test, pedal pulse if able, and vital signs. The client’s fluid intake is minimal. Assess tissue turgor, fluid intake and output, and vital signs. # 153613 Cust: Pearson Au: Berman Pg. No. 514 C/M/Y/K DESIGN SERVICES OF M30_BERM4362_10_SE_CH30.indd 514 S4CARLISLE 04/12/14 11:00 AM Title: Kozier & Erb’s Fundamentals of Nursing 10e Short / Normal Publishing Services Chapter 30 Health Assessment 515 BOX 30–2 Cancer Screening Guidelines for Asymptomatic People COLORECTAL CANCER (MALES AND FEMALES) CERVICAL AND UTERINE CANCER (FEMALES) • Fecal occult blood test or fecal immunochemical test annually • For women ages 21 to 29, screening every 3 years with Pap tests. beginning at age 50 or • For women ages 30 to 65, screening every 5 years with both HPV • Stool DNA test may be done beginning at age 50. test and the Pap test, or every 3 years with the Pap test alone. • Flexible sigmoidoscopy every 5 years beginning at age 50 or • Women ages 65 and older who have had ≥3 consecutive neg- • Colonoscopy every 10 years beginning at age 50 or ative Pap tests or ≥2 consecutive negative HPV and Pap tests • Double contrast barium enema every 5 years beginning at in the last 10 years, the most recent test in the last 5 years, and age 50. women who have had a total hysterectomy should stop cervical • Computerized tomography colonography every 5 years begin- cancer screening. ning at age 50. PROSTATE CANCER (MALES) BREAST CANCER (FEMALES) • For men who have at least a 10-year life expectancy, discussion • Beginning in their early 20s, women should be told about with the primary care provider about the benefits, risks, and un- the benefits and limitations of breast self-examination (BSE) certainties associated with prostate cancer screening. and the importance of reporting breast symptoms to a health HEALTH COUNSELING AND CANCER CHECKUP professional. Those who choose to perform BSE should re- (MALES AND FEMALES) OVER AGE 20 ceive instruction and have their technique reviewed regularly. • Examination for cancers of the thyroid, testicles, ovaries, lymph Women may choose to perform BSE regularly, occasionally, or nodes, oral region, and skin during the regular health examination not at all. • Clinical breast examination every 3 years from ages 20 to 40, From “Cancer Screening in the United States, 2014: A Review of Current American Cancer Society Guidelines and Current Issues in Cancer Screening” by R. A. Smith, D. Manassaram- and then annually beginning at age 40. Baptiste, D. Brooks,
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