Health Assessment and Physical Examination

Half title page
Title page
Imprint page
Brief contents
Contents
Guide to the text
Guide to the online resources
Preface to this edition
Acknowledgements
About the authors
Unit 1: Laying the foundation
	Chapter 1: 
The nursing role in health assessment and physical examination
		Background
		Critical thinking and clinical reasoning
			Applying standards for critical thinking
			Components of critical thinking and clinical reasoning
		Critical thinking and the nursing process
		Critical thinking, cultural considerations for healthcare practice
		Culture
			Defining cultural competence and cultural safety
			Cultural competence
			Cultural safety
		Assessment: Taking the patient’s health history
		Planning for physical examination
		Implementation: Conducting the physical examination
			Physical examination findings
			Diagnostic and laboratory data
		Evaluation of health assessment and physical examination findings
			Putting it all together
			Prioritisation for consumer acuity
			Evidence-based practice
		Clinical (or critical) pathways
		Chapter resources
	Chapter 2: The health consumer interview approaches incorporating developmental considerations
		Background
		The consumer interview
			The nurse
			The consumer
			The nurse’s role in assessing a consumer’s spiritual needs
			General approach to planning for the health assessment interview
			Considerations for interviewing
			Stages of the interview process
			Factors affecting communication
		Effective communication techniques
			Using open-ended questions
			Using closed questions
			Facilitating
			Using silence
			Grouping communication techniques
		Communication: Techniques to avoid
			Requesting an explanation
			Probing
			Offering false reassurance
			Giving approval
			Defending
			Advising
			Questioning techniques which may be problematic
		Interviewing the consumer with special needs
			The consumer with impaired hearing
			The consumer with impaired vision
			The consumer with impaired speech or aphasia
			The consumer with a low literacy level
			The consumer who is culturally or linguistically diverse
			The consumer who has a low level of understanding
			The consumer who is emotional and upset
			Behaviour that may be sexually inappropriate or threatening
			The consumer who is under the influence of alcohol or drugs
		Developmental theories
			Transitional developmental theories
			Ages and stages developmental theories
		Developmental stages, tasks and life events
			Developmental tasks of infants (birth to 1 year)
			Developmental tasks of toddlers (1 to 3 years)
			Developmental tasks of preschoolers (3 to 6 years)
			Developmental tasks of school-age children (6 to 12 years)
			Developmental tasks of adolescents (12 to 18 years)
			Developmental tasks of young adults (18 to 30 years)
			Developmental tasks of early middle adulthood(30 to 50 years)
			Developmental tasks of late middle adulthood (50 to 70 years)
			Developmental tasks of late adulthood (70 years to death)
			Developmental assessment tools
		Chapter resources
	Chaper 3: The complete health history including documentation
		Background
		Types of health history
		Preparing for the health history
			General approach to the health history
		Identifying information
			Today’s date
			Demographic data
		The complete health history assessment tool
			Source and reliability of information
			Consumer profile
			Reason for seeking health care and chief complaint
			Present health and history of the present illness
			Past health history
			Family health history
			Social history
			Health maintenance and education activities
			Review of systems
		Concluding the health history
			Supportive equipment
		Documentation
		Chapter resources
	Chapter 4: Aboriginal and Torres Strait Islander
peoples’ health
		Background
		Introduction to culturally safe and responsive practice
			Cultural safety
			Cultural responsiveness
			Strengths-based communication
			Diversity and identity
		History
			Truth-telling
			Barriers to access: health care
		Strength in partnerships
			Respect
			Holistic health
			Connection and belonging to family, kinships and communities
			Connection and belonging to Country
			Reflexivity
		Communication in clinical practice for health assessment and physical examination
			Shared decision-making
			Dadirri: deep listening
			Yarning: cultural communication
			Keeping track of culturally safe practice
		Chapter resources
Unit 2: Physical examination
	Chapter 5: Physical examination techniques
		Background
		Considerations prior to commencing physical examination
			Standard precautions
			Transmission-based precautions
		Legal considerations
		Physical examination techniques
			General approach to physical examination
			Inspection
			Palpation
			Percussion
			Auscultation
			Equipment
		Chapter resources
	Chapter 6: Examination requirements for every consumer
		Background
		Planning for physical examination
			Environment
			Equipment
		Implementation: Conducting the general survey
			Examination of physical status
			Examination of psychological status
		Examination of vital signs
			General approach to vital signs assessment
			Respiration
			Pulse
			Temperature
			Blood pressure
			Oxygen saturation (SpO2)
		Pain
			Perception of pain
			Source of pain
			Types of pain
			Variables affecting pain
			Effects of pain on the body
			Pain assessment
			Pain management
		Chapter resources
	Chapter 7: Mental status and neurological techniques
		Background
		Anatomy and physiology
			Macrostructure
			Meninges
			Central nervous system
			Blood supply
			Peripheral nervous system
			Reflexes
		Assessment: Taking the consumer’s health history
		Person-centred health education
		Planning for physical examination
			Evaluating subjective data to focus physical examination
			Environment
			Equipment
		Implementation: Conducting the physical examination
			General approach to neurological assessment
			Examination of mental status
			Sensory examination
			Examination of cranial nerves
			Examination of motor system
			Examination of cerebellar function (coordination and gait)
		Evaluation of health assessment and physical examination findings
		Case study 1: The consumer with delirium
		Case study 2: The consumer with early onset dementia
		Case study 3: The consumer with depression and anxiety
		Chapter resources
	Chapter 8: Integumentary
		Background
		Anatomy and physiology
			Skin
			Hair
			Nails
			Function of skin
			Function of hair
			Function of nails
		Assessment: Taking the consumer’s health history
		Person-centred health education
		Planning for physical examination
			Environment
			Equipment
		Implementation: Conducting the physical examination
			General approach to examination of the skin
			Examination of the skin
			Examination of the hair
			Examination of the nails
		Evaluation of health assessment and physical examination findings
		Case study: The consumer with herpes zoster
		Chapter resources
	Chapter 9: Head, neck and regional lymph nodes
		Background
		Anatomy and physiology
			Skull
			Face
			Neck
			Thyroid
			Lymph nodes
			Blood supply
		Assessment: Taking the consumer’s health history
		Person-centred health education
		Planning for physical examination
			Evaluating subjective data to focus physical assessment
			Environment
			Equipment
		Implementation: Conducting the physical examination
			General approach to examination of head, neck and regionallymph nodes
			Examination of the head
			Examination of the scalp
			Examination of the face
			Examination of the mandible
			Examination of the neck
			Examination of regional lymphatics: the thyroid gland
			Examination of regional lymphatics: the lymph nodes
		Evaluation of health assessment and physical examination findings
		Case study: The consumer with hyperthyroidism, Graves’ disease
		Chapter resources
	Chapter 10: Eyes
		Background
		Leading eye health related concerns
		Anatomy and physiology
			External structures
			Internal structures
			Visual pathway
		Assessment: Taking the consumer’s health history
		Person-centred health education
		Planning for physical examination
			Environment
			Equipment
		Implementation: Conducting the physical examination
			General approach to examination of the eyes
			Examination of visual acuity
			Examination of visual fields
			Examination of external eye and lacrimal apparatus
			Examination of extraocular muscle function
			Examination of anterior segment structures
		Evaluation of health assessment and physical examination findings
		Case study: The consumer with senile cataract
		Chapter resources
	Chapter 11: Ears, nose, mouth and throat
		Background
		Anatomy and physiology
			Ear
			Nose
			Sinuses
			Mouth and throat
		Assessment: Taking the consumer’s health history
		Person-centred health education
		Planning for physical examination
			Evaluating subjective data to focus physical examination
			Environment
			Equipment
		Implementation: Conducting the physical examination
			General approach to examination of the ears, nose andsinuses, mouth and throat
			Examination of the ear
			Examination of the nose
			Examination of the sinuses
			Examination of the mouth and throat
			Examination of breath
			Examination of the lips
			Examination of the tongue
			Examination of buccal mucosa
			Examination of the gums
			Examination of the teeth
			Examination of the palate
			Examination of the throat
		Evaluation of health assessment and physical examination findings
		Case study: The consumer with acute rhinosinusitis
		Chapter resources
	Chapter 12: Breasts and regional nodes
		Background
		Anatomy and physiology
			Breasts
			Regional nodes
			Breast development
		Assessment: Taking the consumer’s health history
		Person-centred health education
		Planning for physical examination
			Evaluating subjective data to focus physical examination
			Environment
			Equipment
		Implementation: Conducting the physical examination
			General approach to examination of female breasts and regional nodes
			Examination of female breasts and regional nodes
			Diagnostic techniques
		Evaluation of health assessment and physical examination findings
		Case study: The consumer with fibrocystic breast changes
		Chapter resources
	Chapter 13: Respiratory
		Background
		Anatomy
			Thorax
			Sternum
			Ribs
			Intercostal spaces
			Lungs
			Pleura
			Mediastinum
			Bronchi
			Alveoli
			Diaphragm and muscles of respiration
		Physiology
			Ventilation
			External respiration
			Internal respiration
			Control of breathing
		Assessment: Taking the consumer’s health history
			Person-centred health education
		Planning for physical examination
			Evaluating subjective data to focus physical assessment
			Environment
			Equipment
		Implementation: Conducting the physical examination
			General approach to respiratory assessment
			Examination of the respiratory system
			Examination of respirations
			Assessing consumers with respiratory supportive equipment
		Evaluation of health assessment and physical examination findings
		Case study: The consumer with COVID-19 (moderate disease with deterioration)
		Chapter resources
	Chapter 14: Cardiovascular
		Background
		Anatomy and physiology
			Heart
			Coronary circulation
			Cardiac cycle
			Conduction system of the heart
			Blood vessels
		Assessment: Taking the consumer’s health history
			Calculating target heart rate zone
			Person-centred health education
		Planning for physical examination
			Evaluating subjective data to focus physical examination
			Environment
			Equipment
		Implementation: Conducting the physical examination
			General approach to heart assessment
			Examination of the precordium
			General approach to blood vessels examination
			Examination of the blood vessels
			Examination of the venous system
			Examination of the arterial system
		Evaluation of health assessment and physical examination findings
		Case study: The consumer with hypertension
		Chapter resources
	Chapter 15: Gastrointestinal
		Background
		Abdomen and nutrition assessment
			Nutrients
			Nutrition through the life cycle
			Cultural differences
		Anatomy and physiology
			Abdominal cavity
			Abdominal viscera (organs)
		Assessment: Taking the consumer’s health history
		Person-centred health education
		Planning for physical examination
			Evaluating subjective data to focus physical assessment
			Environment
			Equipment
		Implementation: Conducting the physical examination
			General approach to abdomen and nutrition assessment
			Examination of nutrition and abdomen
			Examination of the abdomen
			Examining consumers with abdominal tubes and drains
		Evaluation of health assessment and physical examination findings
		Case study: The consumer with inflammatory bowel disease
		Chapter resources
	Chapter 16: Musculoskeletal
		Background
		Anatomy and physiology
			Bones
			Muscles
			Tendons
			Cartilage
			Ligaments
			Bursae
			Joints
		Assessment: Taking the patient’s health history
		Person-centred health education
		Planning for physical examination
			Evaluating subjective data to focus physical assessment
			Environment
			Equipment
		Implementation: Conducting the physical examination
			General approach to the musculoskeletal system assessment
			Examination of the musculoskeletal system
			Examination of joints
			Assessing consumers with musculoskeletal supportive equipment
		Evaluation of health assessment and physical examination findings
		Case study: The consumer with musculoskeletal pain related to osteoarthritis
		Chapter resources
	Chapter 17: Genitourinary and reproductive genitalia
		Background
		Female genitalia
		Male genitalia
			Urinary system
		Anatomy and physiology
			Female
			The female reproductive cycle
			Male reproductive system
			Sexual development
			Spermatogenesis
			Male sexual function
			Anatomy and physiology of the urinary system
		Assessment: Taking the consumer’s health history
		Person-centred health education
		Planning for physical examination
			Evaluating subjective data to focus physical assessment
			Environment
			Equipment
		Implementation: Conducting the physical examination of the female
			General approach to female genitalia assessment
			Examination of the bladder
			Examination of the external genitalia
			Collecting specimens for cytological smears and cultures
			Classifications
			Culture specimens
			Examination of the vaginal wall
			Bimanual examination
			Rectovaginal examination
			Examining consumers with urinary diversions
		Implementation: Conducting the physical examination of the male
			General approach to examination of the male genitalia
			Examination of the bladder
			Examination of the male genitalia
			Examining consumers with urinary diversions
		Evaluation of health assessment and physical examination findings
		Case study 1: The consumer with endometriosis
		Case study 2: The male patient – emergency department presentation, renal calculi
		Chapter resources
	Chapter 18: Anus, rectum and prostate
		Background
		Anatomy and physiology
			Rectum
			Anus
			Prostate
		Assessment: Taking the consumer’s health history
		Person-centred health education
		Planning for physical examination
			Evaluating subjective data to focus physical examination
			Environment
			Equipment
		Implementation: Conducting the physical examination
			General approach to assessment of the anus, rectum and prostate
			Examination of the anus, rectum and prostate
		Evaluation of health assessment and physical examination findings
		Case study: The consumer with haemorrhoids and rectal bleeding
		Chapter resources
Unit 3: Specific lifespan populations
	Chapter 19: The pregnant woman
		Background
		Anatomy and physiology
			Skin and hair
			Head and neck
			Eyes, ears, nose, mouth and throat
			Breasts
			Thorax and lungs
			Heart and blood vessels
			Abdomen
			Urinary system
			Musculoskeletal system
			Neurological system
			Female genitalia
			Anus and rectum
			Haematological system
			Endocrine system
		Assessment: Taking the woman’s health history
		Person-centred health education
		Planning for physical examination
			Evaluating subjective data to focus physical assessment
			Environment
			Equipment
		Implementation: Conducting the physical examination
			General approach to examination of the pregnant woman
			Examination of the pregnant woman
			Examination of the anus, perineum and rectum
			Assessment of the haematological system
			Examination of the endocrine system
			Nutritional assessment
			Psychosocial assessment
			Subsequent or return antenatal visits
		Evaluation of health assessment and physical examination findings
		Case study: The pregnant woman
		Chapter resources
	Chapter 20: The paediatric consumer
		Background
		Physical growth
		Anatomy and physiology
			Structural and physiological variations
			Growth and development
		Assessment: Taking the consumer’s health history
		Person-centred health education
		Planning for physical examination
			Evaluating subjective data to focus physical examination
			Environment
			Equipment
		Implementation: Conducting the physical examination
			General approach to paediatric physical examination
			Developmental assessment
			Paediatric pain assessment
			Physical examination
			Vital signs
			Physical growth
			Skin
			Hair
			Head
			Eyes
			Ears
			Nose
			Mouth and throat
			Neck
			Breasts
			Thorax and lungs
			Heart and blood vessels
			Abdomen
			Musculoskeletal system
			Neurological system
			Female genitalia
			Male genitalia
			Anus
		Evaluation of health assessment and physical examination findings
		Case study: The paediatric consumer with acute tonsillitis
		Chapter resources
	Chapter 21: The older adult
		Background
		Key health challenges for older adults
		Anatomy and physiology
			Structural and physiological variations
		Assessment: Taking the consumer’s health history
			Interview of the older adult
			Special assessments
		Planning for physical examination
			Evaluating subjective data to focus physical examination
			Environment
			Equipment
		Implementation: Conducting the physical examination
			General approach to older adult assessment
			Physical examination
			Vital signs
			Height and weight
			Skin
			Hair
			Nails
			Head and neck
			Eyes
			Ears
			Nose
			Mouth and throat
			Breasts
			Thorax and lungs
			Heart and blood vessels
			Abdomen
			Musculoskeletal system
			Mental status and neurological techniques
			Female genitalia
			Male genitalia
			Anus, rectum and prostate
		Evaluation of health assessment and physical examination findings
		Case study: The older adult
		Chapter resources
Unit 4: Putting it all together
	Chapter 22: Health assessment and physical examination in context
		Background
		Legal considerations
		Ethical considerations
		Approach to comprehensive health assessment and physical examination
		Assessment: Taking the consumer’s health history
			Approach to physical examination
		Implementation: Conducting the physical examination
			General appearance
			Measurements and vital signs
			Mental status and neurological assessment
			Skin
			Head and face
			Eyes
			Ears
			Nose and sinuses
			Mouth and throat
			Neck
			Jugular veins
			Back, posterior and lateral thoraxes
			Anterior thorax
			Heart
			Female and male breasts
			Abdomen
			Inguinal area
			Musculoskeletal system
			Upper extremities
			Lower extremities
			Female genitourinary, reproductive, anus and rectum
			Male genitourinary, reproductive, anus, rectum and prostate
		Laboratory and diagnostic data
		The process of pulling it together
		Technology and documentation
		Case study (comprehensive): The consumer with unstable angina
		Case study (focused): The consumer with a Colles fracture
		Conclusion
		Chapter resources
Appendix: Functional assessments
Answers to review questions
Glossary
Index