Chapter 20 Health History and Physical Assessment PDF

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Notes from Fundamentals of Nursing Yoost/Crawford...

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! CHAPTER 20: HEALTH HISTORY AND PHYSICAL ASSESSMENT! ! KEY TERMS! accommodation - Changing the pattern of behavior when encountering new similar objects. The ability of the eyes to focus on near objects. adventitious breath sounds - Abnormal sounds that originate in the lungs and airways. albinism - A congenital loss of pigmentation characterized by a generalized lack of melanin pigment in the eyes, skin, and hair or, in rare instances, in the eyes alone. alopecia - Permanent or temporary hair loss. atelectasis - The collapse of all or part of the lung. auscultation - Listening, with the assistance of a stethoscope, to sounds within the body. borborygmi - Hyperactive bowel sounds audible without a stethoscope. bruit - An abnormal swooshing sound audible on auscultation over an aneurysm, the carotid artery, or an arteriovenous (AV) fistula. capillary refill - An indication of peripheral blood perfusion, measured in seconds. cardiac murmurs - Blowing or swishing sounds heard on systole or diastole, caused by increased or abnormal blood flow through the valves of the heart. cataracts - A condition that causes the lens of the eye to become cloudy and impair vision. cerumen - Earwax. cheilitis - Dry, cracked lips. chief complaint - The patient's presenting problem, reason for seeking care. clinical manifestations - Signs and symptoms. clonus - A repetitive vibratory contraction of the muscle that occurs in response to muscle and tendon stretch. comorbid - Two or more medical conditions existing simultaneously. consistency - The measurement of organ location and size against the expected anatomic norm. crepitation (crepitus) - Crackling or rubbing felt as a result of air in superficial tissues. cyanosis - Bluish discoloration of the skin and mucous membranes, caused by decreased oxygen levels in arterial blood. deep vein thrombosis (DVT) - A blood clot that develops in peripheral circulation. diplopia - Double vision. dysrhythmia - An irregular rhythm in the pulse, caused by an early, late, or missed heartbeat. ecchymosis - Bruising. edema - Swelling. epistaxis - Nosebleed. erythema - Redness of the skin caused by congestion or dilation of the superficial blood vessels in the skin, signaling circulatory changes to an area. excoriation - An abrasion due to rubbing or scratching. focused assessment - An examination in which only specific, relevant areas are examined. guarding - Positioning to prevent movement of a painful body part. hirsutism - A condition affecting both men and women in which hair growth on the upper lip, chin, and cheeks becomes excessive and vellus body hair becomes thicker and coarser. hydrocephalus - An accumulation of cerebrospinal fluid in the ventricles of the brain. hypertonicity - An increase in muscle tone. hypotonicity - A decrease in muscle tone. inspection - The use of vision, hearing, and smell to closely scrutinize physical characteristics of a whole person and individual body systems. jaundice - A yellow hue to the skin, mucous membranes, or eyes of both light- and dark-skinned individuals. kyphosis - An outward curvature of the thoracic spine. lordosis - An inward lumbar curvature just above the buttocks area. nystagmus - Rapid, shaking, involuntary movement of the eyes. pallor - Pale skin tone that is usually uniformly disseminated throughout the skin surface. Pallor can be caused by illness, emotional shock or stress, decreased exposure to sunlight, anemia, or genetics. palpation - Physical examination using touch to assess body organs and skin texture, temperature, moisture, turgor, tenderness, and thickness. paresthesia - Numbness or tingling. percussion - Tapping the patient's skin with short, sharp strokes that cause a vibration to travel through the skin and to the upper layers of the underlying structures. peristalsis - Progressive wave action causing movement of contents through the gastrointestinal system. petechiae - Tiny, dark red spots that indicate hemorrhage under the skin. phlebitis - Inflammation of a vein. physical assessment - A comprehensive data collection followed by an extensive physical examination of every body system. pruritus - Itching. ptosis - Abnormal drooping of the eyelid. pulmonary embolism (PE) - A blood clot that detaches and lodges in the pulmonary artery. pulse deficit - The apical pulse rate exceeds the radial pulse rate. purpura - Bleeding underneath the skin. purulent - Containing pus.

scoliosis - Sideways or S-shaped curvature of the spine that is always abnormal. smegma - A whitish substance under the foreskin. stenosis - Narrowing. strabismus - Crossed eyes. striae - Stretch marks resulting from pregnancy and weight loss or gain. tactile fremitus - A palpable vibration transmitted through the chest wall that occurs with the movement of the vocal cords during speech. thrill - Abnormal vibration felt on palpation over an aneurysm, the carotid artery, or an arteriovenous (AV) fistula. tinnitus - Ringing in the ears.! tortuosity - Bending and twisting. turgor - Tension due to fluid content. venous thromboembolism (VTE), - A condition in which a blood clot forms most often in the deep veins of the legs, groin, or arm (known as deep vein thrombosis, DVT) and may travel in the circulation, lodging in the lungs (known as a pulmonary embolism, PE). vertigo - Disequilibrium, spinning sensation. vitiligo - A loss of skin pigment.

Physical Examination - collect data to get a baseline of the patient upon admission/once a shift! ! Patient Interview: gathers subjective data ! -Health History: subjective data from verbal interaction and objective data through observation! -Review of systems: collect subjective data, closed ended questions! ! Preparing for physical assessment:! Wash hands/critical elements! Environment: lighting/temperature, safety, bed position (raised to a 30-degree angle, small pillow offered beneath head)! Equipment: have all supplies with you! Patient Preparation: start with least invasive to most invasive! Privacy: Nurses must protect the confidentiality of protected info in EHRs.! Positioning the patient: comorbid - two or more medical conditions existing simultaneously ! Integration of assessment skills: chief complaint (presenting problem) , clinical manifestations (signs and symptoms)! ! Assessment techniques: Inspection: Vision and smell, identify variances (normal vs. abnormal)! Palpation: touch, personal, light and (deep is more advanced) turgor, crepitation,! Percussion: tapping (more advanced) ! Auscultation: listening, frequency, loudness, quality, duration (last step unless its an abdominal assessment)! ! General Survey: visual assessment and evaluation General appearance: age, race, gender! Behavior: affect, mood, drug use! Clothing! Hygiene! Safety - assistive devices! Speech! Gait! Vital signs! Height and weight! ! Physical Examination: Neurological: ! • level of consciousness (LOC)!

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! Skin:! • Color - albinism, cyanosis, erythema, purpura, jaundice, pallor, vitiligo! • Moisture! • Temperature! • Texture - petechiae! • Turgor (holding up a pinch)! • Edema (fluid buildup)! ! Nails:! • Nail bed should be light pink to reddish brown ! • Cuticles should be smooth! • Capillary refill: (indication of peripheral blood flow)! • No clubbing, no yellow color! ! Eyes:! • Alignment, eyebrows/lids, conjunctiva, sclera, visual acuity, extraocular movement ! • Pupil assessment (pen light)!

Ears:! • Integrity of structures, anatomy! • Hearing acuity (tinnitus)! • Use of assistive devices! • Discharge (purulent)! • Pull down ear for kids, pull up for adults! ! Nose:! • Inspection and palpation (polyps?) (epistaxis)! • Breathing! • Presence of NG tube or nasal cannula! ! Mouth:! • Lips (cheilitis)! • Buccal mucosa, gums, teeth! • Tongue and floor of mouth! • Palate ! ! ROM:! • Upper and lower extremities! • Assessment is performed at joint levels! • Document variances! ! Motor Function:! • Upper and lower extremities, compare right and left side! • Documentation includes:!

Respiratory:! • Auscultate from top of lungs! • Listen for a complete breath ! • Adventitious sounds!

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! Vascular System:! • Rhythm and strength!

! Cardiac:! • Compare assessment of heart functions with vascular finding! • Inspection and auscultation ! • Anatomical landmarks:!

1. Aortic - 2nd right intercostal space! 2. Pulmonic! 3. Erb’s point! 4. Tricuspid! 5. Mitral - PMI! ! Abdomen:! • Organs of lower GI tract! • Abdominal pain! • 4 quadrants! • Order of assessment:! 1. Inspection! A. Abnormal movement or shadows, contour! B. Color, venous pattern, scars, striae! 2. Auscultation! A. Prior to palpation! B. Turn off suction, if patient has NG tube! 3. Palpation! A. Areas of tenderness, distension, masses! 4. Percussion! ! Complete: don’t forget to document ! ! !

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