Health assessment & physical examination PDF
Preview Health assessment & physical examination
+ Estes H e a l t h A s s e s s m e n t & Physical E x a m i n a t i o n Pauline Calleja Karen Theobald Theresa Harvey --------------- -- ...... ,_. ....... //_,,..-· Estes -------------. ,/,,, Health \._\ I ' /, I Assessment \ \\ I I I l ( & Physical l \. Examination ! \ I \ I \ I \, Pauline Calleja ,/ ' \, Karen Theobald ,,, I ' I ' ',,, Theresa Harvey ,..-,, I '',,,__ ,,' -- --- ,, ... ___ -_,,'' ----- --------- 3RD AUSTRALl,AN & NEW ZEALAND EDITION Copyright 2020 Cengage Leaming. All Rights Reserved. May not be copied, scanned, or duplicated, In whole or In part. WCN 02·200-202 + Estes H e a l t h Assessment & Physical E x a m i n a t i o n Pauline Calleja Karen Theobald Theresa Harvey ·- ~-'~ CENGAGE Health Assessment and Physical Examination © 2020 (engage Leaming Australia Pty limited 3rd Edition Mary Ellen Zator Estes Copyright Notice Pauline Calleja This Work Is copyright. No part of this Work may be reproduced, stored In a Karen Theobald retrieval system, or transmitted In any form or by any means without prior Theresa Harvey written permission of the Publisher. Except as permitted under the Copyright Act 1968. for example any fair dealing for the purposes or pnvate study, research, criticism or review, subject to certain limitations. 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[email protected] Authorised adaptation of, Health Assessment & Physical Examination, Fifth National Library of Australia Cataloguing-in-Publication Data edition, by Mary Ellen Zator Estes© 2014, (engage Learning (97811313610939) ISBN: 9780170420587 A catalogue record for this book is available from the National Library of This 3rd edition published in 2020. Australia. Title page image courtesy Stocksy.com/lumina Images. (engage learning Australia Level 7, 80 Dorcas Street South Melbourne, Victoria Australia 3205 (engage Learning New Zealand Unit 48 Rosedale Office Park 331 Rosedale Road, Albany, North Shore 0632. NZ For learning solutions, visit cengage.com.au Printed In Singapore by 1010 Printing lnternauonal Limited. 1 2 3 4 5 6 7 23 22 212019 pyrlght 2020 Cengage Leaming. All Rights Reserved. May not b. copied, scanned, or duplicated, In whole or In part WCN 02·200-202 UNIT 1 LAYING THE FOUNDATION Chapter 1 Critical thinking and the nursing process 2 Chapter 2 The patient interview and developmental considerations 13 Chapter 3 The complete health history including documentation 51 Chapter 4 Cultural considerations 85 UNIT 2 PHYSICAL EXAMINATION Chapter 5 Physical exa1mination techniques 104 Chapter 6 Examination requirements for every patient 121 Chapter 7 Mental status and neurological techniques 155 Chapter 8 Skin, hair and nails 215 Chapter 9 Head, neck and regional lymph nodes 262 Chapter 10 Eyes 289 Chapter 11 Ears, nose, mouth and throat 320 Chapter 12 Breasts and regional nodes 362 Chapter 13 Thorax and lungs 391 Chapter 14 Heart and blood vessels 442 Chapter 15 Abdomen arnd nutrition 491 Chapter 16 Musculoskeletal system 540 Chapter 17 Female genitalia 604 Chapter 18 Male genitallia 644 Chapter 19 Anus, rectum and prostate 675 UNIT 3 SPECIFIC LIFESPAN POPULATIONS Chapter 20 The pregnarnt woman 697 Chapter 21 The paediatric patient 737 Chapter 22 The older ad ult 802 UNIT 4 PUTTING IT ALL TOGETHER Chapter 23 Health asse:;sment and physical examination in context 840 Appendix: Functional assessments 859 Copyright 2020 Cengage Leaming. All Rights Reserved. May not be copied, scanned, or duplicated, In whole or In part WCN 02·200-202 Copyright 2020 Cengage Leaming. All Rights Reserved. May not be copied, scanned, or duplicated, In whole or in part WCN 02-200-202 vii Guide to the text xiv Offering false reassurance 29 Guide to the online resources xviii Giving approval 29 Preface to this edition xx Defending 30 Acknowledgments xxii Advising 30 About the authors xxiii Questioning techniques which may be problematic 31 Interviewing the patient with special needs 32 The patient with impaired hearing 33 UNIT1 The patient with impaired vision 33 LAVING THE FOUNDATION The patient with impaired speech or aphasia 34 The patient with a low literacy level 34 01 Critical thinking and the nursing process The patient who is culturally or linguistically diverse 34 Background 2 The patient who has a low level of understanding 35 Critical thinking and clinical reasoning 3 The patient who is emotional and upset 35 Applying the Universal Intellectual Standards for critical thinking 4 Behaviour that may be sexually inappropriate or threatening 36 Components of critical thinking and clinical reasoning 5 The patient who is under the influence of alcohol or drugs 36 Critical thinking and the nursing process 6 Developmental theories 37 Assessment: Taking the patient's health history 8 Ages and stages developmental theories 38 Planning for physical examination 8 Developmental stages, tasks and life events 38 Implementation: Conducting the physical examinatio1n 8 Developmental tasks of infants (birth to 1 year) 39 Physical examination findings 9 Developmental tasks of toddlers (1 to 3 years) 40 Diagnostic and laboratory data 9 Developmental tasks of preschoolers (3 to 6 years) 42 Evaluation of health assessment and physical examination Developmental tasks of school-age children (6 to 12 years) 43 findings 10 Developmental tasks of adolescents (12 to 18 years) 43 Putting it all together 10 Developmental tasks of young adults (18 to 30 years) 44 Prioritisation for patient acuity 10 Developmental tasks of early middle adulthood (30 to 50 years) 45 Evidence-based practice 11 Developmental tasks of late middle adulthood (50 to 70 years) 46 Clinical (or critical) pathways 11 Developmental tasks of late adulthood (70 years to death) 47 Chapter resources 12 Developmental assessment tools 47 Chapter resources 49 02 The patient interview and developmental considerations 03 The complete health history including documentation 51 Background 13 Background 51 The patient interview 14 Types of health history 52 The nurse 14 Preparing for the health history 52 The patient 14 General approach to the health history 53 General approach to planning for the patient interview 15 Identifying information 54 Considerations for interviewing 15 Today's date 54 Stages of the interview process 18 Demographic data 54 Factors affecting communication 18 The complete health history assessment tool 54 Effective communication techniques 20 Source and reliability of information 55 Using open-ended questions 21 Patient profile 56 Using closed questions 21 Reason for seeking health care and chief complaint 56 Facilitating 22 Present health and history of the present illness 56 Using silence 22 Past health history 59 Grouping communication techniques 22 Family health history 64 Communication: Techniques to avoid 27 SociaI history 65 Requesting an explanation 28 Probing 28 Copyright 2020 Cengage Leaming. All Rights Reserved. May not be copied, scanned, or duplicated, In whole or in part WCN 02-200-202 viii CONTENTS Health maintenance and education activities 75 Pain 146 Review of systems 78 Perception of pain 146 Concluding the health history 80 Source of pain 146 Supportive equipment 80 Types of pain 148 Documentation 80 Variables affecting pain 148 Chapter resources 83 Effects of pain on the body 149 Pain assessment 149 04 Cultural considerations ~ Pain management 152 Chapter resources 152 Background 85 Culture 86 07 Mental status and neurological techniques 155 Defining cultural competence and cultural safety 86 Cultural competence 87 Background 155 Cultural safety 88 Anatomy and physiology 157 Effects of culturally unsafe practices on health care 90 Macrostructure 157 Australia and New Zealand's First Nations peoples and c1ultural Meninges 157 safety 91 Central nervous system 158 The process of decolonisation 95 Blood supply 162 Spirituality 95 Peripheral nervous system 162 The health effects of religion and spirituality 97 Reflexes 165 Role of the nurse related to a patient's spiritual needs 98 Assessment: Taking the patient's health history 165 Chapter resources 100 Person-centred health education 171 Planning for physical examination 172 Evaluating subjective data to focus physical examination 172 UNIT2 Environment 172 PHYSICAL EXAMINATION Equipment 172 Implementation: Conducting the physical examination 172 05 Physical examination techniques General approach to neurological assessment 173 Background 104 Examination of mental status 175 Considerations prior to commencing physical examination 104 Sensory examination 191 Standard precautions 105 Examination of cranial nerves 192 Transmission-based precautions 108 Examination of motor system 198 Legal considerations 109 Examination of cerebellar function (coordination and gait) 199 Physical examination techniques 109 Evaluation of health assessment and physical examination General approach to physical examination 110 findings 201 Inspection 112 Case study 1: The patient with delirium 201 Palpation 112 Case study 2: The patient with early onset dementia 206 Percussion 114 Case study 3: The patient with depression and anxiety 209 Auscultation 116 Chapter resources 212 Equipment 118 Chapter resources 119 08 Skin, hair and nails 215 Background 215 lllED 06 Examination requirements for every patient Anatomy and physiology 216 Background 121 Skin 216 Planning for physical examination 121 Hair 218 Environment 122 Nails 219 Equipment 122 Function of skin 219 Implementation: Conducting the general survey 122 Function of hair 220 Examination of physical status 122 Function of nails 220 Examination of psychological status 125 Assessment Taking the patient's health history 220 Examination of vital signs 129 Person-centred health education 224 General approach to vital signs assessment 129 Planning for physical examination 225 Respiration 129 Evaluating subjective data to focus physical examination 225 Pulse 131 Environment 225 Temperature 135 Equipment 225 Blood pressure 138 Oxygen saturation (Sp0 144 ) 2 Copyright 2020 Cengage Leaming. All Rights Reserved. May not be copied, scanned, or duplicated, In whole or In part WCN 02-200-202 CONTENTS il\ Implementation: Conducting the physical examinatio1n 226 Examination of extraocular muscle function 305 General approach to examination of the skin 227 Examination of anterior segment structures 307 Examination of the skin 227 Evaluation of health assessment and physical Examination of the hair 249 examination findings 313 Examination of the nails 252 Case study: The patient with senile cataract 314 Evaluation of health assessment and Chapter resources 318 physical examination findings 255 Case study: The patient with herpes zoster 256 11 Ears, nose, mouth and throat 320 Chapter resources 260 Background 320 Anatomy and physiology 321 09 Head, neck and regional lymph nodes Ear 321 Background 262 Nose 323 Anatomy and physiology 263 Sinuses 324 Skull 263 Mouth and throat 325 Face 264 Assessment: Taking the patient's health history 327 Neck 264 Person-centred health education 331 Thyroid 264 Planning for physical examination 332 Lymph nodes 265 Evaluating subjective data to focus physical examination 332 Bl cod supply 265 Environment 332 Assessment: Taking the patient's health history 266 Equipment 332 Person-centred health education 269 Implementation: Conducting the physical examination 333 Planning for physical examination 270 General approach to examination of the ears. nose. Evaluating subjective data to focus physical assessment 271 mouth and throat 334 Environment 271 Examination of the ear 334 Equipment 271 Examination of the nose 340 Implementation: Conducting the physical examinatio1n 271 Examination of the sinuses 343 General approach to examination of head, neck and regional Examination of the mouth and throat 344 lymph nodes 272 Examination of breath 344 Examination of the head 272 Examination of the lips 345 Examination of the scalp 273 Examination of the tongue 346 Examination of the face 274 Examination of buccal mucosa 348 Examination of the mandible 276 Examination of the gums 349 Examination of the neck 276 Examination of the teeth 350 Examination of regional lymphatics: the thyroid gland 277 Examination of the palate 351 Examination of regional lymphatics: the lymph nodes 281 Examination of the throat 351 Evaluation of health assessment and physical Evaluation of health assessment and physical examination findings 282 examination findings 352 Case study: The patient with hyperthyroidism, Graves' disease 283 Case study: The patient with acute rhinosinusitis 353 Chapter resources 286 Chapter resources 360 10 Eyes 12 Breasts and regional nodes 362 Background 289 Background 362 Anatomy and physiology 291 Anatomy and physiology 363 External structures 291 Breasts 363 Internal structures 292 Regional nodes 365 Visual pathway 293 Breast development 366 Assessment: Taking the patient's health history 293 Assessment: Taking the patient's health history 367 Person-centred health education 297 Person-centred health education 370 Planning for physical examination 297 Planning for physical examination 371 Environment 298 Evaluating subjective data to focus physical examination 371 Equipment 298 Environment 371 Implementation: Conducting the physical examinatio1n 298 Equipment 372 General approach to examination of the eyes 299 Implementation: Conducting the physical examination 372 Examination of visual acuity 299 General approach to examination of female breasts Examination of visual fields 302 and regional nodes 372 Examination of external eye and lacrimal apparatus 302 Copyright 2020 Cengage Leaming. All Rights Reserved. May not be copied, scanned, or duplicated, In whole or In part WCN 02-200-202
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