30 Health Assessment - Pearson

1 LEARNING OUTCOMESA fter completing this chapter, you will be able to:1. Identify the purposes of the physical Explain the four techniques used in physical examination: inspection, palpation, percussion, and Identify expected findings during Health Verbalize the steps used in performing selected examination procedures:a. Assessing appearance and mental Assessing the Assessing the Assessing the Assessing the skull and Assessing the eye structures and visual Assessing the ears and Assessing the nose and Assessing the mouth and Assessing the Assessing the thorax and TERMS adventitious breath sounds, 555alopecia, 528angle of Louis, 553antihelix, 539aphasia, 580astigmatism, 533auricle, 539auscultation, 519blanch test, 530bruit, 562caries, 546cataracts, 533cerumen, 539clubbing, 530cochlea, 540conductive hearing loss, 540conjunctivitis, 533cyanosis, 523dacryocystitis, 533diastole, 561dullness, 519duration, 519edema, 523erythema, 523eustachian tube, 540exophthalmos, 532external auditory meatus, 539extinction, 582fasciculation, 577flatness, 519fremitus, 557gingivitis, 546glaucoma, 533glossitis, 546goniometer, 579helix, 539hernia.

2 593hordeolum (sty), 533hyperopia, 533hyperresonance, 519incus, 540inspection, 517intensity, 519intention tremor, 577jaundice, 523lift, 560lobule, 539malleus, 540manubrium, 554mastoid, 539miosis, 534mixed hearing loss, 540mydriasis, 534myopia, 533normocephalic, 531nystagmus, 536one-point discrimination, 582ossicles, 540otoscope, 539pallor, 523palpation, 517parotitis, 546percussion, 518perfusion, 566periodontal disease, 546 PERRLA, 537pinna, 539pitch, 519plaque, 546pleximeter, 518plexor, 518precordium, 560presbyopia, 533proprioceptors, 581pyorrhea, 546quality, 519reflex, 581resonance, 519resting tremor, 577S1, 561S2, 561semicircular canals, 540sensorineural hearing loss, 540sordes, 546stapes, 540stereognosis, 582sternum, 554strabismus, 536systole, 561tartar, 546thrill, 562tragus, 539tremor, 577triangular fossa, 539two-point discrimination, 582tympanic membrane.

3 539tympany, 519vestibule, 540visual acuity, 533visual fields, 533vitiligo, 52330 Health Assessment # 153613 Cust: Pearson Au: Berman Pg. No. 513 Title: Kozier & Erb s Fundamentals of Nursing 10 eC/M/Y/K Short / NormalDESIGN SERVICES OFS4 CARLISLEP ublishing Servicesl. Assessing the heart and central Assessing the peripheral vascular Assessing the breasts and Assessing the Assessing the musculoskeletal Assessing the neurologic Assessing the female genitals and inguinal Assessing the male genitals and inguinal Assessing the Describe suggested sequencing to conduct a physical Health examination in an orderly Discuss variations in examination techniques appropriate for clients of different Recognize when it is appropriate to delegate Assessment skills to unlicensed assistive Demonstrate appropriate documentation and reporting of Health 51304/12/14 11:00 AM# 153613 Cust: Pearson Au: Berman Pg.

4 No. 514 Title: Kozier & Erb s Fundamentals of Nursing 10 eC/M/Y/K Short / NormalDESIGN SERVICES OFS4 CARLISLEP ublishing Services514 Unit 7 Assessing Healththe location of the examination, and the agency s priorities and pro-cedures. The order of head-to-toe Assessment is given in Box 30 1. Regardless of the procedure used, the client s energy and time need to be considered. The Health Assessment is therefore conducted in a systematic and efficient manner that results in the fewest position changes for the , nurses assess a specific body area instead of the entire body. These specific assessments are made in relation to client com-plaints, the nurse s own observation of problems, the client s present-ing problem, nursing interventions provided, and medical therapies.

5 Examples of these situations and assessments are provided in Table 30 are some of the purposes of the physical examination: To obtain baseline data about the client s functional abilities. To supplement, confirm, or refute data obtained in the nursing h i s t o r y. To obtain data that will help establish nursing diagnoses and plans of care. To evaluate the physiological outcomes of Health care and thus the progress of a client s Health problem. To make clinical judgments about a client s Health status. To identify areas for Health promotion and disease a client s Health status is a major component of nursing care and has two aspects: (1) the nursing Health history discussed in Chapter 11 and (2) the physical examination discussed in this chapter. A physical examination can be any of three types: (1) a complete Assessment ( , when a client is admitted to a Health care agency), (2) examination of a body system ( , the cardiovascular system), or (3) examination of a body area ( , the lungs, when dif-ficulty with breathing is observed).

6 Note: Some nurses consider as-sessment to be the broad term used in applying the nursing process to Health data and examination to be the physical process used to gather the data. In this text, the terms Assessment and examination are some-times used interchangeably both referring to a critical investigation and evaluation of client Health ASSESSMENTA complete Health Assessment may be conducted starting at the head and proceeding in a systematic manner downward (head-to-toe as-sessment). However, the procedure can vary according to the age of the individual, the severity of the illness, the preferences of the nurse, BOX 30 1 Head-to-Toe Framework General survey Vital signs Head Hair, scalp, face Eyes and vision Ears and hearing Nose Mouth and oropharynx Neck Muscles Lymph nodes Trachea Thyroid gland Carotid arteries Neck veins Upper extremities Skin and nails Muscle strength and tone Joint range of motion Brachial and radial pulses Sensation Chest and back Skin Thorax shape and size Lungs Heart Spinal column Breasts and axillae Abdomen Skin Abdominal sounds Femoral pulses External genitals Anus Lower extremities Skin and toenails Gait and balance Joint range of motion Popliteal, posterior tibial.

7 And dorsalis pedis pulsesTABLE 30 1 Nursing Assessments Addressing Selected Client SituationsSituationPhysical AssessmentClient complains of abdominal , auscultate, percuss, and palpate the abdomen; assess vital is admitted with a head 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 nurse prepares to administer a cardiotonic drug to a apical pulse and compare with baseline client has just had a cast applied to the lower peripheral perfusion of toes, capillary blanch test, pedal pulse if able, and vital client s fluid intake is tissue turgor, fluid intake and output, and vital 51404/12/14 11:00 AMChapter 30 Health Assessment 515# 153613 Cust: Pearson Au: Berman Pg. No. 515 Title: Kozier & Erb s Fundamentals of Nursing 10 eC/M/Y/K Short / NormalDESIGN SERVICES OFS4 CARLISLEP ublishing Servicesand neck, heart and lungs, and range of motion can be done early in the process, with the ears, mouth, abdomen, and genitals being left for the end of the the EnvironmentIt is important to prepare the environment before starting the assess-ment.

8 The time for the physical Assessment should be convenient to both the client and the nurse. The environment needs to be well lighted and the equipment should be organized for efficient use. A client who is physically relaxed will usually experience little dis-comfort. The room should be warm enough to be comfortable for the privacy is important. Most people are embarrassed if their bodies are exposed or if others can overhear or view them dur-ing the Assessment . Culture, age, and gender of both the client and the Nurses use national guidelines and evidence-based practice to focus Health Assessment on specific conditions. The nurse s judgment is key when the evidence is inconclusive or conflicting. For example, when screening for cancer, nurses should keep in mind the American Cancer Society s guidelines for early detection (Box 30 2).

9 However, whereas those guidelines call for mammography every year begin-ning at age 40, the Preventive Services Task Force (2009) recom-mends breast mammography only every 2 years for women ages 50 to 74 and none the ClientMost people need an explanation of the physical examination. Often clients are anxious about what the nurse will find. They can be reas-sured during the examination by explanations at each step. The nurse should explain when and where the examination will take place, why it is important, and what will happen. Instruct the client that all in-formation gathered and documented during the Assessment is kept confidential in accordance with the Health Insurance Portability and Accountability Act (HIPAA). This means that only those Health care providers who have a legitimate need to know the client s information will have access to examinations are usually painless; however, it is im-portant to determine in advance any positions that are contraindi-cated for a particular client.

10 The nurse assists the client as needed to undress and put on a gown. Clients should empty their bladders before the examination. Doing so helps them feel more relaxed and facilitates palpation of the abdomen and pubic area. If a urinaly-sis is required, the urine should be collected in a container for that assessing adults it is important to recognize that people of the same age differ markedly. Box 30 3 provides special consider-ations for assessing adults, especially older sequence of the Assessment differs with children and adults. With children, always proceed from the least invasive or uncomfort-able aspect of the exam to the more invasive. Examination of the head BOX 30 2 Cancer Screening Guidelines for Asymptomatic PeopleCOLORECTAL CANCER (MALES AND FEMALES) Fecal occult blood test or fecal immunochemical test annually beginning at age 50 or Stool DNA test may be done beginning at age 50.