Chapter 25The Complete Health History and Physical Examination

CompetenciesIdentify 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.

General GuidelinesUtilize a holistic perspectiveUse critical thinking abilitiesRespect the patientDemonstrate self-awarenessAct professionallyAcknowledge emotional reactions to illnessBe sensitive to cultural and spiritual requirements

Tips for Fostering Patient CooperationMinimize waiting timeGreet the patientProceed in an organized mannerUse terminology that is easy to understandEncourage active participation from the patientExpress honesty

Legal ConsiderationsCareful, complete documentationRespect patient privacy, confidentiality, and the right to refuseAdhere to agency and Nurse Practice Act regulationsReport required diseasesUse common sense

Ethical PrinciplesAutonomyBeneficenceNonmaleficenceJusticeFidelityVeracityUtilitarianism

Purpose of Health History Dependent on patients reason for visitTypes of historiesCompleteEpisodicIntervalEmergency

Physical AssessmentGeneral surveyPhysical presencePsychological presenceDistressNeurological statusVital signsHeight, weight

Skin AssessmentHead to toeCharacteristicsColor, bleeding, ecchymosis, vascularity, lesionsMoisture, temperature, texture, turgor, edema

Head-to-Toe AssessmentHead and faceSymmetryCranial nervesHairEyesVisual acuityColor visionExtraocular musclesInternal and external structures(continues)

Head-to-Toe AssessmentEarsGross hearingExternal ear structuresOtoscopic exam(continues)

Head-to-Toe AssessmentNose and sinusesNostril patencyOlfactory senseSinusesMouth and throatBreath odorInspect internal and external structuresCranial nerves(continues)

Head-to-Toe AssessmentNeckROMMusculatureCarotid arteriesJugular veinsLymph nodes

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Head-to-Toe AssessmentUpper extremitiesNailbedsJointsROMPulses(continues)

Head-to-Toe AssessmentBack, posterior, and lateral thoraxesSpineThoracic expansionTactile fremitusDiaphragmatic excursionCostovertebral angle tenderness(continues)

Head-to-Toe AssessmentHeartInspect/palpate for pulsations, thrills, heavesApical pulseCardiac landmarksAorticPulmonicMitralTricuspidErbs point(continues)

Head-to-Toe AssessmentFemale breastsCharacteristics to assess: color, vascularity, thickening/edema, sizePalpate lymph nodesTeach breast self-examination(continues)

Head-to-Toe AssessmentMale breastsGynecomastiaJugular veinsObserve for distensionPatient position: 45 degrees and supine(continues)

Head-to-Toe AssessmentAbdomenContour, symmetry, pigmentation, colorScars, striae, visible peristalsis, masses, pulsationsBowel soundsPalpate all quadrants and internal organs(continues)

Head-to-Toe AssessmentInguinal areaLymph nodesInguinal herniasPalpate femoral pulses(continues)

Head-to-Toe AssessmentLower extremitiesColor, capillary refill, edema, ulcerations, hair distribution, varicose veinsPopliteal, dorsalis pedis, posterior tibial pulsesROMMuscle size, toneTemperature, edema, texture(continues)

Head-to-Toe AssessmentNeurological systemCranial nervesReflexesBalanceMusculoskeletal systemMobilityROM(continues)

Head-to-Toe AssessmentFemale genitalia, anus, and rectumExternal and internal genitaliaVaginal examRectovaginal examOccult blood testing(continues)

Head-to-Toe AssessmentMale genitaliaPenis, urethral meatus, scrotumInguinal areaTeach testicular self-examMale anus, rectum, and prostatePerineum, sacrococcygeal area, anal mucosaAnus and rectumPalpate the prostate