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Test Bank for Health Assessment for Nursing Practice, 4th Edition: Wilson

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This is completed downloadable of Test Bank for Health Assessment for Nursing Practice, 4th Edition: Wilson

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ISBN-10 ‏ : ‎ 032305322X
ISBN-13 ‏ : ‎ 978-0323053228
Author: Jean Foret Giddens PhD RN FAAN (Author), Susan Fickertt Wilson PhD RN (Author)

Using a nursing-oriented, holistic approach, this straightforward text provides you with a visual presentation to conducting physical examinations. This textbook clearly delineates the routine exam techniques from those exams for special circumstances or advanced practice.

UNIQUE! Routine exams and exams for advanced practice are identified with a special icon to help you quickly and easily determine essential assessment content.
Body system chapters are subdivided into clearly delineated sections to allow easy navigation among these consistent sections within the chapters.
UNIQUE! End-of-chapter Documentation Samples demonstrate how to document client data and provide a practice context for client charting.
UNIQUE! Special feature boxes outline common, Frequently Asked Questions (FAQs) about health assessment and provide corresponding answers.
Ethnic and Cultural Variations boxes present differences to anticipate among today’s multicultural client population and show how to vary the exam for varied populations.
Separate sections for special circumstances or special needs show how to vary the exam for clients with special needs.
Feature boxes outline Healthy People 2010 objectives to provide you thorough discussions of recommendations for health promotion and reducing risk.
Interactive Activity Lists at the end of each chapter outline corresponding exercises, checklists, and lab forms that can be found on the companion CD-ROM.
Case Studies with Clinical Reasoning Questions are provided at the end of each chapter to test your application of textbook material.
NCLEX® exam-style review questions are included at the end of each chapter.
PDA-Downloadable Exam Techniques are included on the Evolve companion website to allow you to easily access important summary exam information.

UNIQUE! The 30 Core Assessment Skills identified by research as most commonly performed by nurses are now highlighted with a unique icon.
UNIQUE! The companion CD-ROM now provides the Core Assessment Skills Checklists as quick step-by-step summaries for each of the 30 Core Assessment Skills.
Two new chapters pull all of the essential exam and assessment content together into cohesive chapters for the infant and child and the older adult.
UNIQUE! Clinical Reasoning Exemplars walk you through the thinking process of how an experienced nurse makes decisions.
UNIQUE! Concept boxes feature eight concepts in the context of health assessment including pain, sleep, oxygenation, perfusion, tissue integrity, motion, sensory, and intracranial regulation.

Table of Content:

UNIT 1 FOUNDATIONS FOR HEALTH ASSESSMENT
CHAPTER 1 Why Learn Health Assessment?
COMPONENTS OF HEALTH ASSESSMENT
Health History
Physical Examination
Documentation of Data
BOX 1-1 STANDARDS OF NURSING PRACTICE The Nursing Process
Standard 1: Assessment
Standard 2: Diagnosis
Standard 3: Outcome Identification
Standard 4: Planning
Standard 5: Implementation
Standard 6: Evaluation
TYPES OF HEALTH ASSESSMENT
BOX 1-2 CLARIFICATION OF TERMS Signs & Symptoms and Clinical Manifestations
Signs & Symptoms
Clinical Manifestations
Context of Care
Fig. 1-1 The nurse may take notes while conducting a health assessment.
BOX 1-3 TYPES OF HEALTH ASSESSMENT
Client Need
Expertise of the Nurse
CLINICAL REASONING AND JUDGMENT
BOX 1-4 CORE EXAMINATION SKILLS*
Skin
Head, Eyes, Ears, Nose, Throat
Chest & Lungs
Cardiovascular
Musculoskeletal
Abdomen
Neurologic
Genitalia
Data Organization
TABLE 1-1 Functional Health Pattern Organization
FREQUENTLY ASKED QUESTIONS
Data Analysis, Interpretation, and Clinical Judgment
Fig. 1-2 Clinical Judgment Model. Noticing refers to the nurse’s expectations and initial grasp of a situation. Noticing triggers reasoning patterns that allow the nurse to interpret the situation and respond with interventions. Reflection-in-action specifically relates to evaluating outcomes of interventions while reflection-on-action represents the contribution of an experience to a nurse’s collective experiences.
TABLE 1-2 NANDA Taxonomy II Domains
HEALTH PROMOTION AND HEALTH PROTECTION
TABLE 1-3 Levels of Health Promotion
Fig. 1-3 Overview of Healthy People 2010 goals, leading health indicators, and focus areas.
CLINICAL APPLICATION & CLINICAL REASONING
REVIEW QUESTIONS
CASE STUDY 1
CASE STUDY 2
Interview Data
Examination Data
INTERACTIVE ACTIVITIES
CHAPTER 2 Ethnic and Cultural Considerations
Fig. 2-1 Ethnicity is indicative of a common race, language, and dialect, as well as shared tradition.
Fig. 2-2 Clients receive effective, understandable, and respectful care.
BECOME CULTURALLY COMPETENT
BOX 2-1 WAYS TO ACHIEVE CULTURAL COMPETENCE
DON’T STEREOTYPE
Fig. 2-3 When interviewing clients, recognize that cultural diversity exists.
Fig. 2-4 It is important to develop sensitivity to the differences between your own culture and that of clients from another culture.
DEVELOP A TEMPLATE FOR ASSESSMENT
Introductory Questions
What is the Client’s Primary Language and Method of Communication?
What are the Client’s Personal Beliefs about Health and Illness?
What Religious or Spiritual Influences Affect the Client?
What are the Roles of Individual People in the Family?
Does the Client have Special Dietary Practices?
REMEMBER …
CLINICAL APPLICATION & CLINICAL REASONING
REVIEW QUESTIONS
INTERACTIVE ACTIVITIES
CHAPTER 3 Interviewing to Obtain a Health History
THE INTERVIEW
BOX 3-1 PHASES OF AN INTERVIEW
Introduction Phase
Discussion Phase
Summary Phase
Therapeutic Communication: The Foundation for Interviewing
Fig. 3-1 Introduce yourself when you begin an interview.
The Physical Setting
Professional Nursing Behavior
Client-Related Variables
The Art of Asking Questions
Types of Questions to Ask
Techniques that Enhance Data Collection
Active Listening
Facilitation
Clarification
Restatement
Reflection
Confrontation
Interpretation
Summary
Techniques that Diminish Data Collection
Using Medical Terminology
Expressing Value Judgments
Interrupting the Client
Being Authoritarian or Paternalistic
Using “Why” Questions
Managing Awkward Moments During an Interview
Answering Personal Questions
Silence
Displays of Emotion
Challenges to the Interview
Managing the Overly Talkative Client
Others in the Room
Language Barrier
Cultural Differences
Fig. 3-2 Interact with the client as a unique person and be sensitive to cultural diversities.
THE HEALTH HISTORY
Types of Health Histories
FREQUENTLY ASKED QUESTIONS
Components of the Health History
Biographic Data
Reason for Seeking Health Care
BOX 3-2 BIOGRAPHIC DATA
History of Present Illness
Present Health Status
BOX 3-3 MNEMONIC FOR SYMPTOM ANALYSIS OLD CARTS
Onset: When Did the Symptoms Begin?
Location: Where Are the Symptoms?
Duration: How Long Do the Symptoms Last?
Characteristics: Describe the Characteristics of the Symptom
Aggravating and Alleviating Factors: What Affects the Symptoms?
Related Symptoms: What Other Symptoms Are Present?
Treatment: Describe Self-Treatment Tried before Seeking Care
Severity: Describe the Severity of the Symptom
Past Health History
Family History
Personal and Psychosocial History
Personal Status.
Family and Social Relationships.
Fig. 3-3 Sample genogram identifying grandparents, parents, aunts and uncles, siblings, spouse, and children.
Diet/Nutrition.
Functional Ability.
Mental Health.
Personal Habits.
BOX 3-4 DOMESTIC VIOLENCE
Recognizing Domestic Violence
Screening Questions for Domestic Violence
Health Promotion Activities.
Environment.
Review of Systems
General Symptoms
Integumentary System
Head and Neck
Breasts
Respiratory System/Chest
Cardiovascular System
Gastrointestinal System
Urinary System
Reproductive System
Musculoskeletal System
Neurologic System
Health History Based on Functional Health Patterns
AGE-RELATED VARIATIONS
Infants, Children, and Adolescents
Pregnancy
Older Adults
SUMMARY
CLINICAL APPLICATION & CLINICAL REASONING
REVIEW QUESTIONS
CASE STUDY
Questions
INTERACTIVE ACTIVITIES
CHAPTER 4 Techniques and Equipment for Physical Assessment
TECHNIQUES OF PHYSICAL ASSESSMENT
Inspection
Palpation
Fig. 4-1 Tangential light used to inspect jugular vein pulsation.
Percussion
Direct Percussion
Indirect Percussion
Fig. 4-2 Palpation. A, Superficial palpation. B, Deep palpation.
Fig. 4-3 Hand position for direct fist percussion of kidney.
FREQUENTLY ASKED QUESTIONS
Auscultation
Fig. 4-4 Indirect percussion of lateral chest wall.
Fig. 4-5 The diaphragm of the stethoscope is stabilized between the index and middle fingers.
TABLE 4-1 Percussion Tones
BOX 4-1 CHARACTERISTICS OF SOUNDS HEARD BY AUSCULTATION
POSITIONING
EQUIPMENT USED DURING THE EXAMINATION PROCESS
Thermometers (Temperature Measurement)
TABLE 4-2 Positions for Examination
Fig. 4-6 A, Electronic thermometer. B, Tympanic thermometer.
Stethoscope
Fig. 4-7 A, Acoustic stethoscope. B, Fetoscope.
Equipment to Measure Blood Pressure
Fig. 4-8 A, Aneroid sphygmomanometer. B, Noninvasive blood pressure (NIBP) monitor with disposable blood pressure cuff.
Fig. 4-9 Blood pressure cuffs in various sizes. A, Reusable cuffs in large adult (top), adult (middle), and child (bottom) sizes. Note the range lines above the Velcro material on the right side of each cuff. B, Disposable infant (top) and neonatal (bottom) cuffs. (B,
Fig. 4-10 Pulse oximeter shown with a clip and tape sensor probe.
TABLE 4-3 Sizes for Blood Pressure Cuffs Based on Arm Circumference*
Pulse Oximetry
Scales
Visual Acuity and Screening
Snellen’s Chart
Fig. 4-11 A, Adult platform scale. B, Infant platform scale.
Jaeger and Rosenbaum Charts
Ophthalmoscope
Fig. 4-12 A, Snellen’s visual acuity chart. B, “E” chart.
Fig. 4-13 Rosenbaum near-vision chart.
Fig. 4-14 Ophthalmoscope.
Fig. 4-15 A, Traditional otoscope with pneumatic bulb. B, MacroView ototscope.
Otoscope
Penlight
Fig. 4-16 Penlight.
Fig. 4-17 Centimeter ruler.
Ruler and Tape Measure
Nasal Speculum
Tuning Fork
Fig. 4-18 Nasal speculum.
Percussion, or Reflex, Hammer
Doppler
Fig. 4-19 Tuning forks for vibratory sensation (top) and auditory screening (bottom).
Fig. 4-20 Percussion hammer.
Goniometer
Fig. 4-21 Doppler.
Fig. 4-22 Goniometer.
Calipers for Skinfold Thickness
Vaginal Speculum
Fig. 4-23 Skinfold calipers.
Fig. 4-24 Vaginal specula.
Audioscope
Fig. 4-25 Audioscope.
Monofilament
Fig. 4-26 A, Monofilament. B, Assessing peripheral sensation.
Fig. 4-27 Transilluminator.
Transilluminator
Wood’s Lamp
Magnification Device
Fig. 4-28 Wood’s lamp. The purple color on the skin indicates that no fungal infection is present.
APPLICATION OF INFECTION CONTROL PRINCIPLES
Latex Allergy
BOX 4-3 STANDARD PRECAUTION GUIDELINES Personal Protective Equipment
Gloves
Masks, Eye Protection, Face Shields
Gown
Patient Care Equipment
BOX 4-4 PREVENTING LATEX ALLERGY
BOX 4-2 STANDARD PRECAUTION GUIDELINES Hand Hygiene
CLINICAL APPLICATION & CLINICAL REASONING
REVIEW QUESTIONS
INTERACTIVE ACTIVITIES
CHAPTER 5 General Inspection and Measurement of Vital Signs
GENERAL INSPECTION
Physical Appearance and Hygiene
Body Structure and Position
Body Movement
Fig. 5-1 General inspection begins immediately on meeting the client. Note physical appearance, hygiene, body structure, movement, posture, emotional status, and behavior.
Emotional and Mental Status and Behavior
MEASUREMENT OF VITAL SIGNS, HEIGHT, AND WEIGHT
Temperature
FREQUENTLY ASKED QUESTIONS
Oral Temperature
BOX 5-1 CONVERSIONS BETWEEN FAHRENHEIT AND CELSIUS
Tympanic Membrane Temperature
Axillary Temperature
Fig. 5-2 Taking a tympanic membrane temperature.
Rectal Temperature
Heart Rate
TABLE 5-1 Average Vital Signs Throughout the Life Span
Fig. 5-3 Radial pulse.
Fig. 5-4 Brachial pulse.
Respiratory Rate
Fig. 5-5 Carotid pulse.
Blood Pressure
Measurement of Blood Pressure
Fig. 5-6 Auscultating Korotkoff sounds to measure blood pressure.
Mechanism of Blood Pressure Measurement
BOX 5-2 PROCEDURE FOR MEASURING BLOOD PRESSURE (AUSCULTATION METHOD)
Physiologic Factors that Affect Blood Pressure Measurements
Fig. 5-7 Sounds auscultated during blood pressure measurement can be differentiated into five Korotkoff phases. In this example the blood pressure is 140/90.
Common Errors Associated with Blood Pressure Measurement
BOX 5-3 ERRORS IN BLOOD PRESSURE MEASUREMENT
Errors Resulting in False-High Blood Pressure Measurement
Errors Resulting in False-Low Blood Pressure Measurement
Oxygen Saturation
Pain
Weight
Height
Fig. 5-8 Assessment of height using a platform scale.
AGE-RELATED VARIATONS
Infants and Children
Older Adults
CLINICAL APPLICATION & CLINICAL REASONING
REVIEW QUESTIONS
INTERACTIVE ACTIVITIES
CHAPTER 6 Pain Assessment
Fig. 6-1 A method of classifying pain is by the pathophysiology involved. I, Nociceptive pain (stimuli from somatic and visceral structures). II, Neuropathic pain (stimuli abnormally processed by nervous system).
ANATOMY & PHYSIOLOGY
Fig. 6-2 Outlines the four basic processes involved in nociception: 1, transduction; 2, transmission; 3, perception; and 4, modulation.
Fig. 6-2, cont’d
Fig. 6-3 Illustrates the four steps involved in the pain process: transduction, when nociceptors stimulate the free nerve endings; transmission, when nociceptor stimulation initiates action potentials along A-delta or C fibers to open the gate in the substantia gelatinosa and ascend to the brain in the spinothalamic tract through the thalamus (or stimulate A-alpha or A-beta fibers that close the gate); perception, when impulses move from the thalamus to the parietal lobe, where pain is felt, and to the limbic system, which derives the emotional response to pain; and modulation, when the body produces endorphins and enkephalins to occupy the opiate receptor sites to close the gate.
TABLE 6-1 Examples of How Various Stimuli Produce Pain
LINK TO CONCEPTS Pain
HEALTH HISTORY
HEALTH HISTORY
Present Health Status
DESCRIPTION OF PAIN
Location
Quality
Quantity
Chronology
Setting
Associated Manifestations
Alleviating Factors
Aggravating Factors
RESPONSE TO PAIN
Fig. 6-4 McGill Pain Questionnaire. The descriptors fall into four major groups: sensory, 1 to 10; affective, 11 to 15; evaluative, 16; and miscellaneous, 17 to 20. The rank value of each descriptor is based on its position in the word set. The sum of the rank values is the pain rating index (PRI). The present pain intensity (PPI) is based on a scale of 0 to 5.
Fig. 6-5 A, Descriptive pain intensity scale; B, Numeric pain intensity scale; C, Visual analog scale.
Fig. 6-6 Self-contained, portable, pain-rating instrument that can provide immediate assessment of pain. It is a 5 × 20 cm plastic visual analog scale with a sliding marker that moves within a 10 cm groove. The side facing the client (A) resembles a traditional analog scale, whereas the opposite side (B) is marked in centimeters to quantify pain intensity. The tool has been shown to be valid to measure pain intensity.
FREQUENTLY ASKED QUESTIONS
EXAMINATION
PROCEDURE AND TECHNIQUES WITH NORMAL FINDINGS
OBSERVE client for posture and behavior to relieve pain.
ABNORMAL FINDINGS
OBSERVE facial expressions.
ABNORMAL FINDINGS
LISTEN for sounds the client makes.
ABNORMAL FINDINGS
INSPECT AND PALPATE skin for color, temperature, and moisture.
ABNORMAL FINDINGS
MEASURE blood pressure and pulse.
ABNORMAL FINDINGS
ASSESS respiratory rate and pattern.
ABNORMAL FINDINGS
OBSERVE pupillary size.
ABNORMAL FINDINGS
AGE-RELATED VARIATIONS
Infants & Children
Older Adults
CLINICAL APPLICATION & CLINICAL REASONING
REVIEW QUESTIONS
SAMPLE DOCUMENTATION
SUBJECTIVE DATA
OBJECTIVE DATA
Interview Data
Examination Data
CLINICAL Reasoning
INTERACTIVE ACTIVITIES
CHAPTER 7 Mental Health and Mental Status Assessment
ANATOMY & PHYSIOLOGY
Fig. 7-1 The limbic system.
ETHNIC & CULTURAL VARIATIONS
Culturally Relevant Phenomena in Mental Health Nursing
HEALTH HISTORY
RISK FACTORS Depression and Anxiety
Risk Factors for Depression
Risk Factors for Anxiety
GENERAL HEALTH HISTORY
Present Health Status
Self-Concept
TABLE 7-1 Problems of Word Usage Associated with Alterations in Thought Processes
Interpersonal Relationships
Stressors
TABLE 7-2 Holmes Social Readjustment Rating Scale
Anger
Alcohol Use
Recreational Drug Use
Past Medical History
Family History
PROBLEM-BASED HISTORY
Depression
FREQUENTLY ASKED QUESTIONS
Anxiety
Fig. 7-2 Beck Depression Inventory.
Alcohol Abuse
TABLE 7-3 AUDIT Structured Interview*
BOX 7-1 CAGE Questions Used to Screen for Alcoholism
Drug Abuse
ETHNIC & CULTURAL VARIATIONS
Altered Mental Status
HEALTH PROMOTION Mental Illness and Suicide Prevention
Goals and Objectives—Healthy People 2010
Recommendations to Reduce Risk (Primary Prevention)
Institute of Medicine (IOM)
Screening Recommendations (Secondary Prevention)
U.S. Preventive Services Task Force
HEALTH PROMOTION Substance Abuse
Goals and Objectives—Healthy People 2010
Recommendations to Reduce Risk (Primary Prevention)
National Institute on Drug Abuse
Screening Recommendations (Secondary Prevention)
U.S. Preventive Services Task Force
Recommendations for Treatment (Tertiary Prevention)
Substance Abuse and Mental Health Administration
EXAMINATION
PROCEDURE AND TECHNIQUES WITH NORMAL FINDINGS
OBSERVE the client’s posture and movements.
ABNORMAL FINDINGS
OBSERVE for appropriate dress and hygiene.
ABNORMAL FINDINGS
OBSERVE for changes in voice tone, rate of speech, perspiration, and muscle tension or tremors.
ABNORMAL FINDINGS
ASSESS mental status by determining orientation, memory, calculation ability, communication skills, judgment, and abstraction.
Orientation
ABNORMAL FINDINGS
Memory
ABNORMAL FINDINGS
Calculation ability
ABNORMAL FINDINGS
Communication skills od pressure.
ABNORMAL FINDINGS
PALPATE the radial pulse for rate.
ABNORMAL FINDINGS
OBSERVE and COUNT respirations for rate and breathing pattern.
ABNORMAL FINDINGS
OBSERVE eye movements and MEASURE pupil size.
ABNORMAL FINDINGS
TABLE 7-4 Clinical Findings of Acute Drug Intoxication
TABLE 7-5 Common Eye Signs Detected after Abuse of Selected Drugs
BOX 7-2 RAPID EYE TEST TO DETECT CURRENT DRUG INTOXICATION
General Observation
Pupil Size
Pupil Reaction to Light
Nystagmus
Convergence
Corneal Reflex
AGE-RELATED VARIATIONS
Infants, Children & Adolescents
Older Adults
COMMON PROBLEMS & CONDITIONS
ALTERATIONS OF MOOD AND AFFECT
Major Depression
Bipolar Disorder
Anxiety
Obsessive-Compulsive Disorder
Psychotic Disorders
Schizophrenia (Dopamine Dysregulation Disorder)
Substance Abuse Disorders
Alcohol Withdrawal Syndrome
Drug Intoxication
Delirium and Dementia
Delirium
Dementia
CLINICAL APPLICATION & CLINICAL REASONING
REVIEW QUESTIONS
CASE STUDY
Interview Data
Examination Data
CLINICAL Reasoning
INTERACTIVE ACTIVITIES
CHAPTER 8 Sleep Assessment
ANATOMY & PHYSIOLOGY
STAGES OF SLEEP
Fig. 8-1 The RAS and BSR control sensory input, intermittently activating and suppressing the brain’s higher centers to control sleep and wakefulness.
TABLE 8-1 Physiologic Changes during Sleep
Fig. 8-2 Histogram showing stages of sleep.
LINK TO CONCEPTS Sleep
HEALTH HISTORY
RISK FACTORS Insomnia and Sleep Apnea
INSOMNIA
SLEEP APNEA
Obstructive Sleep Apnea
Central Sleep Apnea
GENERAL HEALTH HISTORY
Present Health Status
BOX 8-1 DRUGS AND THEIR EFFECTS ON SLEEP
Hypnotics
Diuretics
Antidepressants and Stimulants
Alcohol
Caffeine
Beta-Adrenergic Blockers
Benzodiazepines
Narcotics (Morphine/Demerol)
Anticonvulsants
PROBLEM-BASED HISTORY
Insomnia
Sleep Apnea
EXAMINATION
PROCEDURES AND TECHNIQUES WITH NORMAL FINDINGS
OBSERVE the client for mental status, thought patterns, and speech patterns.
ABNORMAL FINDINGS
OBSERVE gross motor movements and posture.
ABNORMAL FINDINGS
MEASURE blood pressure and weight.
ABNORMAL FINDINGS
INSPECT nasal septum for patency and deviation.
ABNORMAL FINDINGS
INSPECT pharynx for tonsillar hypertrophy.
ABNORMAL FINDINGS
AGE-RELATED VARIATIONS
Infants, Children, and Adolescents
Older Adults
COMMON PROBLEMS & CONDITIONS
INSOMNIA
NARCOLEPSY
SLEEP APNEA
CLINICAL APPLICATION & CLINICAL REASONING
REVIEW QUESTIONS
SAMPLE DOCUMENTATION
SUBJECTIVE DATA
OBJECTIVE DATA
CASE STUDY
Interview Data
Examination Data
CLINICAL Reasoning
INTERACTIVE ACTIVITIES
CHAPTER 9 Nutritional Assessment
ANATOMY & PHYSIOLOGY
MACRONUTRIENTS
BOX 9-2 CALCULATING THE PERCENT OF CALORIES FROM MACRONUTRIENTS
BOX 9-1 CALCULATING GRAMS OF A MACRONUTRIENT
MICRONUTRIENTS
TABLE 9-1 Vitamins
TABLE 9-2 Minerals
WATER
HEALTH HISTORY
RISK FACTORS Nutrition
GENERAL HEALTH HISTORY
Present Health Status
ETHNIC & CULTURAL VARIATIONS
Past Medical History and Family History
PROBLEM-BASED HISTORY
Weight Loss
Weight Gain
Difficulty Chewing or Swallowing
Loss of Appetite or Nausea
ASSESSMENT OF DIETARY INTAKE
ETHNIC & CULTURAL VARIATIONS
Jewish Dietary Laws
TABLE 9-3 Techniques to Assess Dietary Intake
HEALTH PROMOTION Overweight and Obesity
Goals and Objectives—Healthy People 2010
Recommendations to Reduce Risk (Primary Prevention)
U.S. Preventive Services Task Force
Screening Recommendations (Secondary Prevention)
U.S. Preventive Services Task Force
Recommendations for Treatment/Referral (Tertiary Prevention)
U.S. Preventive Services Task Force
Fig. 9-1 MyPyramid Food Guide.
HEALTH PROMOTION Diabetes Mellitus
Goals and Objectives—Healthy People 2010
Recommendations to Reduce Risk (Primary Prevention)
American Diabetes Association
Screening Recommendations (Secondary Prevention)
American Diabetes Association
Recommendations for Treatment (Tertiary Prevention)
American Diabetes Association
EXAMINATION
TABLE 9-4 Clinical Signs and Symptoms of Various Nutrient Deficiencies
ROUTINE TECHNIQUES: NUTRITION
PROCEDURES AND TECHNIQUES WITH NORMAL FINDINGS
MEASURE height and weight for body mass index (BMI).
ABNORMAL FINDINGS
ETHNIC & CULTURAL VARIATIONS
ASSESS general appearance and level of orientation.
ABNORMAL FINDINGS
TABLE 9-5 Body Mass Index Chart*
Fig. 9-2 Nomogram to estimate body mass index. Measure height to the nearest inch and weight to the nearest pound; mark on the two corresponding scales. Use a straight-edge ruler to connect the two points and circle the spot where the straight line crosses the center line.
BOX 9-3
Calculation of Body Mass Index (BMI)
Calculation Using Kilograms and Meters
Calculation Using Pounds and Inches
INSPECT the skin for surface characteristics, hydration, and lesions.
ABNORMAL FINDINGS
Fig. 9-3 Follicular hyperkeratosis.
INSPECT the hair and nails for appearance and texture.
ABNORMAL FINDINGS
INSPECT the eyes for surface characteristics.
ABNORMAL FINDINGS
Fig. 9-4 Xerophthalmia.
INSPECT the oral cavity for dentition and intact mucous membranes.
ABNORMAL FINDINGS
INSPECT and PALPATE the extremities for shape, size, coordinated movement, and sensation.
ABNORMAL FINDINGS
SPECIAL CIRCUMSTANCES OR ADVANCED PRACTICE: NUTRITION
CALCULATE desirable body weight (DBW).
ABNORMAL FINDINGS
BOX 9-4 Calculation of Desirable Body Weight (DBW)
CALCULATE percent change in weight.
ABNORMAL FINDINGS
CALCULATE the waist-to-hip ratio.
ABNORMAL FINDINGS
Fig. 9-5 Distribution of body fat. A, Pear shape. B, Apple shape.
ESTIMATE body fat by measuring triceps skinfold.
ABNORMAL FINDINGS
Fig. 9-6 A, Placement of calipers for triceps skinfold thickness measurement. B, Cross section of arm with triceps skinfold measurement.
ASSESS nutritional status by reviewing laboratory tests.
ABNORMAL FINDINGS
TABLE 9-6 Percentiles for Triceps Skinfold Measurements (Adults)
FREQUENTLY ASKED QUESTIONS
FREQUENTLY ASKED QUESTIONS
TABLE 9-7 Laboratory Tests Used for Nutritional Assessment
AGE-RELATED VARIATIONS
INFANTS AND CHILDREN
OLDER ADULTS
COMMON PROBLEMS & CONDITIONS
OBESITY
Fig. 9-7 Obesity.
HYPERLIPIDEMIA
PROTEIN CALORIE MALNUTRITION (PCM)
Fig. 9-8 Loss of subcutaneous fat and muscle wasting in patient with protein calorie malnutrition.
EATING DISORDERS
Fig. 9-9 Anorexia nervosa.
CLINICAL APPLICATION & CLINICAL REASONING
REVIEW QUESTIONS
SAMPLE DOCUMENTATION
SUBJECTIVE DATA
OBJECTIVE DATA
CASE STUDY
Interview Data
Examination Data
CLINICAL Reasoning
INTERACTIVE ACTIVITIES
UNIT 2 HEALTH ASSESSMENT OF THE ADULT
CHAPTER 10 Skin, Hair, and Nails
ANATOMY & PHYSIOLOGY
SKIN
Epidermis
Fig. 10-1 Anatomic structures of the skin and hair.
Dermis
Subcutaneous Layer
APPENDAGES
Hair
Nails
Eccrine Sweat Glands
Apocrine Sweat Glands
Sebaceous Glands
Fig. 10-2 Structures of the nail.
LINK TO CONCEPTS Tissue Integrity
ETHNIC & CULTURAL VARIATIONS
HEALTH HISTORY
RISK FACTORS Skin, Hair, and Nails
GENERAL HEALTH HISTORY
Present Health Status
Past Medical History and Family History
PROBLEM-BASED HISTORY
Skin
Pruritis
Rash
Pain/Discomfort of Skin
BOX 10-1 FOCUS ON PAIN Skin, Hair, and Nails
Lesion or Changes in Mole
Change in Skin Color
Skin Texture
Wounds
Hair
HEALTH PROMOTION Skin Cancer
Goals and Objectives—Healthy People 2010
Recommendations to Reduce Risk (Primary Prevention)
American Cancer Society (ACS)
Screening Recommendations (Secondary Prevention)
American Cancer Society
Nails
EXAMINATION
PROCEDURES AND TECHNIQUES WITH NORMAL FINDINGS
ROUTINE TECHNIQUES
INSPECT the skin for general color.
ABNORMAL FINDINGS
TABLE 10-1 Comparison of Skin-Related Findings in Clients with Light Skin and Clients with Dark Skin
INSPECT the skin for localized variations in skin color.
ABNORMAL FINDINGS
ETHNIC & CULTURAL VARIATIONS
BOX 10-2 EARLY SIGNS OF MELANOMA
PALPATE the skin for texture, temperature, moisture, mobility, turgor, and thickness.
Texture
ABNORMAL FINDINGS
Fig. 10-3 Maceration in a skin fold.
Temperature
ABNORMAL FINDINGS
Moisture
ABNORMAL FINDINGS
Mobility and Turgor
Fig. 10-4 Elastic skin turgor.
ABNORMAL FINDINGS
Fig. 10-5 Poor skin turgor.
Thickness
Fig. 10-6 Callus.
ABNORMAL FINDINGS
INSPECT and PALPATE the scalp and hair for surface characteristics, hair distribution, texture, quantity, and color.
ABNORMAL FINDINGS
ETHNIC & CULTURAL VARIATIONS
INSPECT facial and body hair for distribution, quantity, and texture.
ABNORMAL FINDINGS
INSPECT and PALPATE the nails for shape, contour, consistency, color, thickness, and cleanliness.
ABNORMAL FINDINGS
Fig. 10-7 Severe spooning with thinning of the nail.
ABNORMAL FINDINGS
Fig. 10-8 Nail bed color of a dark-skinned person (pigmented bands occur as a normal finding in over 90% of African Americans).
Fig. 10-9 Leukonychia punctata. Transverse white bands result from repeated minor trauma to the nail matrix.
ABNORMAL FINDINGS
Fig. 10-10 Assessment of finger clubbing. A, Normally when opposing fingers are placed together, a small space is visible between the fingers and the nail beds meet. B, With finger clubbing, no space is observed between the fingers, and the nail beds angle away from one another. C, With finger clubbing, the base if the nail is enlarged and curved.
ABNORMAL FINDINGS
Fig. 10-11 Beau’s lines.
Fig. 10-12 Nail pitting.
ABNORMAL FINDINGS
SPECIAL CIRCUMSTANCES OR ADVANCED PRACTICE
INSPECT and PALPATE the skin for lesions.
ABNORMAL FINDINGS
BOX 10-3 LESION CHARACTERISTIC TO BE NOTED DURING EXAMINATION
Fig. 10-13 Shapes and patterns of lesions.
Primary Lesions
ABNORMAL FINDINGS
ABNORMAL FINDINGS
TABLE 10-2 Primary Skin Lesions
Secondary Lesions
ABNORMAL FINDINGS
TABLE 10-3 Secondary Skin Lesions
Vascular Lesions
ABNORMAL FINDINGS
TABLE 10-4 Vascular Skin Lesions
Fig. 10-14 Cherry angioma.
FREQUENTLY ASKED QUESTIONS
FREQUENTLY ASKED QUESTIONS
Documenting Expected Findings
Skin Assessment: Adult Female
CLINICAL REASONING Skin, Hair, and Nails
AGE-RELATED VARIATIONS
Infants & Children
Adolescents
Older Adults
CLIENTS WITH SITUATIONAL VARIATIONS
CLIENTS WITH LIMITED MOBILITY (HEMIPLEGIA, PARAPLEGIA, QUADRIPLEGIA)
Expected and Abnormal Findings (Skin)
ETHNIC & CULTURAL VARIATIONS
Fig. 10-15 Bony prominences vulnerable to pressure.
TABLE 10-5 Staging of Pressure Ulcers
COMMON PROBLEMS & CONDITIONS
SKIN
Hyperkeratosis
Clavus (Corn)
Dermatitis
Fig. 10-16 Corn (clavus).
Atopic Dermatitis
Fig. 10-17 Atopic dermatitis.
Contact Dermatitis
Seborrheic Dermatitis
Stasis Dermatitis
Fig. 10-18 Contact dermatitis. In this case, allergic reaction to nickel.
Fig. 10-19 Seborrheic dermatitis.
Fig. 10-20 Stasis dermatitis.
Psoriasis
Fig. 10-21 Psoriasis on elbow and buttocks.
Pityriasis Rosea
Lesions Caused by Viral Infection
Warts (Verruca)
Fig. 10-22 Pityriasis rosea. A, Large herald patch on the chest. B, Many oval lesions on the chest.
Fig. 10-23 Common warts on hand and fingers.
Herpes Simplex
Fig. 10-24 Herpes simplex. Typical manifestation with vesicles appearing on the lips and extending onto the skin.
Herpes Varicella (Chickenpox)
Herpes Zoster (Shingles)
Fig. 10-25 Herpes varicella (chickenpox). Lesions in various stages of development, including red papules, vesicles, umbilicated vesicles, and crusts. A, Light-skinned person. B, Dark-skinned person.
Fig. 10-26 Herpes zoster (shingles).
Lesions Caused by Fungal Infections
Tinea Infections
Fig. 10-27 Fungal infections. A, Tinea corporis. B, Tinea cruris. C, Tinea capitis. D, Tinea pedis.
Candidiasis
Lesions Caused by Bacterial Infections
Cellulitis
Fig. 10-28 Candidiasis.
Fig. 10-29 Cellulitis to the lower leg.
Impetigo
Folliculitis
Fig. 10-30 Impetigo.
Fig. 10-31 Folliculitis.
Fig. 10-32 Furuncle.
Furuncle or Abscess (Boil)
Lesions Associated with Arthropods
Scabies
Lyme Disease
Spider Bites
Fig. 10-33 Lyme disease. Note expanding erythematous lesion with central clearing on trunk.
Fig. 10-34 Brown recluse spider bite. Note necrotic ulcer and erythema.
Neoplasia
Basal Cell Carcinoma
Fig. 10-35 Basal cell carcinoma.
Squamous Cell Carcinoma
Melanoma
Fig. 10-36 Squamous cell carcinoma.
Fig. 10-37 Malignant melanoma.
Kaposi’s Sarcoma
Skin Lesions Caused by Abuse
Bruise (Ecchymosis)
Fig. 10-38 A, Kaposi’s sarcoma of the heel and lateral foot. B, Oral Kaposi’s sarcoma.
Fig. 10-39 Loop mark pattern of bruising caused by whipping with an electrical cord.
Bites
Fig. 10-40 Bite injury.
Burns
Fig. 10-41 Stocking burn patterns to perineum, thighs, legs, and feet.
Fig. 10-42 Cigarette burn to a child’s abdomen.
HAIR
Pediculosis (Lice)
Alopecia Areata
Fig. 10-43 Pediculosis (lice). The eggs, or nits, are visible attached to hair shafts.
Fig. 10-44 Alopecia areata. Note areas of regrowth (fine, light-colored hairs).
Hirsutism
Fig. 10-45 Facial hirsutism. A, Hair growth on the jaw line and neck of a young woman. B, Hair growth on the chin of a postmenopausal woman.
NAILS
Onychomycosis
Fig. 10-46 Onychomycosis (fungal infection of the fingernail).
Fig. 10-47 Chronic paronychia with swollen posterior nail folds and nail dystrophy.
Paronychia
Ingrown Toenail
Fig. 10-48 Ingrown toenail.
CLINICAL APPLICATION & CRITICAL THINKING
REVIEW QUESTIONS
SAMPLE DOCUMENTATION
ABNORMAL FINDINGS
SUBJECTIVE DATA
OBJECTIVE DATA
CASE STUDY
Interview Data
Examination Data
CLINICAL Reasoning
INTERACTIVE ACTIVITIES
CHAPTER 11 Head, Eyes, Ears, Nose, and Throat
ANATOMY & PHYSIOLOGY
THE HEAD
THE EYES
External Ocular Structures
Ocular Structures
Fig. 11-1 Bones of the skull and face. A, Anterior view. B, Posterior view.
Fig. 11-2 External ocular structures.
Ocular Function
Fig. 11-3 Anatomy of the human eye.
THE EAR
External Ear
Fig. 11-4 Visual pathway.
Fig. 11-5 Anatomic structure of the auricle (pinna).
Middle Ear
Inner Ear
THE NOSE
Fig. 11-6 Anatomy of the ear showing the outer ear, external auditory canal, tympanic membrane, and structures of the middle and inner ear.
Fig. 11-7 Cross-sectional view of the structures of the nose and nasopharynx.
THE MOUTH AND OROPHARYNX
Oropharynx
Fig. 11-8 Paranasal Sinuses. A, Front view. B, Side view.
Fig. 11-9 Structures of the mouth. A, View of dorsal tongue surface. B, View of ventral tongue surface.
NECK
Fig. 11-10 Underlying structures of the neck.
Larynx
Thyroid Gland
Fig. 11-11 Anterior and posterior triangles of the neck.
Cardiovascular Structures
LYMPH NODES
Fig. 11-12 Lymph nodes of the head and neck.
LINK TO CONCEPTS Sensory Perception
HEALTH HISTORY
GENERAL HEALTH HISTORY
Present Health Status
RISK FACTORS Vision, Hearing, Mouth Cancer
Hearing Loss
Cataracts
Glaucoma
Macular Degeneration
Oropharyngeal Cancer
Past Medical History
Family History
PROBLEM-BASED HISTORY
Headache
BOX 11-1 HEADACHE-TRIGGERING FOODS
Dizziness and Vertigo
BOX 11-2 DIFFERENTIATING DIZZINESS
Difficulty with Vision
Hearing Loss
Ringing in the Ears (Tinnitus)
Earache
BOX 11-3 FOCUS ON PAIN Earache
Nasal Discharge / Nose Bleed
Sore Throat
Mouth Lesions
HEALTH PROMOTION Hearing
Goals and Objectives—Healthy People 2010
Recommendations to Reduce Risk (Primary Prevention)
American Speech-Language Hearing Association (ASLHA)
Screening Recommendations (Secondary Prevention)
Healthy People 2010
Intervention Recommendations (Tertiary Prevention)
CDC
EXAMINATION
PROCEDURES AND TECHNIQUES WITH NORMAL FINDINGS
ROUTINE TECHNIQUES: HEAD
INSPECT the head.
Head for size, shape, skin characteristics.
ABNORMAL FINDINGS
Facial structures for size, symmetry, movement, intactness, skin characteristics, and facial expression.
Fig. 11-13 Symmetry of facial features (the eyebrows, palpebral fissures, nasolabial folds, and corners of the mouth) is a normal finding.
ABNORMAL FINDINGS
Fig. 11-14 Right facial palsy causing asymmetry of facial features.
SPECIAL CIRCUMSTANCES OR ADVANCED PRACTICE: HEAD
PALPATE the structures of the head.
Skull for contour, tenderness, and intactness.
ABNORMAL FINDINGS
Bony structures of the face and jaw noting size, intactness, and tenderness, and jaw movement.
ABNORMAL FINDINGS
Fig. 11-15 Position fingers in front of each ear to palpate the temporomandibular joint (TMJ).
Temporal arteries.
ABNORMAL FINDINGS
ROUTINE TECHNIQUES: EYES
TEST visual acuity (distance vision).
ABNORMAL FINDINGS
TEST visual acuity (near vision).
ABNORMAL FINDINGS
INSPECT the external ocular structures.
Eyebrows, eyelashes, and eyelids for symmetry, hair distribution, skin characteristics, and discharge.
ABNORMAL FINDINGS
Fig. 11-16 Ptosis. Client with left ptosis and right upper lid retraction.
Fig. 11-17 Exophthalmos.
Fig. 11-18 Enophthalmos. The eyelid and lashes are rolled in.
ETHNIC & CULTURAL VARIATIONS
ETHNIC & CULTURAL VARIATIONS
Conjunctiva for color, moisture, drainage, lesions.
Fig. 11-19 To inspect the palpebral conjunctiva, gently pull down and evert the lower eyelid.
Fig. 11-20 Everting upper eyelid.
ABNORMAL FINDINGS
INSPECT the ocular structures.
Corneal light reflex for symmetry (Hirschberg’s test).
Fig. 11-21 Normal position of eyes and eyelids. The symmetric light reflection in both corneas is a normal finding.
ABNORMAL FINDINGS
Sclera for color, surface characteristics.
ABNORMAL FINDINGS
ETHNIC & CULTURAL VARIATIONS
Cornea for transparency and surface characteristics.
ABNORMAL FINDINGS
Iris for shape and color.
ABNORMAL FINDINGS
Pupils for size, shape, reaction to light, accommodation, and consensual reaction.
ABNORMAL FINDINGS
BOX 11-4 DOCUMENTATION TIPS FOR EYES
PERRLA
Remembering C’s and D’s for Expected Findings for Accommodation
TABLE 11-1 Pupil Abnormalities
SPECIAL CIRCUMSTANCES OR ADVANCED PRACTICE: EYE
ASSESS visual fields for peripheral vision (confrontation test).
ABNORMAL FINDINGS
Fig. 11-22 Assessing a client’s peripheral vision nasally by moving object medially into the field of vision.
ASSESS eye movement.
Six Cardinal Fields of Gaze (tests cranial nerves III, IV, and VI).
Fig. 11-23 The six cardinal fields of gaze.
ABNORMAL FINDINGS
Cover-Uncover Test
ABNORMAL FINDINGS
Fig. 11-24 The cover-uncover test is used to evaluate function of eye muscles. A, Left eye covered; observe right eye. B, Left eye uncovered; observe it for movement. C, Exophoria; the right eye shifted from right to center when the eye was uncovered.
PALPATE the eye, eyelids, and lacrimal puncta.
ABNORMAL FINDINGS
TEST the corneal reflex.
ABNORMAL FINDINGS
INSPECT the anterior chamber for transparency, iris surface, and chamber depth.
ABNORMAL FINDINGS
Fig. 11-25 Evaluation of depth of anterior chambers. A, Normal anterior chamber. B, Shallow anterior chamber.
INSPECT intraocular structures (ophthalmoscopic examination).
Inspect for a red reflex.
ABNORMAL FINDINGS
Inspect the optic disc for discrete margin, shape, size, color, and physiologic cup.
ABNORMAL FINDINGS
ABNORMAL FINDINGS
Fig. 11-26 Examining the retina. A, The red reflex is created by light illuminating the retina. B, Move close to the client until you nearly touch foreheads.
ABNORMAL FINDINGS
ABNORMAL FINDINGS
Fig. 11-27 Retinal structures of the left eye.
Inspect the retinal vessels for color, arteriolar light reflex, artery-to-vein ratio, and arteriovenous crossing changes.
ABNORMAL FINDINGS
Inspect the retinal background for color, presence of microaneurysms, hemorrhages, and exudates.
ABNORMAL FINDINGS
Inspect the macula for color and surface characteristics.
ABNORMAL FINDINGS
ROUTINE TECHNIQUES: EARS
ASSESS hearing based on response from conversation.
ABNORMAL FINDINGS
INSPECT the external ears.
Observe the alignment and position.
Fig. 11-28 Normal ear position and alignment.
ABNORMAL FINDINGS
Inspect for size, shape, symmetry, skin color, and skin intactness.
ABNORMAL FINDINGS
Fig. 11-29 A darwinian tubercle.
TABLE 11-2 Abnormal Findings of the External Ear
Inspect the external auditory meatus for discharge or lesions.
ABNORMAL FINDINGS
SPECIAL CIRCUMSTANCES OR ADVANCED PRACTICE: EARS
PALPATE the external ears and mastoid areas for tenderness, edema, and nodules.
ABNORMAL FINDINGS
INSPECT the internal ear structures.
Fig. 11-30 Use of an otoscope. A, Pull the client’s helix upward and slightly toward the back of the head. B, Holding the otoscope “upside down,” rest the back of your hand against the client’s temple area to steady the otoscope.
Inspect the external ear canal for cerumen, edema, erythema, discharge, and foreign bodies.
ABNORMAL FINDINGS
ETHNIC & CULTURAL VARIATIONS
BOX 11-5 REMOVING CERUMEN FROM THE AUDITORY CANAL
Fig. 11-31 A, Normal piece of cerumen (earwax) in the external meatus. B, Excessive earwax in the external auditory canal.
Inspect the tympanic membrane for landmarks, color, contour, translucence, and fluctuation.
ABNORMAL FINDINGS
Fig. 11-32 The tympanic membrane. A, Landmarks of tympanic membrane with “clock” superimposed (right ear). B, Photograph of a normal-appearing tympanic membrane.
Fig. 11-33 Perforated tympanic membrane.
BOX 11-6 ABNORMAL COLOR CHARACTERISTICS OF THE TM AND POSSIBLE CAUSES
TEST the acoustic cranial nerve (VIII) to evaluate auditory function.
Whispered Voice Test
ABNORMAL FINDINGS
Finger-Rubbing Test
ABNORMAL FINDINGS
Weber’s Test
ABNORMAL FINDINGS
Fig. 11-34 Weber’s test. The tuning fork is placed on the midline of the skull.
Fig. 11-35 A, Client with conduction loss; sound lateralizes to the defective ear because the sound transmits through the bone rather than air. B, Client with sensorineural loss; sound lateralizes to the unaffected ear.
Fig. 11-36 Rinne test. A, The tuning fork is placed on the mastoid bone for bone conduction. B, The tuning fork is placed in front of the ear for air conduction.
Fig. 11-37 A, Client with conduction loss will hear bone conduction longer than air conduction (BC greater than AC). B, Client with sensorineural loss will hear air conduction longer than bone conduction (AC greater than BC).
Rinne Test
ABNORMAL FINDINGS
Audioscope
ABNORMAL FINDINGS
ROUTINE TECHNIQUES: NOSE
INSPECT the nose for general appearance, symmetry, discharge, and tenderness.
ABNORMAL FINDINGS
SPECIAL CIRCUMSTANCES OR ADVANCED PRACTICE: NOSE
PALPATE the nose for tenderness and to assess patency.
ABNORMAL FINDINGS
INSPECT the internal nasal cavity.
Fig. 11-38 Inspect the nasal cavity with a light source.
ABNORMAL FINDINGS
Fig. 11-39 View of the nasal mucosa through the nasal speculum.
PALPATE the frontal and maxillary paranasal sinus areas for tenderness.
ABNORMAL FINDINGS
TRANSILLUMINATE the sinus area.
ABNORMAL FINDINGS
Fig. 11-40 Palpation of the sinuses. A, Frontal. B, Maxillary.
ROUTINE TECHNIQUES: MOUTH
INSPECT the mouth and oropharynx.
Lips for color, symmetry, moisture, and texture.
ABNORMAL FINDINGS
Teeth and gums for condition, color, surface characteristics, stability, and alignment.
ABNORMAL FINDINGS
Fig. 11-41 Malocclusion of the teeth.
ETHNIC & CULTURAL VARIATIONS Variations in the Number and Size of Teeth
ETHNIC & CULTURAL VARIATIONS
Tongue for movement, color, and surface characteristics.
ABNORMAL FINDINGS
Buccal mucosa and anterior and posterior pillars for color and surface characteristics.
ABNORMAL FINDINGS
Fig. 11-42 Leukoplakia.
Palate, uvula, posterior pharynx, and tonsils for texture, color, surface characteristics, and movement.
ABNORMAL FINDINGS
ETHNIC & CULTURAL VARIATIONS
Fig. 11-43 Displace the tongue with a tongue depressor for inspection of the pharynx.
Fig. 11-44 Tonsil enlargement. A, 1+, visible; B, 2+, halfway between tonsilar pillars and uvula; C, 3+, nearly touching the uvula; D, 4+, touching each other.
SPECIAL CIRCUMSTANCES OR ADVANCED PRACTICE: MOUTH
PALPATE structures of the mouth.
Teeth, inner lips, and gums for condition and tenderness.
ABNORMAL FINDINGS
Tongue for texture
ABNORMAL FINDINGS
Fig. 11-45 Grasp the tongue with a 4 × 4 inch gauze pad.
ROUTINE TECHNIQUES: NECK
INSPECT the neck.
Position in relation to the head and trachea.
ABNORMAL FINDINGS
Fig. 11-46 Bilateral symmetry of the neck muscles.
Fig. 11-47 Goiter. Note visible enlargement over the anterior neck.
Skin characteristics, presence of lumps, masses.
ABNORMAL FINDINGS
SPECIAL CIRCUMSTANCES OR ADVANCED PRACTICE: NECK
INSPECT the neck for range of motion.
ABNORMAL FINDINGS
PALPATE the neck.
Positioning of anatomic structures and trachea.
ABNORMAL FINDINGS
Thyroid gland for size, shape consistency, tenderness, and presence of nodules.
Fig. 11-48 Palpation of the thyroid gland. A, Posterior approach. B, Anterior approach.
ABNORMAL FINDINGS
ABNORMAL FINDINGS
SPECIAL CIRCUMSTANCES OR ADVANCED PRACTICE: LYMPH NODES
PALPATE lymph nodes for size, consistency, mobility, boarders, tenderness, and warmth.
Fig. 11-49 Palpation of the preauricular nodes.
Fig. 11-50 Palpation of the posterior superficial cervical chain nodes.
Documenting Expected Findings
Head, Ears, Eyes, Nose, and Throat in an Adult Male
CLINICAL REASONING HEENT
AGE-RELATED VARIATIONS
INFANTS AND CHILDREN
OLDER ADULTS
COMMON PROBLEMS & CONDITIONS
HEAD & NECK
Headaches
Migraine Headache
Cluster Headache
Tension Headache
Posttraumatic Headache
Hydrocephalus
Fig. 11-51 Three-month-old infant with hydrocephalus.
EYES
External Eye
Chalazion
Hordeolum (Sty)
Conjunctivitis
Fig. 11-52 Chalazion (right upper eyelid).
Fig. 11-53 Hordeolum (sty).
Corneal Abrasion or Ulcer
Strabismus
Fig. 11-54 Acute conjunctivitis.
Fig. 11-55 Paralytic strabismus involving left lateral rectus muscle innervated by cranial nerve VI (abducens nerve).
Internal Eye
Cataract
Fig. 11-56 Cataract. Note cloudy white spot over pupil.
Fig. 11-57 Diabetic retinopathy. A, Nonproliferative. B, Proliferative.
Diabetic Retinopathy
Glaucoma
EARS
Foreign Body
Infection
Acute Otitis Media
Fig. 11-58 Client inserted a small stone into the deep part of the external ear canal. It is lying against the tympanic membrane.
Fig. 11-59 Acute otitis media with redness and edematous swelling of the pars flaccida, shown in the central part of the illustration (left ear).
Otitis Media with Effusion
Fig. 11-60 Otitis media with effusion.
Hearing Loss
Conductive Hearing Loss
Sensorineural Hearing Loss
NOSE
Epistaxis
Inflammation
Allergic Rhinitis
Rhinophyma
Acute Sinusitis
Fig. 11-61 Rhinophyma associated with rosacea.
MOUTH
Inflammation/Infection
Herpes Simplex Type 1 (Cold Sore)
Fig. 11-62 Herpes simplex lesion (cold sore) of the lower lip.
Fig. 11-63 Gingivitis. Note enlargement of the gums.
Gingivitis
Tonsillitis
Fig. 11-64 Tonsillitis and pharyngitis.
Candidiasis (Thrush)
Lesions
Aphthous Ulcer (Canker Sore)
Oral Cancer
Fig. 11-65 Candidiasis.
Fig. 11-66 A small aphthous ulcer (canker sore) on the lower lip.
Oral Kaposi’s Sarcoma
NECK
Thyroid Disorders
Hyperthyroidism
Fig. 11-67 A, Early squamous cell carcinoma on the floor of the mouth. B, Squamous cell carcinoma on the lip.
Fig. 11-68 The bluish raised lesion seen on the palate of this client who has AIDS is Kaposi’s sarcoma.
Hypothyroidism
Thyroid cancer
Lymphoma
CLINICAL APPLICATION & CLINICAL REASONING
REVIEW QUESTIONS
SAMPLE DOCUMENTATION
SUBJECTIVE DATA
OBJECTIVE DATA
CASE STUDY
Interview Data
Examination Data
CLINICAL Reasoning
INTERACTIVE ACTIVITIES
CHAPTER 12 Lungs and Respiratory System
ANATOMY & PHYSIOLOGY
STRUCTURES WITHIN THE THORAX
EXTERNAL THORAX
Fig. 12-1 Structures within the thoracic cavity.
Fig. 12-2 Right and left lung. Note fissures dividing lobes of the lungs.
MECHANICS OF BREATHING
Fig. 12-3 Thorax and underlying structures. A, Anterior view. B, Posterior view.
Fig. 12-4 Muscles involved in ventilation. A, Anterior view. B, Posterior view.
Fig. 12-5 Structures of the upper airway.
Fig. 12-6 Structures of the lower airway.
Fig. 12-7 Alveolar sac.
TOPOGRAPHIC MARKERS
Anterior Chest Wall
Fig. 12-8 Topographic landmarks of the thorax. A, Anterior. B, Lateral. C, Posterior.
Lateral Chest Wall
Posterior Chest Wall
LINK TO CONCEPTS Oxygenation
Concept Model: Oxygenation
HEALTH HISTORY
RISK FACTORS Lung Cancer
GENERAL HEALTH HISTORY
Present Health Status
Past Medical History
Family History
BOX 12-1 RECORDING TOBACCO USE
Home Environment
Occupational Environment
Travel
PROBLEM-BASED HISTORY
Cough
Shortness of Breath
BOX 12-2 CLINICAL NOTES
Chest Pain with Breathing
HEALTH PROMOTION Tobacco Use
Goals and Objectives—Healthy People 2010
Recommendations to Reduce Risk (Primary Prevention)
U.S. Preventive Services Task Force
Recommendations for Treatment (Tertiary Prevention)
U.S. Preventive Services Task Force
EXAMINATION
PROCEDURES AND TECHNIQUES WITH NORMAL FINDINGS
ROUTINE TECHNIQUES
INSPECT the client for general appearance, posture, and breathing effort.
ABNORMAL FINDINGS
Fig. 12-9 Observing the client for breathing effort.
Fig. 12-10 Tripod position.
OBSERVE respirations for rate and quality, breathing pattern, and chest expansion.
ABNORMAL FINDINGS
Fig. 12-11 Normal breathing pattern.
Fig. 12-12 Sigh.
Fig. 12-13 Abnormal breathing patterns. A, Bradypnea is a respiratory rate less than 12 breaths per minute. The rate and depth remain smooth and even. B, Tachypnea is a respiratory rate greater than 20 breaths per minute. The rate and depth remain smooth and even. Tachypnea can be caused by a number of factors, including fever, fear, or activity. C, Hyperventilation is characterized by increased rate and depth of respiration. D, When hyperventilation occurs with ketoacidosis, it is very deep and laborious and is termed Kussmaul breathing. E, Biot breathing pattern is characterized by irregularly interspersed periods of apnea in a disorganized and irregular pattern, rate, or depth. It may be associated with persistent intracranial pressure, respiratory distress, or damage to the medulla. F, Cheyne-Stokes is characterized by intervals of apnea interspersed with a deep and rapid breathing pattern. This may be seen in clients with severe illness, brain damage, or drug overdose. G, Air trapping is an abnormal respiratory pattern frequently seen in clients with chronic obstructive pulmonary disease. It is characterized by rapid inspirations with prolonged, forced expirations. Air is not fully exhaled; thus it becomes trapped in the lungs, which eventually leads to a barrel chest.
INSPECT the client’s nails, skin, and lips for color.
ABNORMAL FINDINGS
POSTERIOR THORAX
INSPECT the posterior thorax for shape and symmetry and muscle development.
ABNORMAL FINDINGS
AUSCULTATE the posterior and lateral thorax for breath sounds.
Fig. 12-14 Auscultating the posterior and lateral chest. A, Posterior thorax. B, Lateral thorax.
Fig. 12-15 Landmarks for chest auscultation and percussion. A, Posterior view. B, Anterior view. C, Lateral view.
ABNORMAL FINDINGS
Fig. 12-16 Auscultatory sounds. A, Anterior thorax. B, Posterior thorax.
TABLE 12-1 Characteristics of Breath Sounds
BOX 12-3 CLINICAL NOTES
ABNORMAL FINDINGS
TABLE 12-2 Characteristics of Adventitious Sounds
ANTERIOR THORAX
INSPECT the anterior thorax for shape and symmetry, muscle development, anteroposterior diameter to lateral diameter, and costal angle.
ABNORMAL FINDINGS
Fig. 12-17 Normal chest findings. A, Angulation of ribs. B, AP diameter is about half the lateral diameter. C, Costal angle less than 90 degrees.
Fig. 12-18 Barrel chest. A, Horizontal ribs. B, Increased AP diameter. C, Costal angle greater than 90 degrees.
AUSCULTATE the anterior thorax for breath sounds.
ABNORMAL FINDINGS
Fig. 12-19 Pectus carinatum, or pigeon chest. Note prominent sternum.
Fig. 12-20 Pectus excavatum, or funnel chest. Note that sternum is indented above xiphoid.
Fig. 12-21 Auscultating the anterior chest. A, Left apex. B, Right middle anterior thorax. C, Left lower anterior thorax.
ABNORMAL FINDINGS
SPECIAL CIRCUMSTANCES OR ADVANCED PRACTICE POSTERIOR THORAX
PALPATE posterior thoracic muscles for tenderness, bulges, and symmetry.
ABNORMAL FINDINGS
PALPATE the posterior chest wall for thoracic expansion.
ABNORMAL FINDINGS
Fig. 12-22 Assessing for posterior thoracic expansion.
PALPATE the posterior thoracic wall for vocal (tactile) fremitus.
ABNORMAL FINDINGS
Fig. 12-23 Assessing for posterior vocal (tactile) fremitus. A, Hand positions for assessment. B, Position hands over both lung fields, making bilateral comparisons.
PERCUSS the posterior and lateral thorax for tone.
ABNORMAL FINDINGS
Fig. 12-24 Percussing the posterior thorax using the tip of the middle finger of the right hand to strike the middle finger of the left hand.
TABLE 12-3 Percussion Tones over the Lungs
Fig. 12-25 Percussion tones of the chest. A, Anterior chest. B, Posterior chest.
PERCUSS the thorax for diaphragmatic (respiratory) excursion.
ABNORMAL FINDINGS
Fig. 12-26 Measuring amount of diaphragmatic excursion. Excursion usually measures 3 to 5 cm.
AUSCULTATE the thorax for vocal sounds (vocal resonance).
ABNORMAL FINDINGS
Bronchophony
Whispered Pectoriloquy
ABNORMAL FINDINGS
Egophony
ABNORMAL FINDINGS
ANTERIOR THORAX
PALPATE the trachea for position.
Fig. 12-27 Palpating to evaluate midline position of trachea.
ABNORMAL FINDINGS
PALPATE the anterior thoracic muscles for tenderness, bulges, and symmetry.
ABNORMAL FINDINGS
PALPATE the anterior chest wall for thoracic expansion.
ABNORMAL FINDINGS
Fig. 12-28 Assessing for anterior thoracic expansion.
PALPATE the anterior thoracic wall for vocal (tactile) fremitus.
ABNORMAL FINDINGS
Fig. 12-29 Assessing for anterior vocal (tactile) fremitus.
PERCUSS the anterior thorax for tone.
ABNORMAL FINDINGS
AGE-RELATED VARIATIONS
INFANTS, CHILDREN, AND ADOLESCENTS
OLDER ADULTS
Documenting Expected Findings
CLINICAL REASONING Respiratory System
COMMON PROBLEMS & CONDITIONS
INFECTIONS AND INFLAMMATORY CONDITIONS
Acute Bronchitis
Pneumonia
Fig. 12-30 Bronchitis. Irritation of the bronchi causes inflammation.
Fig. 12-31 Right upper lobe pneumonia.
Tuberculosis
Pleural Effusion
Fig. 12-32 Tuberculosis.
Fig. 12-33 Pleural effusion.
CHRONIC PULMONARY DISEASE
Asthma
Emphysema
Chronic Bronchitis
Fig. 12-34 Factors causing airway obstruction in asthma. A, Cross section of a bronchiole occluded by muscle spasm, mucosal edema, and mucus. B, Longitudinal section of a bronchiole.
Fig. 12-35 Emphysema in upper left lobe.
ACUTE OR TRAUMATIC CONDITIONS
Pneumothorax
Fig. 12-36 Chronic bronchitis.
Fig. 12-37 Tension pneumothorax.
Fig. 12-38 Hemothorax.
Hemothorax
OTHER PULMONARY CONDITIONS
Atelectasis
Lung Cancer
Fig. 12-39 Atelectasis.
Fig. 12-40 Cancer of the lung. A, Squamous cell carcinoma. B, small cell (oat cell) carcinoma. C, Adenocarcinoma. D, Large cell carcinoma.
CLINICAL APPLICATION & CLINICAL REASONING
REVIEW QUESTIONS
SAMPLE DOCUMENTATION
SUBJECTIVE DATA
OBJECTIVE DATA
CASE STUDY
Interview Data
Examination Data
CLINICAL Reasoning
INTERACTIVE ACTIVITIES
CHAPTER 13 Heart and Peripheral Vascular System
ANATOMY & PHYSIOLOGY
THE HEART AND GREAT VESSELS
PERICARDIUM AND CARDIAC MUSCLE
Fig. 13-1 Position of the heart chambers and great vessels. Intercostal spaces 1 to 9 are numbered.
BLOOD FLOW THROUGH THE HEART: THE CARDIAC CYCLE
Diastole
Fig. 13-2 Cross section of cardiac muscle.
Fig. 13-3 Anterior cross section showing the valves and chambers of the heart.
Fig. 13-4 Blood flow during diastole.
Fig. 13-5 Blood flow during systole.
Fig. 13-6 Events of the cardiac cycle showing venous pressure waves, electrocardiograph, and heart sounds in systole and diastole. a, Atrial contraction; AV, atrioventricular; c, carotid artery; ECG, electrocardiogram; PCG, phonocardiogram; p, p wave (atrial contraction); QRS, QRS complex (ventricular contraction); S1, first heart sound; S2, second heart sound; S3, third heart sound; S4, fourth heart sound; T, T wave (ventricular repolarization); v, venous return coming into the atrium.
Systole
Cardiac Cycle
ELECTRIC CONDUCTION
PERIPHERAL VASCULAR SYSTEM
Fig. 13-7 Cardiac conduction.
LYMPH SYSTEM
Fig. 13-8 Schematic drawing of artery and vein. Shown are the comparative thickness of three layers (tunica adventitia), muscle layer (tunica media), and lining of endothelium (tunica intima). Note the muscle and outer coats are much thinner in the veins than in the arteries and that veins have valves.
Fig. 13-9 System of deep and superficial collecting ducts, carrying lymph from upper extremity to subclavian lymphatic trunk. The only peripheral lymph center is the epitrochlear, which receives some of the collecting ducts from the pathway of the ulnar and radial vessels.
Fig. 13-10 Lymphatic drainage of lower extremity.
LINK TO CONCEPTS Perfusion
Concept Model: Perfusion
HEALTH HISTORY
RISK FACTORS Hypertension and Coronary Artery Disease
Hypertension
Coronary Artery Disease
GENERAL HEALTH HISTORY
Present Health Status
Past Medical History
Family History
PROBLEM-BASED HISTORY
Chest Pain
TABLE 13-1 Differentiation of Chest Pain
Shortness of Breath
Cough
Urinating During the Night
Fatigue
Fainting
HEALTH PROMOTION Cardiovascular Disease
Goals and Objectives—Healthy People 2010
Recommendations to Reduce Risk (Primary Prevention)
American Heart Association
Screening Recommendations (Secondary Prevention)
U.S. Preventive Services Task Force
Tertiary Prevention
American Heart Association
Swelling of Extremities
Leg Cramps or Pain
EXAMINATION
PROCEDURES AND TECHNIQUES WITH NORMAL FINDINGS
ROUTINE TECHNIQUES
ASSESS General Appearance
INSPECT the client for general appearance, skin color, and breathing effort.
ABNORMAL FINDINGS
ASSESS the Peripheral Vascular System
PALPATE temporal and carotid pulses for amplitude.
ABNORMAL FINDINGS
Fig. 13-11 Palpating temporal pulses lateral to each eyebrow.
Fig. 13-12 Arteries of the head and neck.
Fig. 13-13 Palpating carotid pulse in the lower third of the neck.
Fig. 13-14 Right and left common carotid arteries that are palpated.
BOX 13-1 PALPATING PULSES
Procedures and Techniques
Rate
Abnormal Findings
Rhythm
Abnormal Findings
Amplitude
Abnormal Findings
Contour (Outline of the Pulse that is Felt)
INSPECT the jugular vein for pulsations.
ABNORMAL FINDINGS
Fig. 13-15 Tangential light to view jugular veins and pulsations.
Fig. 13-16 Neck vein distention.
MEASURE blood pressure.
ABNORMAL FINDINGS
Fig. 13-17 Assessing blood pressure.
ETHNIC & CULTURAL VARIATIONS
ABNORMAL FINDINGS
INSPECT and PALPATE the upper extremities for skin turgor.
ABNORMAL FINDINGS
Fig. 13-18 Technique for testing for pitting edema. A, The nurse presses into the shin area. B, An indentation remains after the fingers are lifted when pitting edema is present.
TABLE 13-2 Pitting Edema Scale
INSPECT and PALPATE the upper extremities for symmetry, skin integrity, color, and temperature, capillary refill, and color and angle of the nail beds.
ABNORMAL FINDINGS
Fig. 13-19 Clubbing of fingers.
PALPATE brachial and radial pulses for rate, rhythm, amplitude, and contour.
ABNORMAL FINDINGS
Fig. 13-20 Palpating brachial pulse at the antecubital fossa.
Fig. 13-21 Palpating radial pulse on the thumb side of the forearm at the wrist.
Fig. 13-22 Arteries of the upper extremity that are palpated.
FREQUENTLY ASKED QUESTIONS
INSPECT and PALPATE the lower extremities for skin turgor.
ABNORMAL FINDINGS
INSPECT and PALPATE the lower extremities for symmetry, skin integrity, color, and temperature, hair distribution, capillary refill, color and angle of nail beds, tenderness, and superficial veins.
ABNORMAL FINDINGS
ABNORMAL FINDINGS
ABNORMAL FINDINGS
Fig. 13-23 Chronic venous stasis.
PALPATE femoral, popliteal, posterior tibial, and dorsalis pedis pulses for amplitude.
Fig. 13-24 Palpating femoral pulse below the inguinal ligament between the symphysis pubis and anterior superior iliac crest.
Fig. 13-25 Palpating popliteal pulse behind the knee.
ABNORMAL FINDINGS
Fig. 13-26 Palpating posterior tibial pulse on the inner aspect of the ankle.
Fig. 13-27 Palpating dorsalis pedis pulse on top of the foot between the first and second toes.
FREQUENTLY ASKED QUESTIONS
Fig. 13-28 Arteries of the leg that are palpated.
ASSESS THE HEART
INSPECT the anterior chest wall for contour, pulsations, lifts, heaves, and retractions.
ABNORMAL FINDINGS
BOX 13-2 ABBREVIATIONS FOR TOPOGRAPHIC LANDMARKS
BOX 13-3 DEFINITIONS OF LIFT, HEAVE, THRILL, AND RETRACTION
PALPATE apical pulse for location.
ABNORMAL FINDINGS
Fig. 13-29 Palpating the apical pulse at the fourth or fifth intercostal space, left midclavicular line.
AUSCULTATE S1 and S2 heart sounds for rate, rhythm, pitch, and splitting.
BOX 13-4 TECHNIQUE FOR LOCATING INTERCOSTAL SPACES FOR AUSCULTATION OF THE HEART
BOX 13-5 LOW- AND HIGH-PITCHED SOUNDS OF THE HEART
FREQUENTLY ASKED QUESTIONS
Fig. 13-30 Transmission of closure sounds from the heart valves.
BOX 13-6 TIP TO REMEMBER
Fig. 13-31 Position for cardiac auscultation. A, Aortic area. B, Pulmonic area. C, Erb’s point. D, Tricuspid area. E, Mitral area.
ASSESS Heart Rate
ABNORMAL FINDINGS
ASSESS Rhythm
ABNORMAL FINDINGS
TABLE 13-3 Abnormal Heart Sounds
ASSESS Pitch
ABNORMAL FINDINGS
ASSESS Splitting
TABLE 13-4 Listening to Murmurs
TABLE 13-5 Murmurs Caused by Valvular Defects
INTERPRET the electrocardiogram of the conduction of the heart.
Fig. 13-32 Electrocardiogram (EKG) and cardiac electrical activity. A, Ideal EKG deflections represent depolarization and repolarization of cardiac muscle tissue. B, Principal EKG interval among P, QRS, and T waves. Note that the RP interval is measured from the start of the P wave to the end of the Q wave. C, Schematic representation of EKG and its relationship to the cardiac electrical activity. AV, Atrioventricular; LA, left atrium; LBB, left bundle branch; LV, left ventricle; RA, right atrium; RBB, right bundle branch; RV, right ventricular, SA, sinoatrial.
SPECIAL CIRCUMSTANCES OR ADVANCED PRACTICE
ASSESS the Peripheral Vascular System
AUSCULTATE the carotid artery for bruits.
ABNORMAL FINDINGS
Fig. 13-33 Auscultating the carotid artery.
ESTIMATE jugular venous pressure for pulsations.
ABNORMAL FINDINGS
Fig. 13-34 Measuring jugular venous pressure.
PALPATE epitrochlear lymph nodes for size, consistency, mobility, borders, tenderness, and warmth.
ABNORMAL FINDINGS
Fig. 13-35 Palpation for epitrochlear lymph nodes is performed in the depression above and posterior to the medial condyle of the humerus.
PALPATE inguinal lymph nodes for size, consistency, mobility, borders, tenderness, and warmth.
ABNORMAL FINDINGS
Fig. 13-36 A, Palpation of inferior superficial inguinal (femoral) lymph nodes. B, Palpation of superior superficial inguinal lymph nodes.
CALCULATE the ankle brachial index (ABI) to estimate arterial occlusion.
ABNORMAL FINDINGS
PERFORM Trendelenburg’s test to evaluate competence of venous valves in clients who have varicose veins.
ABNORMAL FINDINGS
ASSESS the Heart
PALPATE the precordium for pulsations, thrills, lifts, and heaves.
ABNORMAL FINDINGS
ABNORMAL FINDINGS
ABNORMAL FINDINGS
ABNORMAL FINDINGS
ABNORMAL FINDINGS
Fig. 13-37 Palpation of precordium. A, Palpating base. B, Palpating left sternal border. C, Palpating apex.
PERCUSS the heart borders for the heart size.
ABNORMAL FINDINGS
AGE-RELATED VARIATIONS
INFANTS, CHILDREN, AND ADOLESCENTS
OLDER ADULTS
Documenting Expected Findings
Heart and Peripheral Vascular System
CLINICAL REASONING Cardiovascular System
COMMON PROBLEMS & CONDITIONS
CARDIAC DISORDERS
Valvular Heart Disease
Angina Pectoris
Myocardial Infarction
Heart Failure
Fig. 13-38 Bacterial endocarditis.
Fig. 13-39 Pericarditis.
Left ventricular failure
Right ventricular failure
Infective Endocarditis
Pericarditis
PERIPHERAL VASCULAR DISEASE
Hypertension
BOX 13-7 CLASSIFICATION OF BLOOD PRESSURE FOR ADULTS AGE 18 AND OLDER
Venous Thrombosis and Thrombophlebitis
Aneurysm
Fig. 13-40 Sites of venous thrombosis.
Fig. 13-41 Arterial aneurysm.
CLINICAL APPLICATION & CLINICAL REASONING
REVIEW QUESTIONS
SAMPLE DOCUMENTATION
CASE STUDY
Interview Data
SUBJECTIVE DATA
OBJECTIVE DATA
Examination Data
CLINICAL Reasoning
INTERACTIVE ACTIVITIES
CHAPTER 14 Abdomen and Gastrointestinal System
ANATOMY & PHYSIOLOGY
PERITONEUM, MUSCULATURE, AND CONNECTIVE TISSUE
ALIMENTARY TRACT
Fig. 14-1 Anatomy of the gastrointestinal system.
Fig. 14-2 Anatomy of the urinary system and major vessels of the abdominal cavity.
Fig. 14-3 Muscles of the abdomen.
Stomach
Small Intestine
Large Intestine (Colon) and Rectum
ACCESSORY ORGANS
Liver
Gallbladder
Pancreas
Spleen
URINARY TRACT
Kidneys
Ureters
Bladder
VASCULATURE OF THE ABDOMEN
HEALTH HISTORY
RISK FACTORS Abdominal Cancers
Esophageal Cancer
Stomach Cancer
Colon Cancer
Liver Cancer
Pancreatic Cancer
Bladder Cancer
GENERAL HEALTH HISTORY
Present Health Status
Past Medical History
Family History
PROBLEM-BASED HISTORY
Abdominal Pain
TABLE 14-1 Differentiation of Abdominal Pain
Nausea and Vomiting
Indigestion
Abdominal Distention
Change in Bowel Habits
Yellow Discoloration of Eyes or Skin (Jaundice)
Problems with Urination
HEALTH PROMOTION Colorectal Cancer
Goals and Objectives—Healthy People 2010
Recommendations to Reduce Risk (Primary Prevention)
American Cancer Society
EXAMINATION
PROCEDURES AND TECHNIQUES WITH NORMAL FINDINGS
ROUTINE TECHNIQUES
OBSERVE client’s general behavior and position.
ABNORMAL FINDINGS
INSPECT the abdomen for skin color, surface characteristics, contour, and surface movements.
ABNORMAL FINDINGS
ABNORMAL FINDINGS
Fig. 14-4 Landmarks of the abdomen.
ABNORMAL FINDINGS
ABNORMAL FINDINGS
ABNORMAL FINDINGS
ABNORMAL FINDINGS
ABNORMAL FINDINGS
AUSCULTATE the abdomen for bowel sounds.
Fig. 14-5 Quadrants of the abdomen.
BOX 14-1 ANATOMIC CORRELATES OF THE QUADRANTS OF THE ABDOMEN
ABNORMAL FINDINGS
Fig. 14-6 Nine regions of the abdomen.
BOX 14-2 ANATOMIC CORRELATES OF THE NINE REGIONS OF THE ABDOMEN
AUSCULTATE the abdomen for arterial and venous vascular sounds.
Fig. 14-7 Sites to auscultate for bruits: renal arteries, iliac arteries, aorta, and femoral arteries.
ABNORMAL FINDINGS
PALPATE the abdomen lightly for tenderness, muscle tone, and surface characteristics.
ABNORMAL FINDINGS
Fig. 14-8 Light palpation of the abdomen.
PALPATE the abdomen deeply for tenderness, masses, and aortic pulsation.
ABNORMAL FINDINGS
Fig. 14-9 Deep palpation of the abdomen.
Fig. 14-10 Deep bimanual palpation.
Fig. 14-11 Palpating the aorta.
SPECIAL CIRCUMSTANCES OR ADVANCED PRACTICE
PERCUSS the abdomen for tones.
Fig. 14-12 Systematic route for abdominal percussion.
ABNORMAL FINDINGS
PERCUSS the liver to determine span and descent.
ABNORMAL FINDINGS
Fig. 14-13 A, Liver percussion route. B, Percussion method of estimating size of liver in the midclavicular line. C, Distance between the two marks measured in estimating the liver span in midclavicular line is usually 2.5 to 4.5 inches (6 to 12 cm).
PERCUSS the spleen for size.
ABNORMAL FINDINGS
PALPATE around the umbilicus for bulges, nodules, and the umbilical ring.
ABNORMAL FINDINGS
Fig. 14-14 Percussion of the spleen.
PALPATE the liver for lower border and tenderness.
ABNORMAL FINDINGS
Fig. 14-15 Methods of palpating the liver. A, Fingers are extended, with tips on right midclavicular line below the level of liver tenderness and pointing toward the head. B, Fingers parallel to the costal margin. C, Fingers hooked over the costal margin.
PALPATE the gallbladder for tenderness.
ABNORMAL FINDINGS
PALPATE the spleen for border and tenderness.
ABNORMAL FINDINGS
Fig. 14-16 Palpation of the spleen.
PALPATE the kidneys for presence, contour, and tenderness.
ABNORMAL FINDINGS
Fig. 14-17 Palpation of the left kidney.
Fig. 14-18 Eliciting superficial abdominal reflexes. Stroke the upper abdominal area upward, away from the umbilicus, and the lower umbilicus area downward, away from the umbilicus.
ELICIT abdominal reflexes for presence.
ABNORMAL FINDINGS
PERCUSS the kidneys for costovertebral angle (CVA) tenderness.
ABNORMAL FINDINGS
Fig. 14-19 Fist percussion of costovertebral angle for kidney tenderness. A, Direct percussion. B, Indirect percussion.
Fig. 14-20 Anatomic drawing showing landmarks for indirect percussion of the costovertebral angle.
ASSESS the abdomen for fluid.
ABNORMAL FINDINGS
ABNORMAL FINDINGS
Fig. 14-21 Testing for shifting dullness. Dullness shifts to the dependent side.
Fig. 14-22 Testing for fluid wave. Strike one side of the abdomen sharply with the fingertips. Feel for the impulse of a fluid wave with the other hand.
Fig. 14-23 Massive ascites in an individual with cirrhosis. Distended abdomen, dilated upper abdominal veins, and inverted umbilicus are classic manifestations.
ASSESS the abdominal pain due to inflammation.
ABNORMAL FINDINGS
ABNORMAL FINDINGS
ABNORMAL FINDINGS
ABNORMAL FINDINGS
Fig. 14-24 Testing for rebound tenderness. A, Press deeply and gently into the abdomen; then, B, rapidly withdraw the hand and fingers.
Fig. 14-25 Iliopsoas muscle test.
Fig. 14-26 Obturator muscle test.
ASSESS the abdomen for floating mass.
ABNORMAL FINDINGS
Fig. 14-27 Ballottement technique. A, Single-handed ballottement. Push inward at a 90-degree angle; if the object is freely movable, it will float upward to touch the fingertips. B, Bimanual ballottement. P, Pushing hand; R, Receiving hand.
Documenting Expected Findings
Abdomen and Gastrointestinal System
CLINICAL REASONING Gastrointestinal System
AGE-RELATED VARIATIONS
INFANTS, CHILDREN, AND ADOLESCENTS
OLDER ADULTS
COMMON PROBLEMS & CONDITIONS
ALIMENTARY TRACT
Gastroesophageal Reflux Disease
Hiatal Hernia
Fig. 14-28 Hiatal hernia. A, Sliding hernia. B, Paraesophageal.
Peptic Ulcer Disease
Fig. 14-29 Duodenal peptic ulcer.
Crohn’s Disease
Ulcerative Colitis
Fig. 14-30 Crohn’s disease showing deep ulcers and fissures, creating “cobblestone” effect.
Fig. 14-31 Ulcerative colitis showing severe mucosal edema and inflammation with ulcerations and bleeding.
Diverticulitis
HEPATOBILIARY SYSTEM
Viral Hepatitis
Cirrhosis
Cholecystitis with Cholelithiasis
Fig. 14-32 Diverticulosis (diverticulitis).
PANCREAS
Pancreatitis
Fig. 14-33 Cirrhosis of the liver.
Fig. 14-34 The gallstone in the common bile duct causes biliary colic and may cause jaundice when the bile cannot flow from the liver and gallbladder to the duodenum.
URINARY SYSTEM
Urinary Tract Infections
Nephrolithiasis
Fig. 14-35 Most common locations of renal calculi formation.
CLINICAL APPLICATION & CLINICAL REASONING
REVIEW QUESTIONS
SAMPLE DOCUMENTATION
Subjective Data
Objective Data
CASE STUDY
Interview Data
Examination Data
CLINICAL Reasoning
INTERACTIVE ACTIVITIES
CHAPTER 15 Musculoskeletal System
ANATOMY & PHYSIOLOGY
SKELETON
SKELETAL MUSCLES
JOINTS
Fig. 15-1 Structures of a synovial joint (the knee).
LIGAMENTS AND TENDONS
Fig. 15-2 A posterior view of the left knee. The medial collateral ligament prevents the knee from going into too much valgus during stress (inward). The lateral collateral ligament prevents the knee from going into too much varus during stress (outward).
CARTILAGE AND BURSAE
AXIAL SKELETON AND SUPPORTING STRUCTURES
Skull and Neck
Trunk and Pelvis
APPENDICULAR SKELETON AND SUPPORTING STRUCTURES
Upper Extremities
Shoulder and Upper Arm
Elbow, Forearm, and Wrist
Fig. 15-3 Bones of the trunk and pelvis.
Fig. 15-4 Muscles of the trunk and pelvis.
Hand
Lower Extremities
Hip and Thigh
Fig. 15-5 Bones of the upper extremities.
Fig. 15-6 Muscles of the upper extremities.
Fig. 15-7 Structures of the glenohumeral and acromioclavicular joint of the shoulder.
Fig. 15-8 Bones of the lower extremities.
Fig. 15-9 Muscles of the lower extremities.
Fig. 15-10 Structures of the hip.
Knee and Lower Leg
Ankle and Foot
Fig. 15-11 Bones and joints of the ankle and foot.
LINK TO CONCEPTS Motion
Concept Model: Motion
ETHNIC & CULTURAL VARIATIONS
HEALTH HISTORY
RISK FACTORS Musculoskeletal System
Temporomandibular Joint (TMJ) Dysfunctiona
Goutb
Osteoarthritis (OA)c
Osteoporosisd
GENERAL HEALTH HISTORY
Present Health Status
Past Medical History
Family History
PROBLEM-BASED HISTORY
Pain
Problems with Movement
Problems with Daily Activities
HEALTH PROMOTION Osteoporosis
Goals and Objectives—Healthy People 2010
Recommendations to Reduce Risk (Primary Prevention)
National Osteoporosis Foundation
Screening Recommendations (Secondary Prevention)
U.S. Preventive Services Task Force
HEALTH PROMOTION Low Back Pain
Goals and Objectives—Healthy People 2010
Recommendations to Reduce Risk (Primary Prevention)
American Academy of Orthopaedic Surgeons
EXAMINATION
PROCEDURES AND TECHNIQUES WITH NORMAL FINDINGS
ROUTINE TECHNIQUES
INSPECT axial skeleton and extremities for alignment, contour, symmetry, size, and gross deformities.
ABNORMAL FINDINGS
Fig. 15-12 Inspection of overall body posture. Note the even contour of the shoulders, level scapulae and iliac crests, alignment of the head over the gluteal folds, and symmetry and alignment of extremities. A, Anterior view. B, Posterior view. C, Lateral view showing normal cervical concave, thoracic convex, and lumbar concave curves of the spine.
INSPECT muscles for size and symmetry.
ABNORMAL FINDINGS
Fig. 15-13 Sites at which a limb is measured. A, Measure limb length from the anterior superior iliac spine to the medial malleolus. B, Measurement of the lower leg at 5 cm below the patella and of the upper leg at 5 and 10 cm above the patella. Exact location of measurement should be noted for future comparison.
PALPATE bones for tenderness; joints for tenderness, heat, and edema; and muscles for tenderness, heat, edema, and tone.
ABNORMAL FINDINGS
OBSERVE range of motion for major joints and adjacent muscles for tenderness on movement, joint stability, and deformity.
ABNORMAL FINDINGS
TABLE 15-1 Range of Motion for Diarthrodial Joints
Fig. 15-14 Use of goniometer to measure joint range of motion.
BOX 15-1 HOW TO USE A GONIOMETER
TEST muscle strength and compare sides.
ABNORMAL FINDINGS
TABLE 15-2 Screening Tests for Muscle Strength
TABLE 15-3 Criteria for Grading and Recording Muscle Strength
EXAMINATION OF SPECIFIC MUSCULOSKELETAL REGIONS
OBSERVE gait for conformity, symmetry, and rhythm.
ABNORMAL FINDINGS
INSPECT musculature of the face and neck for symmetry.
ABNORMAL FINDINGS
PALPATE each temporomandibular joint for movement, sounds, and tenderness.
ABNORMAL FINDINGS
OBSERVE jaw for range of motion.
ABNORMAL FINDINGS
Fig. 15-15 A, Palpation of temporomandibular joint. B, Lateral range of motion in the temporomandibular joint.
PALPATE the neck for pain.
ABNORMAL FINDINGS
OBSERVE the neck for range of motion.
ABNORMAL FINDINGS
TEST the neck muscles for strength.
ABNORMAL FINDINGS
Fig. 15-16 Range of motion of the cervical spine. A, Flexion and hyperextension. B, Lateral bending. C, Rotation.
Fig. 15-17 Examining the strength of the sternocleidomastoid and trapezius muscles. A, Rotation against resistance. B, Flexion with palpation of the sternocleidomastoid muscle. C, Extension against resistance.
INSPECT the shoulders and cervical, thoracic, and lumbar spine for alignment and symmetry.
ABNORMAL FINDINGS
Fig. 15-18 Landmarks of the back.
Fig. 15-19 Defects of the spinal column. A, Normal spine. B, Kyphosis. C, Lordosis. D, Normal spine in balance. E, Mild scoliosis. F, Severe scoliosis, not in balance. G, Rib hump and flank asymmetry seen in flexion.
OBSERVE range of motion of the thoracic and lumbar spine.
ABNORMAL FINDINGS
ABNORMAL FINDINGS
ABNORMAL FINDINGS
Fig. 15-20 Range of motion of the thoracic and lumbar spine. A, Flexion. B, Hyperextension. C, Lateral bending. D, Rotation of the upper trunk.
PALPATE the posterior neck, spinal processes, and paravertebral muscles for alignment and tenderness.
ABNORMAL FINDINGS
PERCUSS the spinal processes for tenderness.
ABNORMAL FINDINGS
INSPECT the shoulders and shoulder girdle for equality of height and contour.
ABNORMAL FINDINGS
PALPATE the shoulders for firmness, fullness, tenderness, and masses.
ABNORMAL FINDINGS
TEST the trapezius muscles for strength.
ABNORMAL FINDINGS
Fig. 15-21 Palpation of the spinal processes of the vertebrae.
Fig. 15-22 Test strength of the trapezius muscle with the shrugged shoulder movement.
Fig. 15-23 Range of motion of the shoulders. A, Forward flexion and hyperextension. B, Abduction and adduction. C, External rotation and abduction. D, Internal rotation and adduction.
OBSERVE the shoulders for range of motion.
ABNORMAL FINDINGS
TEST the arms for muscle strength.
ABNORMAL FINDINGS
Fig. 15-24 Testing muscle strength of arms. A, Testing triceps muscle strength. B, Testing biceps muscle strength.
PALPATE the elbows for tenderness, edema, and nodules.
ABNORMAL FINDINGS
Fig. 15-25 Palpation of the olecranon process grooves.
OBSERVE the elbows for range of motion.
ABNORMAL FINDINGS
Fig. 15-26 Range of motion of the elbow. A, Flexion and extension. B, Palm up, supination; palm down, pronation.
INSPECT the joints of the wrists and hands for position, contour, and number of digits.
ABNORMAL FINDINGS
Fig. 15-27 A, Bony structures of the right hand and wrist. Note alignment of fingers with the radius. B, Palmar aspect of right hand.
Fig. 15-28 A, Ulnar deviation and subluxation of metacarpophalangeal joints. B, Swan-neck deformity. C, Boutonnière deformity.
Fig. 15-29 Osteoarthritis.
Fig. 15-30 Palpation of joints of the hand and wrist. A, Interphalangeal joints. B, Metacarpophalangeal joints. C, Radiocarpal groove.
PALPATE each joint of the hand and wrist for surface characteristics and tenderness.
ABNORMAL FINDINGS
TEST for muscle strength and OBSERVE for range of motion of wrists and fingers.
ABNORMAL FINDINGS
Fig. 15-31 A, Assessment of finger strength. B, Assessment of grip strength.
Fig. 15-32 Range of motion of hand and wrist. A, Wrist flexion and hyperextension. B, Metacarpophalangeal flexion and hyperextension. C, Wrist radial and ulnar deviation. D, Finger abduction. E, Finger flexion: fist formation. F, Finger extension: thumb to each fingertip and to base of little finger.
ABNORMAL FINDINGS
INSPECT the hips for symmetry.
ABNORMAL FINDINGS
PALPATE the hips for stability and tenderness.
ABNORMAL FINDINGS
OBSERVE the hips for range of motion.
ABNORMAL FINDINGS
Fig. 15-33 Range of motion of hips. A, Hip flexion, knee flexed. B, Hip flexion, leg extended. C, External rotation of hip. D, Internal rotation of hip. E, Abduction and adduction of hip. F, Hyperextension of hip, leg extended.
TEST the hips for muscle strength.
ABNORMAL FINDINGS
TEST the leg muscles for strength.
ABNORMAL FINDINGS
Fig. 15-34 Assessment of hamstring muscle strength. Client flexes knee while examiner tries to straighten it.
INSPECT the knees for symmetry and alignment.
ABNORMAL FINDINGS
PALPATE the knees for contour, tenderness, and edema.
ABNORMAL FINDINGS
OBSERVE the knees for range of motion.
ABNORMAL FINDINGS
Fig. 15-35 Flexion and hyperextension of knee.
INSPECT the ankles and feet for contour, alignment, and number of toes.
ABNORMAL FINDINGS
Fig. 15-36 Hallux valgus with bunions and hammer toes.
PALPATE the ankles and feet for contour, edema, and tenderness.
ABNORMAL FINDINGS
OBSERVE the ankles and feet for range of motion.
ABNORMAL FINDINGS
TEST the ankle and feet muscles for strength.
ABNORMAL FINDINGS
Fig. 15-37 Range of motion of the ankle. A, Dorsiflexion and plantar flexion. B, Inversion and eversion. C, Abduction and adduction.
SPECIAL CIRCUMSTANCES OR ADVANCED PRACTICE
ASSESS for carpal tunnel syndrome.
ABNORMAL FINDINGS
Fig. 15-38 Phalen’s test for carpal tunnel syndrome.
ABNORMAL FINDINGS
Fig. 15-39 Tinel’s sign for carpal tunnel syndrome.
ASSESS for rotator cuff damage.
ABNORMAL FINDINGS
ASSESS for knee effusion.
ABNORMAL FINDINGS
ABNORMAL FINDINGS
Fig. 15-40 Bulge sign to detect small effusion in knee joint. A, Milk the medial aspect of the knee two or three times. B, Then tap the lateral side of the patella.
Fig. 15-41 Ballottement procedure to detect large effusion in knee joint.
ASSESS for knee stability.
ABNORMAL FINDINGS
ABNORMAL FINDINGS
ABNORMAL FINDINGS
Fig. 15-42 Assessing knee stability. A, Assessing collateral ligaments. B, Drawer test for assessing anterior and posterior cruciate ligaments.
Fig. 15-43 Examination of the knee with McMurray’s test. Knee is flexed, stabilized with thumb and index finger; with the other hand rotate and extend the lower leg.
Fig. 15-44 Examination of the knee with the Apley test.
ABNORMAL FINDINGS
ASSESS for hip flexion contractures.
ABNORMAL FINDINGS
ASSESS for nerve root compression.
ABNORMAL FINDINGS
Fig. 15-45 Examination of the hip with the Thomas test. Response is negative in this client because the extended leg remains flat on the table.
Fig. 15-46 Straight leg raising test.
AGE-RELATED VARIATIONS
Infants, Children, and Adolescents
Older Adults
Documenting Expected Findings
Musculoskeletal System
CLINICAL REASONING Musculoskeletal System
COMMON PROBLEMS & CONDITIONS
BONES
Fracture
Osteoporosis
Fig. 15-47 Open and closed fractures.
JOINTS
Rheumatoid Arthritis
Fig. 15-48 Hallmark of osteoporosis: dowager’s hump (kyphosis).
Osteoarthritis
Bursitis
Gout
Fig. 15-49 Olecranon bursitis.
SPINE
Herniated Nucleus Pulposus (HNP)
Fig. 15-50 Gout with many tophi present on the hands, on the wrists, and in both olecranon bursae.
Fig. 15-51 Herniated intervertebral disk.
Fig. 15-52 Scoliosis.
Scoliosis
LIGAMENTS AND MUSCLES
Carpal Tunnel Syndrome
CLINICAL APPLICATION & CLINICAL REASONING
REVIEW QUESTIONS
SAMPLE DOCUMENTATION
SUBJECTIVE DATA
OBJECTIVE DATA
CASE STUDY
Interview Data
Examination Data
CLINICAL Reasoning
INTERACTIVE ACTIVITIES
CHAPTER 16 Neurologic System
ANATOMY & PHYSIOLOGY
CENTRAL NERVOUS SYSTEM
Protective Structures
Cerebrospinal Fluid and Cerebral Ventricular System
Brain
Fig. 16-1 Structures of the brainstem and cerebrospinal fluid (CSF) circulation. Red arrows represent the route of the CSF. Black arrows represent the route of blood flow. Cerebrospinal fluid is produced in the ventricles, exits the fourth ventricle, and returns to the venous circulation in the superior sagittal sinus. The inset depicts the arachnoid granulations in the superior sagittal sinus, where the CSF enters the circulation.
Cerebrum
Fig. 16-2 A, Major arteries supplying blood to the brain. B, The circle of Willis. Note the anterior, middle, and posterior cerebral arteries, which are the major pairs of arteries supplying the cerebrum.
Fig. 16-3 Cerebral hemispheres. Lateral view of the brain. The motor cortex in the frontal lobe is depicted in pink, and the somesthetic cortex in the parietal lobe is depicted in blue.
Diencephalon
Basal Ganglia
Brainstem
Fig. 16-4 Topography of the somesthetic and motor cortex. Cerebral cortex seen in coronal section on the left side of the brain. The figure of the body (homunculus) depicts the relative nerve distributions; the size indicates the relative number of nerves in the distribution. Each cortex occurs on both sides of the brain but appears only on one side in this illustration. The inset shows the motor and somesthetic regions of the left hemisphere. A, Somesthetic cortex. B, Motor cortex.
Fig. 16-5 Diencephalon. Lateral view of the brain.
Fig. 16-6 Coronal section of the brain shows six ganglia that make up the basal ganglia.
Cerebellum
Spinal Cord
Fig. 16-7 Inferior surface of the brain showing the origin of the cranial nerves.
Fig. 16-8 View of the spinal column showing vertebrae, spinal cord, and spinal nerves exiting.
Fig. 16-9 Examples of somatic motor and sensory pathways. A Motor: the pyramidal pathway through the lateral corticospinal tract and the extrapyramidal pathways through the rubrospinal and reticulospinal tracts.
PERIPHERAL NERVOUS SYSTEM
Cranial Nerves
Spinal Nerves
B Sensory: pathways of the medial lemniscal system that conducts information about discriminating touch and kinesthesis and the spinothalamic pathway that conducts information about pain and temperature.
Reflex Arc
AUTONOMIC NERVOUS SYSTEM
TABLE 16-1 The Cranial Nerves and Their Functions
BOX 16-1 HOW TO REMEMBER NAMES AND NERVE TYPE OF CRANIAL NERVES
Fig. 16-10 Dermatomal map. Letters and numbers indicate the spinal nerves innervating a given region of skin.
Fig. 16-11 Cross section of the spinal cord showing three-neuron reflex arc.
TABLE 16-2 Superficial and Deep Tendon Reflexes
Fig. 16-12 Innervation of organs by the autonomic nervous system. Preganglionic fibers are indicated by solid lines, and postganglionic fibers are indicated by broken lines.
LINK TO CONCEPTS Intracranial Regulation
Concept Model: Intracranial Regulation
HEALTH HISTORY
RISK FACTORS CVA, Stroke
Cerebrovascular Accident (CVA), Stroke
GENERAL HEALTH HISTORY
Present Health Status
Past Medical History
Family History
PROBLEM-BASED HISTORY
Headache
Dizziness
Seizures
Loss of Consciousness
Changes in Movement
Changes in Sensation
Difficulty Swallowing (Dysphagia)
Difficulty Communicating (Dysphasia/Aphasia)
HEALTH PROMOTION Traumatic Brain Injury
Goals and Objectives—Healthy People 2010
Recommendations to Reduce Risk (Primary Prevention)
U.S. Preventive Services Task Force
Centers for Disease Control and Prevention
EXAMINATION
PROCEDURES AND TECHNIQUES WITH NORMAL FINDINGS
ASSESS mental status and level of consciousness.
ABNORMAL FINDINGS
EVALUATE speech for articulation and voice quality and conversation for comprehension of verbal communication.
ABNORMAL FINDINGS
NOTICE cranial nerve functions.
ABNORMAL FINDINGS
ABNORMAL FINDINGS
ABNORMAL FINDINGS
ABNORMAL FINDINGS
ABNORMAL FINDINGS
ABNORMAL FINDINGS
ABNORMAL FINDINGS
ABNORMAL FINDINGS
ABNORMAL FINDINGS
ABNORMAL FINDINGS
OBSERVE gait for balance and symmetry.
ABNORMAL FINDINGS
EVALUATE extremities for muscle strength.
ABNORMAL FINDINGS
SPECIAL CIRCUMSTANCES AND ADVANCED PRACTICE
ASSESS individual cranial nerves.
TEST nose for smell.
ABNORMAL FINDINGS
Fig. 16-13 Examination of the olfactory cranial nerve (CN I).
TEST eyes for visual acuity.
ABNORMAL FINDINGS
TEST eyes for peripheral vision.
ABNORMAL FINDINGS
OBSERVE eyes for extraocular muscle movement.
ABNORMAL FINDINGS
OBSERVE eyes for pupillary size, shape, equality, constriction and accommodation.
ABNORMAL FINDINGS
EVALUATE face for movement and sensation.
ABNORMAL FINDINGS
ABNORMAL FINDINGS
Fig. 16-14 Examination of the trigeminal nerve (CN V) for motor function, A, and sensory function, B.
ABNORMAL FINDINGS
ABNORMAL FINDINGS
ABNORMAL FINDINGS
Fig. 16-15 Examination of the facial nerve (CN VII). Ask the client to make the following movements: A, Raise eyebrows and wrinkle forehead. B, Smile. C, Puff out cheeks. D, Purse lips and blow out. E, Show teeth. F, Squeeze eyes shut while you try to open them.
TEST ears for hearing.
ABNORMAL FINDINGS
TEST tongue for taste.
ABNORMAL FINDINGS
INSPECT oropharynx for gag reflex and movement of soft palate.
ABNORMAL FINDINGS
Fig. 16-16 Location of the taste bud regions tested for sensory function of the facial and glossopharyngeal cranial nerves.
TEST the tongue for movement, symmetry, strength, and absence of lesions; test for muscle strength.
ABNORMAL FINDINGS
Fig. 16-17 Examination of the hypoglossal nerve (CN XII).
TEST shoulders and neck muscles for strength and movement.
ABNORMAL FINDINGS
ABNORMAL FINDINGS
TEST cerebellar function for balance and coordination.
ABNORMAL FINDINGS
Tests for Balance
ABNORMAL FINDINGS
ABNORMAL FINDINGS
ABNORMAL FINDINGS
ABNORMAL FINDINGS
ABNORMAL FINDINGS
ABNORMAL FINDINGS
Fig. 16-18 Evaluation of balance with heel-toe walking on a straight line.
Fig. 16-19 Evaluation of balance with the client hopping in place on one foot.
Upper Extremity
ABNORMAL FINDINGS
ABNORMAL FINDINGS
ABNORMAL FINDINGS
ABNORMAL FINDINGS
Fig. 16-20 Examination of coordination with rapid alternating movements. Ask client to tap top of thighs with both hands, alternately with palms down (A) and palms up (B).
Fig. 16-21 Examination of finger coordination. Ask client to touch each finger to thumb in rapid sequence.
Fig. 16-22 Examination of fine motor function. Ask client to alternately touch own nose and the nurse’s index finger with the index finger of one hand.
Lower Extremity
ABNORMAL FINDINGS
Fig. 16-23 Examination of lower extremity coordination. Ask client to run heel of one foot down shin of other leg. Repeat with opposite leg.
ASSESS peripheral nerves.
ASSESS for sensation.
ABNORMAL FINDINGS
ABNORMAL FINDINGS
ABNORMAL FINDINGS
ABNORMAL FINDINGS
Fig. 16-24 Evaluation of peripheral nerve sensory function. A, Superficial tactile sensation. B, Superficial pain sensation. C, Vibratory sensation. D, Position sense of joints.
ABNORMAL FINDINGS
ABNORMAL FINDINGS
ABNORMAL FINDINGS
ABNORMAL FINDINGS
Fig. 16-25 Evaluation of cortical sensory function. A, Stereognosis: identification of a familiar object by touch. B, Two-point discrimination. C, Graphesthesia: draw letter or number on palm and ask client to identify by touch.
BOX 16-2 MINIMAL DISTANCES FOR DISTINGUISHING TWO POINTS
EVALUATE extremities for deep tendon reflexes.
ABNORMAL FINDINGS
BOX 16-3 SCORING DEEP TENDON REFLEXES
Fig. 16-26 Location of tendons for evaluation of deep tendon reflexes. A, Triceps reflex. B, Biceps reflex. C, Brachioradialis reflex. D, Patellar reflex. E, Achilles reflex. F, Babinski’s reflex. G, Ankle tonus.
ABNORMAL FINDINGS
ABNORMAL FINDINGS
EVALUATE for superficial reflexes.
ABNORMAL FINDINGS
ABNORMAL FINDINGS
ADDITIONAL ASSESSMENT TECHNIQUES FOR SPECIAL CASES
Altered Level of Consciousness
Assessing Awareness
Assessing Arousal
Documenting Altered Level of Conscious Using Descriptors or a Scale
TABLE 16-3 Techniques for Applying Painful Stimuli
Fig. 16-27 Glasgow Coma Scale.
Meningeal Irritation
Documenting Expected Findings
Neurologic System
Fig. 16-28 Kernig’s sign and Brudzinski’s sign are tests of meningeal irritation. A, Kernig’s sign. Flex one of the client’s legs at the hip and knee. Note resistance or pain. B, Brudzinski’s sign. With the client recumbent, place your hands behind the client’s head and flex the neck forward. Note resistance or pain. Watch also for flexion of the client’s hips and knees in reaction to your maneuver.
AGE-RELATED VARIATIONS
INFANTS, CHILDREN, AND ADOLESCENTS
OLDER ADULTS
CLINICAL REASONING Neurologic System
COMMON PROBLEMS & CONDITIONS
DISORDERS OF THE CENTRAL NERVOUS SYSTEM
Multiple Sclerosis
Meningitis
Encephalitis
Spinal Cord Injury
Fig. 16-29 Posture and shuffling gait associated with Parkinson’s disease.
Craniocerebral Injury (Head Injury)
Parkinson’s Disease
Cerebrovascular Accident (Stroke)
Alzheimer Disease
DISORDERS OF CRANIAL NERVES
Trigeminal Neuralgia
Bell’s Palsy
DISORDERS OF PERIPHERAL NERVES
Myasthenia Gravis
Guillain-Barré Syndrome
CLINICAL APPLICATION & CLINICAL REASONING
REVIEW QUESTIONS
SAMPLE DOCUMENTATION
SUBJECTIVE DATA
OBJECTIVE DATA
CASE STUDY
Interview Data
Examination Data
CLINICAL Reasoning
INTERACTIVE ACTIVITIES
CHAPTER 17 Breasts and Axillae
ANATOMY & PHYSIOLOGY
FEMALE BREAST
Fig. 17-1 Quadrants of the left breast and axillary tail of Spence.
Fig. 17-2 Anatomy of the breast, showing position and major structures.
Lymphatic Network
Fig. 17-3 Lymphatic drainage of the breast.
MALE BREAST
HEALTH HISTORY
RISK FACTORS Breast Cancer
GENERAL HEALTH HISTORY
Present Health Status
Past Medical History
Family History
PROBLEM-BASED HISTORY
Breast Pain or Tenderness
Breast Lump
Nipple Discharge
Axillary Lumps or Tenderness
Breast Swelling or Enlargement (Men)
HEALTH PROMOTION Breast Cancer
Goals and Objectives—Healthy People 2010
Recommendations to Reduce Risk (Primary Prevention)
U.S. Preventive Services Task Force
Screening Recommendations (Secondary Prevention)
American Cancer Society
EXAMINATION
PROCEDURES AND TECHNIQUES WITH NORMAL FINDINGS
FEMALE BREAST EXAMINATION
ROUTINE TECHNIQUES
INSPECT the breasts, noting size, shape, contour, and symmetry.
ABNORMAL FINDINGS
INSPECT the skin of the breasts for color, pigmentation, vascularity, surface characteristics, and lesions.
Fig. 17-4 Breasts should appear bilaterally symmetric.
Fig. 17-5 Erythema of the breast.
ABNORMAL FINDINGS
Fig. 17-6 Peau d’orange appearance caused by edema.
INSPECT the areolae for color and surface characteristics.
ABNORMAL FINDINGS
INSPECT the nipples for position, symmetry, surface characteristics, lesions, bleeding, and discharge.
Fig. 17-7 Variations in color of areola. A, Pink. B, Brown. C, Black. Note presence of Montgomery’s tubercles in B.
ABNORMAL FINDINGS
Fig. 17-8 Nipple retraction.
Fig. 17-9 A, Supernumerary nipple. B, Supernumerary nipples may arise along the “milk line.”
ABNORMAL FINDINGS
Fig. 17-10 Paget’s disease.
BOX 17-1 COLLECTING A SPECIMEN FOR CYTOLOGIC EXAMINATION
TABLE 17-1 Nipple Discharge
SPECIAL CIRCUMSTANCES OR ADVANCED PRACTICE
INSPECT the breasts in various positions for bilateral pull, symmetry, and contour.
ABNORMAL FINDINGS
Fig. 17-11 A, Client with arms extended overhead. B, Client with arms raised and leaning forward. C, Client sitting and pressing her hands on hips.
INSPECT and PALPATE the axillae for evidence of rash, lesions, or masses.
ABNORMAL FINDINGS
PALPATE the breasts for tissue characteristics.
Fig. 17-12 Raise and support client’s arm while palpating axilla.
Fig. 17-13 Palpate the breasts using your finger pads.
ABNORMAL FINDINGS
TABLE 17-2 Methods for Breast Palpation
Fig. 17-14 Manual palpation of large breasts.
Fig. 17-15 Palpate the borders and mobility of a breast mass.
BOX 17-2 BREAST MASS CHARACTERISTICS
PALPATE the nipples for surface characteristics and discharge.
Fig. 17-16 Express nipple discharge by palpating on the areola.
ABNORMAL FINDINGS
MALE BREAST EXAMINATION
INSPECT the breasts and nipples.
ABNORMAL FINDINGS
PALPATE the breasts and nipples
ABNORMAL FINDINGS
PALPATE the axilla.
ABNORMAL FINDINGS
FREQUENTLY ASKED QUESTIONS
FREQUENTLY ASKED QUESTIONS
Documenting Expected Findings
Breast
Female breast exam
Male breast exam
AGE-RELATED VARIATIONS
INFANTS AND CHILDREN
ADOLESCENTS
OLDER ADULTS
CLIENTS WITH SITUATIONAL VARIATIONS
CLIENTS WITH A MASTECTOMY
Fig. 17-17 A, Appearance of chest following bilateral mastectomy. Postoperative breast reconstruction before, B, and after, C, nipple-areolar reconstruction.
COMMON PROBLEMS & CONDITIONS
BENIGN BREAST DISEASE
Fibrocystic Changes to the Breast
Fibroadenoma
Fig. 17-18 Fibrocystic changes to the breast. The cysts are depicted as green masses.
Ductal Ectasia
Intraductal Papilloma
BREAST CANCER
ETHNIC & CULTURAL VARIATIONS
Invasive Breast Cancer
TABLE 17-3 Differentiation of Breast Masses
Noninvasive Breast Cancer
Fig. 17-19 Fibroadenoma.
Fig. 17-20 Clinical signs of breast cancer: nipple retraction and dimpling of skin.
OTHER BREAST CONDITIONS
Mastitis
Galactorrhea
Gynecomastia
Fig. 17-21 Clinical signs of acute mastitis.
Fig. 17-22 Galactorrhea.
Fig. 17-23 Gynecomastia in an adult male.
CLINICAL APPLICATION & CLINICAL REASONING
REVIEW QUESTIONS
SAMPLE DOCUMENTATION
Subjective Data
Objective Data
CASE STUDY
Interview Data
Examination Data
CLINICAL Reasoning
INTERACTIVE ACTIVITIES
CHAPTER 18 Reproductive System and the Perineum
ANATOMY & PHYSIOLOGY
FEMALE REPRODUCTIVE SYSTEM
External Genitalia
Fig. 18-1 Female external genitalia.
Fig. 18-2 Midsagittal view of female pelvic organs.
Internal Structures and Organs
Fig. 18-3 Types of cervical cells: endocervical, external os, and ectocervix.
Vagina
Uterus
Fallopian Tubes
Ovaries
Fig. 18-4 Cross-sectional view of internal female genitalia and pelvic contents.
Menstrual Cycle
Stage 1: Menstrual Phase (Days 1 to 4).
Stage 2: Postmenstrual or Preovulatory Phase (Days 5 to 12).
Stage 3: Ovulation (Days 13 or 14).
Fig. 18-5 Female menstrual cycle. Diagram shows the interrelationship of the cerebral, hypothalamic, pituitary, and uterine functions throughout a standard 28-day menstrual cycle. The variations in basal body temperature are also shown.
Stage 4: Secretory Phase (Days 15-20).
Stage 5: Premenstrual Phase (Days 21 to 28).
Menopause
MALE REPRODUCTIVE SYSTEM
Internal Structures
Testes
Ducts
Fig. 18-6 Male reproductive organs.
Glands
External Genitalia
Scrotum
Fig. 18-7 Scrotum and its contents.
Penis
RECTUM AND ANUS
Rectum
Anal Canal and Anus
Fig. 18-8 Anatomy of the anus and rectum.
HEALTH HISTORY
RISK FACTORS Reproductive Cancer
FEMALE REPRODUCTIVE CANCERS
Cervical Cancer
Ovarian Cancer
Endometrial Cancer
MALE REPRODUCTIVE CANCERS
Testicular Cancer
Prostate Cancer
RISK FACTORS Sexually Transmitted Disease (STD)
GENERAL HEALTH HISTORY
Present Health Status
Past Medical History
Family History
Sexual History
OBSTETRIC HISTORY
Menstruation
Pregnancy
FREQUENTLY ASKED QUESTIONS
PROBLEM-BASED HISTORY
Pain
Lesion
BOX 18-1 FOCUS ON PAIN Anus and Rectum
Vaginal or Penile Discharge
Problems with Menstruation
Menopausal Symptoms
ETHNIC & CULTURAL VARIATIONS
Difficulty with Erection
Problems with Urination
HEALTH PROMOTION Sexually Transmitted Disease
Background
Goals and Objectives—Healthy People 2010
Recommendations to Reduce Risk (Primary Prevention)
Centers for Disease Control and Prevention (CDC)
Screening Recommendations (Secondary Prevention)
Centers for Disease Control and Prevention
Rectal Bleeding
TABLE 18-1 The American Urological Association Symptom Index for Benign Prostatic Hyperplasia
HEALTH PROMOTION Reproductive Cancers
Background
Goals and Objectives—Healthy People 2010
Recommendations to Reduce Risk (Primary Prevention)
U.S. Preventive Services Task Force
Screening Recommendations (Secondary Prevention)
EXAMINATION
FEMALE EXAM
PREPARING FOR THE FEMALE EXAMINATION
PROCEDURES AND TECHNIQUES WITH NORMAL FINDINGS
ROUTINE TECHNIQUES: FEMALE EXAM
INSPECT the pubic hair and skin over the mons pubis and inguinal area for distribution and surface characteristics.
ABNORMAL FINDINGS
INSPECT and PALPATE the labia majora, labia minora, and clitoris for pigmentation and surface characteristics.
ABNORMAL FINDINGS
ABNORMAL FINDINGS
ABNORMAL FINDINGS
Fig. 18-9 Inspection of the external genitalia.
Fig. 18-10 Inspection of the labia.
INSPECT the urethral meatus, vaginal introitus, and perineum for positioning and surface characteristics.
ABNORMAL FINDINGS
INSPECT the perianal area and anus for color and surface characteristics.
ABNORMAL FINDINGS
SPECIAL CIRCUMSTANCES OR ADVANCED PRACTICE: FEMALE EXAM
PALPATE the Skene’s and Bartholin’s glands for surface characteristics, discharge, and pain or discomfort.
ABNORMAL FINDINGS
Fig. 18-11 Palpation of Skene’s gland.
Fig. 18-12 Palpation of Bartholin’s gland.
Fig. 18-13 Assessing vaginal tone.
ABNORMAL FINDINGS
INSPECT and PALPATE for vaginal wall tone.
ABNORMAL FINDINGS
SPECULUM EXAMINATION
BOX 18-2 CLINICAL NOTES
Fig. 18-14 Apply downward pressure on vagina before inserting the speculum.
Fig. 18-15 Insertion of closed speculum blades with oblique angle.
Fig. 18-16 A, Direct the speculum downward at a 45-degree angle. B, Cross-sectional view.
Fig. 18-17 A, Open speculum blades. B, Cross-sectional view.
INSPECT the cervix for color, surface characteristics, position, size and shape, and discharge.
ABNORMAL FINDINGS
ABNORMAL FINDINGS
ABNORMAL FINDINGS
ABNORMAL FINDINGS
BOX 18-3 CLINICAL NOTE
Fig. 18-18 Common appearances of the cervix. A, Nulliparous cervix. Note rounded os. B, Parous cervix. Note slit appearance of os. C, Multigravidous, lacerated. D, Everted. E, Eroded. F, Nabothian cysts.
OBTAIN smears and cultures.
TABLE 18-2 Procedure for Collecting Pap Smear Specimen
BOX 18-4 TESTING FOR CERVICAL CANCER
INSPECT the vaginal walls for color and surface characteristics.
ABNORMAL FINDINGS
BIMANUAL EXAMINATION
PALPATE the vagina for surface characteristics and discomfort.
ABNORMAL FINDINGS
PALPATE the cervix and uterus for position, size, surface characteristics, mobility, and discomfort.
ABNORMAL FINDINGS
Fig. 18-19 Bimanual palpation.
ABNORMAL FINDINGS
ABNORMAL FINDINGS
PALPATE the adnexa and ovaries for size, shape, and tenderness.
ABNORMAL FINDINGS
Fig. 18-20 Bimanual palpation of the adnexa.
TABLE 18-3 Positions of the Uterus
PALPATE the uterus and ovaries using the rectovaginal approach.
ABNORMAL FINDINGS
Fig. 18-21 Rectovaginal examination.
RECTAL EXAMINATION
PALPATE the rectal wall for surface characteristics.
ABNORMAL FINDINGS
PALPATE the anal sphincter for muscle tone.
ABNORMAL FINDINGS
EXAMINE stool for characteristics and presence of occult blood.
ABNORMAL FINDINGS
BOX 18-5 GUAIAC TESTING
BOX 18-6 STOOL COLORS AND SIGNIFICANCE
Documenting Expected Findings
Male Examination
MALE EXAM
PREPARING FOR THE MALE EXAMINATION
BOX 18-7 CLINICAL NOTE
ROUTINE TECHNIQUES: MALE EXAM
INSPECT pubic hair for distribution and general characteristics.
ABNORMAL FINDINGS
INSPECT and PALPATE the penis for surface characteristics, color, tenderness, and discharge.
ABNORMAL FINDINGS
Fig. 18-22 A, Uncircumcised penis. B, Circumcised penis.
Fig. 18-23 Phimosis.
Fig. 18-24 Paraphimosis.
ABNORMAL FINDINGS
ABNORMAL FINDINGS
Fig. 18-25 Balanitis.
Fig. 18-26 Purulent penile discharge.
ABNORMAL FINDINGS
ABNORMAL FINDINGS
Fig. 18-27 Examination of urethral meatus.
INSPECT and PALPATE the sacrococcygeal areas for surface characteristics and tenderness.
ABNORMAL FINDINGS
INSPECT the perianal area and anus for pigmentation and surface characteristics.
ABNORMAL FINDINGS
INSPECT the scrotum for color, texture, surface characteristics, and position.
ABNORMAL FINDINGS
Fig. 18-28 Inspect the scrotum and ventral surface of the penis as the client positions his penis.
INSPECT the inguinal region and the femoral area for bulges.
ABNORMAL FINDINGS
SPECIAL CIRCUMSTANCES OR ADVANCED PRACTICE: MALE EXAM
PALPATE the scrotum for surface characteristics and tenderness.
ABNORMAL FINDINGS
PALPATE the testes, epididymides, and vas deferens for location, consistency, tenderness, and nodules.
ABNORMAL FINDINGS
ABNORMAL FINDINGS
ABNORMAL FINDINGS
Fig. 18-29 Palpating the scrotum and testes.
TRANSILLUMINATE the scrotum for evidence of fluid and masses.
ABNORMAL FINDINGS
Fig. 18-30 Transillumination of the scrotum.
INGUINAL REGION
PALPATE the inguinal canal for evidence of indirect hernia or direct hernia.
ABNORMAL FINDINGS
Fig. 18-31 A, Palpating for inguinal hernia. B, Position of gloved finger inserted through inguinal canal.
RECTAL EXAMINATION
PALPATE the anus for sphincter tone.
ABNORMAL FINDINGS
Fig. 18-32 Positions for rectal examination. A, Left lateral or Sims’ position. B, Knee-chest position. C, Standing position. D, Lithotomy position.
Fig. 18-33 Rectal examination. A, Relax sphincter with gentle pressure with the palmar surface of the finger. B, Insert the finger into the anal canal.
PALPATE the anal canal and rectum for surface characteristics.
ABNORMAL FINDINGS
PALPATE the prostate (through the anterior rectal surface) for size, contour, consistency, mobility, and tenderness.
ABNORMAL FINDINGS
BOX 18-8 CLASSIFICATIONS OF PROSTATE ENLARGEMENT
Fig. 18-34 Palpation of the anterior surface of the prostate gland. Feel for the lateral lobes and median sulcus.
EXAMINE stool for characteristics and presence of occult blood.
ABNORMAL FINDINGS
Documenting Expected Findings
Male Examination
FREQUENTLY ASKED QUESTIONS
ETHNIC & CULTURAL VARIATIONS
AGE-RELATED VARIATIONS
INFANTS AND CHILDREN
ADOLESCENTS
OLDER ADULTS
COMMON PROBLEMS & CONDITIONS
INFECTIONS
Bacterial Vaginosis
Candida Vaginitis
Sexually Transmitted Disease
Chlamydia
Gonorrhea
Syphilis
Trichomonas
Herpes Genitalis
Fig. 18-35 A, Syphilis chancre on vulva. B, Syphilis chancre on the penis. C, Secondary syphilis lesions (condylomata lata) around the anus.
Fig. 18-36 Trichomoniasis. The vaginal mucosa and cervix are inflamed and speckled with petechial lesions.
BOX 18-9 CLINICAL NOTE
Human Papillomavirus (Genital Warts, Condylomata Acuminatum)
Fig. 18-37 Herpes lesions. A, Female. B, Male.
Fig. 18-38 Condyloma acuminatum. A, Female. B, Male.
Fig. 18-39 Pelvic inflammatory disease.
Pediculosis Pubis (Crabs, Pubic Lice)
Pelvic Inflammatory Disease (Women)
Epididymitis
Fig. 18-40 Epididymitis.
BENIGN REPRODUCTIVE CONDITIONS AFFECTING WOMEN
Premenstrual Syndrome
Endometriosis
Uterine Leiomyomas
Ovarian Cysts
MALIGNANT REPRODUCTIVE CONDITIONS AFFECTING WOMEN
Cervical Cancer
Fig. 18-41 Common sites of endometriosis.
Fig. 18-42 Uterine leiomyomas (fibroids).
Fig. 18-43 Ovarian cyst.
Fig. 18-44 Cervical cancer. The lesion is seen on the cervical os.
Fig. 18-45 Endometrial cancer.
Fig. 18-46 Cancer of the ovaries.
ETHNIC & CULTURAL VARIATIONS
Endometrial Cancer
Ovarian Cancer
CONDITIONS OF THE SCROTUM/TESTICLES
Testicular Torsion
Fig. 18-47 A, Hydrocele. B, Cross section of hydrocele.
Hydrocele
Spermatocele
Varicocele
Testicular Cancer
Fig. 18-48 Spermatocele.
Fig. 18-49 Varicocele.
Fig. 18-50 Scrotal asymmetry caused by testicular cancer.
CONDITIONS OF THE PROSTATE
Benign Prostatic Hyperplasia
Prostatitis
Fig. 18-51 Benign prostatic hyperplasia.
Fig. 18-52 Prostatitis.
Prostate Cancer
Fig. 18-53 Carcinoma of the prostate.
CONDITIONS OF THE ANUS AND RECTUM
Pilonidal Sinus
Fig. 18-54 A, Pilonidal sinus. B, Inflamed pilonidal cyst.
Fig. 18-55 A, Internal and external hemorrhoids. B, External hemorrhoid.
Fig. 18-56 Lateral anal fissure.
Fig. 18-57 Common sites of anorectal fistula and abscess formation.
Hemorrhoids
Fig. 18-58 A, Types of rectal polyps. B, Endoscopic image of a pedunculated polyp.
Anorectal Fissure
Anorectal Abscess and Fistula
Rectal Polyp
Fig. 18-59 Rectal carcinoma.
Carcinoma of the Rectum and Anus
PROLAPSE OR HERNIATION
Hernia
TABLE 18-4 Comparisons of Hernias
Fig. 18-60 Prolapse of the rectum.
Rectal Prolapse
Uterine Prolapse
Cystocele
Rectocele
Fig. 18-61 Uterine prolapse. A, First-degree prolapse of the uterus. B, Second-degree prolapse of the uterus. C, Third-degree prolapse of the uterus.
Fig. 18-62 A, Normal anatomical position. B, Cystocele, protrusion of the wall of urinary bladder through the vagina. C, Rectocele, protrusion of the rectal wall through the vagina.
CLINICAL APPLICATION & CLINICAL REASONING
REVIEW QUESTIONS
SAMPLE DOCUMENTATION
SUBJECTIVE DATA
OBJECTIVE DATA
CASE STUDY
Interview Data
Examination Data
CLINICAL Reasoning
INTERACTIVE ACTIVITIES
UNIT 3 HEALTH ASSESSMENT ACROSS THE LIFE SPAN
CHAPTER 19 Developmental Assessment Throughout the Life Span
THEORIES OF DEVELOPMENT
Personality Development: Erikson’s Theory
TABLE 19-1 Erikson’s Eight Stages of Human Development
Cognitive Development: Piaget’s Theory
TABLE 19-2 Piaget’s Levels of Cognitive Development
Adult Intelligence
DEVELOPMENTAL TASKS
INFANTS
Physical Growth
Behavioral and Cognitive Development
Fig. 19-1 At 4 months, infant actively lifts head and looks about.
TABLE 19-3 Expected Development of Infants
BOX 19-1 DEVELOPMENTAL TASKS OF INFANTS
CHILDREN
Toddlers
Physical Growth
Behavioral and Cognitive Development
Preschoolers
Physical Growth
Behavioral and Cognitive Development
Fig. 19-2 Denver II.
Fig. 19-2 , cont’d Denver II.
Fig. 19-3 The toddler takes great pleasure in building a tower of four blocks.
TABLE 19-4 Expected Development of Toddlers
BOX 19-2 DEVELOPMENTAL TASKS OF TODDLERS
ETHNIC & CULTURAL VARIATIONS
School-Age Children
BOX 19-3 DEVELOPMENTAL TASKS OF PRESCHOOLERS
TABLE 19-5 Expected Development of Preschoolers
Physical Growth
Fig. 19-4 Preschooler develops the ability to help dress self.
ETHNIC & CULTURAL VARIATIONS
Fig. 19-5 School-age children learn the basic skills required for school.
Behavioral and Cognitive Development
ADOLESCENTS
Physical Growth
BOX 19-4 DEVELOPMENTAL TASKS OF SCHOOL-AGE CHILDREN
Fig. 19-6 The peer group is a major influence in adolescent development.
Behavioral and Cognitive Development
ADULTS
Early Adulthood
BOX 19-5 DEVELOPMENTAL TASKS OF ADOLESCENTS
Career Choice
Mate Selection
Middle Adulthood
Physical Growth
Behavioral and Cognitive Development
Older Adulthood
Physical Growth
BOX 19-6 DEVELOPMENTAL TASKS OF YOUNG ADULTS
BOX 19-7 DEVELOPMENTAL TASKS OF MIDDLE ADULTS
BOX 19-8 DEVELOPMENTAL TASKS OF OLDER ADULTS
Behavioral and Cognitive Development
FAMILY DEVELOPMENT AND ASSESSMENT
Fig. 19-7 The family unit typically shares some degree of time, financial, and physical resources and responsibilities for the unit maintenance.
TABLE 19-6 Preventive Services Throughout the Life Span*
BOX 19-9 DEVELOPMENTAL TASKS OF YOUNG-OLD AND OLD-OLD ADULTS
Young-Old (Approximately 65 to 85 Years)
Old-Old (Approximately over 85 Years)
ETHNIC & CULTURAL VARIATIONS
TABLE 19-7 Developmental Tasks of the Family
CLINICAL APPLICATION & CLINICAL REASONING
REVIEW QUESTIONS
CASE STUDY
CLINICAL Reasoning
INTERACTIVE ACTIVITIES
CHAPTER 20 Assessment of the Infant and Child
ANATOMY & PHYSIOLOGY
HEALTH HISTORY
TABLE 20-1 Pediatric Age Groups
BOX 20-1 SELECTED ANATOMIC AND PHYSIOLOGIC DIFFERENCES IN CHILDREN
Skin
Head
Ears, Nose, Throat, Mouth
Lungs
Heart
Musculoskeletal
Lymph System
Neurologic
Breasts
Reproductive System
RISK FACTORS Ears and Auditory System (Neonates/Infants)
Risk Factors for Congenital or Perinatal Hearing Loss*
Neonatal Risk Factors (Birth to 1 Month)
Infant Risk Factors (1 to 24 Months)
Risk Factors for Otitis Media
Fig. 20-1 Most data are obtained from the adult accompanying the child.
COMPONENTS OF THE PEDIATRIC HEALTH HISTORY
Biographic Data
Reason for Seeking Health Care
History of Present Illness/Present Health Status
Past Health History
BOX 20-2 THE PERINATAL HISTORY
Family History
Personal and Psychosocial History
General Status / Child Profile
Diet and Nutrition
TABLE 20-2 Adolescent Psychosocial History
Sleep
Sexuality
BOX 20-3 CLINICAL NOTE
Development
Health Promotion Habits
Social and Family Relationships
Family composition:
Family life:
Family Socioeconomic Status:
Home Environment:
Friends:
Mental Health
BOX 20-4 CRAFFT SCREENING TOOL
Review of Systems
General Symptoms
Integumentary System
Head and Neck
Breasts
Cardiovascular
Respiratory System
Fig. 20-2 Wong-Baker FACES Pain Rating Scale. Recommended for children 3 years of age and older. Ask the child to choose the face that best describes how he or she if feeling.
Fig. 20-3 Oucher Pain Scales. A, Caucasian, B, African American, C, Hispanic.
Fig. 20-4 Guidelines for Adolescent Preventive Services.
Fig. 20-4, cont’d Guidelines for Adolescent Preventive Services.
Fig. 20-5 Pediatric Symptom Checklist and Pediatric Symptom Checklist Youth Report.
Fig. 20-5 , cont’d Pediatric Symptom Checklist and Pediatric Symptom Checklist Youth Report.
Urinary System
Gastrointestinal System
Reproductive System
Musculoskeletal System
BOX 20-5 TALKING WITH CHILDREN WHO REVEAL ABUSE
Neurologic System
EXAMINATION
OVERVIEW: THE ART OF THE PEDIATRIC PHYSICAL EXAM
Newborns and Infants
Toddlers and Children
Fig. 20-6 Allow the child to touch examination equipment to reduce fear.
Adolescent
VITAL SIGNS AND BASELINE MEASUREMENTS
Temperature
Heart and Respiratory Rates
Blood Pressure
BOX 20-6 CLINICAL NOTE
Height and Weight
Height
Fig. 20-7 Measurement of head and chest circumference and recumbent length.
Weight
Head and Chest Circumference
Head Circumference
ETHNIC & CULTURAL VARIATIONS
Fig. 20-8 A, Measure the height of a child using a platform with movable headboard. B, Side view showing correct posture for accurate measurement.
Fig. 20-9 Weighing an infant on an infant scale.
Fig. 20-10 Measuring head circumference in an infant.
TABLE 20-3 Average Chest and Head Circumference of U.S. Children
BOX 20-7 HEAD CIRCUMFERENCE GROWTH RATES
Chest Circumference
EXAMINATION OF THE SKIN, HAIR, NAILS
Newborns and Infants
Skin
Normal and Abnormal Findings.
Fig. 20-11 Mongolian spot.
Fig. 20-12 Café-au-lait spot.
Fig. 20-13 Stork bite.
Fig. 20-14 A, Port-wine stain. B, Strawberry hemangioma.
Fig. 20-15 Cavernous hemangioma.
Fig. 20-16 Milia on the forehead of a newborn.
Fig. 20-17 Erythema toxicum on the trunk of an infant.
Hair and Nails
Normal and Abnormal Findings.
Toddlers and Children
Skin
Normal and Abnormal Findings.
Fig. 20-18 Seborrheic dermatitis (cradle cap).
Hair and Nails
Normal and Abnormal Findings.
Adolescents
Fig. 20-19 Newborn silky body hair (lanugo).
Fig. 20-20 Comedonal acne. Note closed comedones.
Skin
Normal and Abnormal Findings.
Hair and Nails
Normal and Abnormal Findings.
Fig. 20-21 Severe acne.
EXAMINATION OF THE HEAD, EYES, EARS, NOSE, THROAT
Newborns and Infants
Head
Procedure and Techniques.
Normal and Abnormal Findings.
Eyes
Procedure and Techniques.
Normal and Abnormal Findings.
Fig. 20-22 Alignment of the outer canthus with the pinna of the ear is a normal finding.
Ears
Procedures and Techniques.
Fig. 20-23 Immobilization of young child or infant during otoscopic examination. Note that lower portion of pinna of ear is pulled down and slightly backward. A, Prone position. B, Supine position.
Normal and Abnormal Findings.
Fig. 20-24 Microtia. A, Grade I. B, Grade III.
Nose and Mouth
Procedures and Techniques.
Normal and Abnormal Findings.
Fig. 20-25 Positioning of infant for examination of nose and mouth.
Neck
Toddlers and Children
Head
Fig. 20-26 Epstein’s pearls (gingival cysts) in an infant.
Eyes
Procedures and Techniques.
Normal and Abnormal Findings.
Ears
Procedures and Techniques.
Fig. 20-27 Corneal light reflex.
Normal and Abnormal Findings.
Fig. 20-28 Tympanotomy tube protruding from the right tympanic membrane.
Nose and Mouth
Procedures and Techniques.
Fig. 20-29 Technique for immobilizing a young child’s head for examination.
Normal and Abnormal Findings.
Neck
Procedures and Techniques.
Fig. 20-30 Koplik spots.
Normal and Abnormal Findings.
Adolescents
EXAMINATION OF THE RESPIRATORY SYSTEM
Newborns and Infants
Procedures and Techniques.
Fig. 20-31 The pediatric stethoscope has a smaller head compared to the adult stethoscope.
Normal and Abnormal Findings.
Toddlers and Children
Procedures and Techniques.
Fig. 20-32 Auscultation of lungs on a young child.
Normal and Abnormal Findings.
Adolescents
EXAMINATION OF THE CARDIOVASCULAR SYSTEM
Newborns and Infants
Procedures and Techniques.
Normal and Abnormal Findings.
Toddlers and Children
Procedures and Techniques.
Fig. 20-33 Auscultation on a young child.
Normal and Abnormal Findings.
Fig. 20-34 Auscultation for venous hum.
Adolescents
EXAMINATION OF THE ABDOMEN AND GASTROINTESTINAL SYSTEM
Newborns and Infants
Procedures and Techniques.
Normal and Abnormal Findings.
Toddlers and Children
Procedures and Techniques.
Normal and Abnormal Findings.
Fig. 20-35 Umbilical hernia on a toddler.
Adolescents
EXAMINATION OF THE MUSCULOSKELETAL SYSTEM
Newborns and Infants
Procedures and Techniques.
Normal and Abnormal Findings.
Fig. 20-36 Barlow-Ortolani maneuver to detect hip dislocation. A, Phase I, adduction. B, Phase II, abduction. This is a negative finding because no dislocation is found.
Fig. 20-37 Positive Allis’ sign shows that the left leg is shorter than the right leg, indicating left hip dysplasia.
Toddlers and Children
Procedures and Techniques.
ETHNIC & CULTURAL VARIATIONS
Fig. 20-38 Sign of hip dislocation: the three skin folds on the left upper leg and limited abduction indicate left hip dysplasia.
Normal and Abnormal Findings.
Fig. 20-39 Trendelenburg’s test or sign. A, Normally when standing on the left foot, the right pelvis rises. B, Lack of pelvic tilt when standing on the affected leg indicates hip dysplasia, a positive Trendelenburg’s test.
Adolescents
Procedures and Techniques.
Normal and Abnormal Findings.
EXAMINATION OF THE NEUROLOGIC SYSTEM
Newborns and Infants
Procedures and Techniques.
Normal and Abnormal Findings.
TABLE 20-4 Infantile Reflexes
Toddlers and Children
Procedures and Techniques.
Fig. 20-40 Ask the child to make a “funny face” to assess Cranial Nerve VII.
Normal and Abnormal Findings.
Adolescents
EXAMINATION OF THE BREASTS
Newborns and Infants
Procedures and Techniques.
Normal and Abnormal Findings.
Older Children and Adolescents
Procedures and Techniques.
Normal and Abnormal Findings.
EXAMINATION OF THE REPRODUCTIVE SYSTEM AND PERINEUM
Newborns and Infants
Female Exam
Procedures and Techniques.
Normal and Abnormal Findings.
TABLE 20-5 Screening Assessment of Neurologic “Soft” Signs
Male Exam
Procedures and Techniques.
Fig. 20-41 Marked enlargement of breast bud in neonate. This is an exaggerated response to maternal hormones.
Normal and Abnormal Findings.
Fig. 20-42 Tanner’s five stages of breast development in females. M1—Only the nipple is raised above the level of the breast, as in the child. M2—Budding stage: bud-shaped elevation of the areola. On palpation, a fairly hard disk- or cherry-shaped “button” can be felt. The areola is increased in diameter and the surrounding area is slightly elevated. M3—Further elevation of the mammary gland. Diameter of areola increases further. Shape of mammary tissue is now visibly feminine. M4—Increasing fat deposits. The areola forms a secondary elevation above that of the breast. This secondary mound apparently occurs in roughly half of all young females and in some cases persists in adulthood. M5—Adult stage. The areola (usually) subsides to the level of the breast and is strongly pigmented.
Toddlers and Children
Female Exam
Procedures and Techniques.
Fig. 20-43 Summary of maturational development of girls. See Fig. 20-42 for explanation of numbers 2 through 5 in breast development. Number ranges in graph (e.g., 9.5-14.5) indicate average or common range of age for development of characteristic.
Fig. 20-44 Prepubertal gynecomastia.
Fig. 20-45 Palpation of the scrotum in an infant.
Normal and Abnormal Findings.
TABLE 20-6 Tanner’s Sex Maturity Development (Female)
Male Exam
Procedures and Techniques.
Normal and Abnormal Findings.
Adolescents
Female Exam
Procedures and Techniques.
Fig. 20-46 Position of young child for examination of genitalia.
Normal and Abnormal Findings.
Male Exam
Procedures and Techniques.
Normal and Abnormal Findings.
PERIANAL EXAMINATION
Newborns and Infants
Procedures and Techniques.
Fig. 20-47 Development of male genitalia and pubic hair. (2, 3, 4, 5 refer to Tanner’s stages. See Table 20-7.)
Fig. 20-48 Position for rectal examination of the infant.
TABLE 20-7 Tanner’s Sex Maturity Development (Male)
Normal and Abnormal Findings.
Toddlers and Children
Procedures and Techniques.
Fig. 20-49 Imperforate anus.
Normal and Abnormal Findings.
Adolescents
COMMON PROBLEMS & CONDITIONS
SKIN CONDITIONS
Atopic Dermatitis
Diaper Dermatitis
Fig. 20-50 Atopic dermatitis.
Impetigo
Fig. 20-51 Severe diaper rash.
Fig. 20-52 Impetigo.
Herpes Varicella (Chickenpox)
EAR CONDITIONS
Acute Otitis Media
Fig. 20-53 Chickenpox (Varicella).
Fig. 20-54 Acute otitis media of the left ear with redness and edema of the pars flaccid.
EYE CONDITIONS
Conjunctivitis
MOUTH
Tonsillitis
Cleft Lip and Cleft Palate
Fig. 20-55 Tonsillitis and pharyngitis.
Fig. 20-56 Bilateral cleft lip and complete cleft palate.
RESPIRATORY CONDITIONS
Cystic Fibrosis
Childhood Asthma
Fig. 20-57 Cystic fibrosis.
Croup Syndromes
CARDIOVASCULAR CONDITIONS
Congenital Heart Defects
MUSCULOSKELETAL CONDITIONS
Muscular Dystrophies
Spina Bifida
NEUROLOGIC CONDITIONS
Hydrocephalus
Fig. 20-58 Infantile hydrocephalus.
Cerebral Palsy
Attention Deficit Hyperactivity Disorder
CLINICAL APPLICATION & CLINICAL REASONING
REVIEW QUESTIONS
SAMPLE DOCUMENTATION
SELECTED SUBJECTIVE DATA
INITIAL OBJECTIVE DATA
CASE STUDY
Interview Data
Examination Data
CLINICAL Reasoning
INTERACTIVE ACTIVITIES
CHAPTER 21 Assessment of the Pregnant Client
ANATOMY & PHYSIOLOGY
SIGNS OF PREGNANCY
BOX 21-1 SELECTED ANATOMIC AND PHYSIOLOGIC CHANGES ASSOCIATED WITH PREGNANCY
Integumentary System
Respiratory System
Cardiovascular System
Gastrointestinal System
Urinary System
Musculoskeletal System
Reproductive System
Breasts
TABLE 21-1 Signs of Pregnancy
HEALTH HISTORY
RISK FACTORS High-Risk Pregnancy
Maternal Characteristics
Maternal Habits
Obstetric History
Current Medical Problems
Problems with Current Pregnancy
COMPONENTS OF PRENATAL HEALTH HISTORY
Reason for Seeking Care
Present Health Status
Past Health History
Family History
BOX 21-2 ESTIMATED DATE OF BIRTH (EDB)
Nagele’s Rule
Gynecologic and Obstetric History
Personal and Psychosocial History
Attitude Toward the Pregnancy
TABLE 21-2 Determining Gravidity and Parity Using a Five-Digit (GTPAL) System
BOX 21-3 FOCUS ON PAIN Childbirth
Nutritional History
ETHNIC & CULTURAL VARIATIONS
Personal Habits
Environment
Review of Systems
HEALTH PROMOTION Maternal-Infant Health
Goals and Objectives—Healthy People 2010
Recommendations to Reduce Risk (Primary Prevention)
American College of Obstetricians and Gynecologists (ACOG)
Screening Recommendations (Secondary Prevention)
U.S. Preventive Services Task Force
EXAMINATION
PROCEDURES AND TECHNIQUES WITH NORMAL FINDINGS
VITAL SIGNS AND BASELINE MEASUREMENTS
MEASURE temperature, blood pressure, pulse, and respiration.
ABNORMAL FINDINGS
MEASURE height and weight.
ABNORMAL FINDINGS
BOX 21-4 EXPECTED WEIGHT GAIN DURING PREGNANCY
EXAMINATION OF THE EXTREMITIES
INSPECT the hands and nails for color and surface characteristics, movement, and sensation.
ABNORMAL FINDINGS
INSPECT and PALPATE the lower extremities for edema, surface characteristics, redness, and tenderness.
ABNORMAL FINDINGS
EXAMINATION OF THE HEAD
INSPECT the head and face for skin characteristics, pigmentation, and edema.
ABNORMAL FINDINGS
INSPECT the eyes and TEST vision for acuity.
ABNORMAL FINDINGS
INSPECT the ears, nose, and mouth.
ABNORMAL FINDINGS
INSPECT and PALPATE the neck.
ABNORMAL FINDINGS
EXAMINATION OF THE ANTERIOR AND POSTERIOR CHEST
INSPECT, AUSCULTATE, PERCUSS, and PALPATE the anterior and posterior chest.
ABNORMAL FINDINGS
Fig. 21-1 Changes in position of heart, lungs, and thoracic cage during pregnancy. Broken line, nonpregnant; solid line, changes during pregnancy.
Fig. 21-2 Enlarged breasts in pregnancy with venous network and darkened areolae and nipples.
EXAMINATION OF THE BREAST
INSPECT and PALPATE the breast for surface and tissue characteristics.
ABNORMAL FINDINGS
INSPECT and PALPATE the nipples for surface characteristics and nipple shape.
ABNORMAL FINDINGS
EXAMINATION OF THE MUSCULOSKELETAL SYSTEM
INSPECT and PALPATE the spine, extremities, and joints.
ABNORMAL FINDINGS
Fig. 21-3 Lordosis during pregnancy.
EXAMINATION OF THE NEUROLOGIC SYSTEM
EXAMINE the client for neurologic changes.
ABNORMAL FINDINGS
EXAMINATION OF THE ABDOMEN
INSPECT the abdomen for surface characteristics and fetal movement.
ABNORMAL FINDINGS
Fig. 21-4 Linea nigra on abdomen.
PALPATE the abdomen for fetal movement and uterine contraction.
MEASURE the fundus for height.
ABNORMAL FINDINGS
Fig. 21-5 Measuring fundal height.
Fig. 21-6 Changes in fundal height during pregnancy. Weeks 1 through 12, the uterus is within the pelvis. Weeks 36 through 40, fundal height drops as the fetus begins to engage in the pelvis (lightening).
AUSCULTATE the abdomen for fetal heart sounds.
ABNORMAL FINDINGS
Fig. 21-7 Auscultating fetal heart tones with a fetoscope.
PALPATE fetal position for fetal lie and presentation, position, and attitude.
ABNORMAL FINDINGS
Fig. 21-8 Leopold’s maneuvers. A, First maneuver. Place hand(s) over fundus and identify the fetal part. B, Second maneuver. Use the palmar surface of one hand to locate the back of the fetus. Use the other hand to feel the irregularities such as hands and feet. C, Third maneuver. Use thumb and third finger to grasp presenting part over the symphysis pubis. D, Fourth maneuver. Use both hands to outline the fetal head. With a head presenting deep in the pelvis, only a small portion may be felt.
TABLE 21-3 Fetal Assessment Terms
EXAMINATION OF THE GENITALIA
INSPECT the external and internal genitalia for general appearance and discharge.
ABNORMAL FINDINGS
PALPATE the cervix to determine length (effacement) and dilation.
ABNORMAL FINDINGS
Fig. 21-9 Measurement of cervical length (effacement) and dilation.
EXAMINATION OF THE RECTUM AND ANUS
INSPECT and PALPATE the anus and rectum.
ABNORMAL FINDINGS
COMMON PROBLEMS & CONDITIONS
ABRUPTIO PLACENTAE
PLACENTA PREVIA
Fig. 21-10 Abruptio placentae. Premature separation of normally implanted placenta.
Fig. 21-11 Types of placenta previa after onset of labor. A, Complete, or total. B, Incomplete, or partial.
HYDRAMNIOS (POLYHYDRAMNIOS)
PREGNANCY-INDUCED HYPERTENSION (PIH)
PREMATURE RUPTURE OF MEMBRANES
CLINICAL APPLICATION & CLINICAL REASONING
REVIEW QUESTIONS
SAMPLE DOCUMENTATION
SUBJECTIVE DATA
OBJECTIVE DATA
CASE STUDY
Interview Data
Examination Data
CLINICAL Reasoning
INTERACTIVE ACTIVITIES
CHAPTER 22 Assessment of the Older Adult
ANATOMY & PHYSIOLOGY
BOX 22-1 SELECTED ANATOMIC AND PHYSIOLOGIC CHANGES ASSOCIATED WITH OLDER ADULTS
Mental health
Sleep
Integument System
Head, Eyes, Ears, Nose, and Throat
Respiratory System
Cardiovascular System
Gastrointestinal System
Musculoskeletal System
Neurologic System
Reproductive System
Female Genitourinary System
Male Genitourinary System
Breast
HEALTH HISTORY
RISK FACTORS Older Adult
Falls
Malnutrition in Older Adults
GENERAL HEALTH HISTORY
Present Health Status
Past Health History
Family History
Personal and Psychosocial History
Personal Status
Family and Social Relationships
Functional Ability
BOX 22-2 ACTIVITIES OF DAILY LIVING ASSESSMENT
Sleep
Mental Health
Environment
Review of Systems
Head, Eyes, Ears, Nose, and Throat
Fig. 22-1 Yesavage Geriatric Depression Scale, Short Form.
BOX 22-3 HEARING HANDICAP INVENTORY FOR THE ELDERLY—SCREENING VERSION (HHIE-S)
Respiratory System
Cardiovascular System
Gastrointestinal System
Urinary System
Musculoskeletal System
Reproductive System
BOX 22-4 RISK OF FALLS ASSESSMENT TOOL
Fall Assessment Scoring System
EXAMINATION
OVERVIEW: THE OLDER ADULT PHYSICAL EXAMINATION
VITAL SIGNS AND BASELINE MEASUREMENTS
Temperature
Heart and Respiratory Rates
Blood Pressure
Pain
Height and Weight
Normal and Abnormal Findings
Fig. 22-2 Hands of older adult. Note prominent veins and thin appearance of the skin.
EXAMINATION OF THE SKIN, HAIR, NAILS
Procedure and Techniques
Normal and Abnormal Findings
Skin
Fig. 22-3 Solar lentigo (liver spots). Brown macules that appear in chronically sun-exposed areas.
Hair
Fig. 22-4 Multiple seborrheic keratosis lesions on the trunk.
Fig. 22-5 Multiple skin tags.
Nails
EXAMINATION OF THE HEAD, EYES, EARS, NOSE, AND THROAT
Neck
Procedure and Technique
Normal and Abnormal Findings
Eyes and Vision
Normal and Abnormal Findings
Fig. 22-6 Sebaceous hyperplasia.
Fig. 22-7 Arcus senilis (a gray-white circle around the limbus).
Fig. 22-8 Ectropion.
Fig. 22-9 Entropion.
Ears and Hearing
Normal and Abnormal Findings
Mouth
Normal and Abnormal Findings
BOX 22-5 HEARING LOSS STATISTICS IN MIDDLE-AGE ADULTS, OLDER ADULTS, AND OLD-OLD ADULTS
EXAMINATION OF THE RESPIRATORY SYSTEM
Normal and Abnormal Findings
EXAMINATION OF THE CARDIOVASCULAR SYSTEM
Normal and Abnormal Findings
EXAMINATION OF THE ABDOMEN AND GASTROINTESTINAL SYSTEM
Normal and Abnormal Findings
EXAMINATION OF THE MUSCULOSKELETAL SYSTEM
Normal and Abnormal Findings
EXAMINATION OF THE NEUROLOGIC SYSTEM
Normal and Abnormal Findings
EXAMINATION OF THE BREASTS
BOX 22-6 FUNCTIONAL ASSESSMENT: TINETTI BALANCE AND GAIT ASSESSMENT TOOL
Normal and Abnormal Findings
EXAMINATION OF THE REPRODUCTIVE SYSTEM AND PERINEUM
Female Exam
Procedure and Techniques
Normal and Abnormal Findings
Male Exam
Normal and Abnormal Findings
Perianal Examination
Procedure and Techniques
Normal and Abnormal Findings
COMMON PROBLEMS & CONDITIONS
MACULAR DEGENERATION
Fig. 22-10 Amsler grid used to evaluate central vision as occurs in macular degeneration; here showing visual changes caused by fluid leakage under the retina.
ANEMIA
URINARY INCONTINENCE
CLINICAL APPLICATION & CLINICAL REASONING
REVIEW QUESTIONS
SAMPLE DOCUMENTATION
SUBJECTIVE DATA
OBJECTIVE DATA
CASE STUDY
Interview Data
Examination Data
CLINICAL Reasoning
INTERACTIVE ACTIVITIES
CHAPTER 23 Conducting a Head-to-Toe Assessment
PERFORMING A HEALTH ASSESSMENT
BOX 23-1 EQUIPMENT FOR HEALTH EXAMINATION IN SUGGESTED ORDER OF USE
GUIDELINES FOR ADULT HEAD-TO-TOE EXAMINATION
Procedures
Assessment Data Collected in the General Survey During the History
Assess Vital Signs and Other Baseline Measurements
Examine Hands
Examine Head and Face
Examine Eyes
Examine Ears
Examine Nose, Mouth, and Oropharynx
Examine Neck
Examine Upper Extremities
Assess Posterior Chest
Assess Anterior Chest
Female Breasts
Male Breasts
All Clients
Assess Anterior Chest in Recumbent Position
Female Breasts
Assess Abdomen
Assess Lower Extremities
Assess Remaining Neurologic System
Assess Genitalia, Pelvic Region, and Rectum
Males
Females
INTERACTIVE ACTIVITIES
CHAPTER 24 Documenting the Health Assessment
HEALTH HISTORY
Biographic Data
Reason for Seeking Care
History of Present Illness
Present Health Status
Past Health History
Family History
Personal and Psychosocial History
Personal Status
Family and Social Relationships
Diet/Nutrition
Functional Ability
Mental Health
Personal Habits
Health Promotion Activities
Environment
Review of Systems
General Symptoms
Integumentary System
HEENT
Breasts
Cardiovascular System
Respiratory System
Gastrointestinal System
Urinary System
Musculoskeletal System
Neurologic System
Reproductive System
PHYSICAL EXAMINATION
General Survey
Skin, Hair, Nails
Head
Eyes
Ears
Nose and Sinuses
Mouth and Throat
Neck
Chest and Lungs
Breasts
Heart
Peripheral Vascular
Abdomen
Musculoskeletal
Neurologic
Gynecologic
PROBLEM LIST
NURSING DIAGNOSES
INTERACTIVE ACTIVITIES
Back Matter
APPENDIX A North American Nursing Diagnosis Association (NANDA) Nursing Diagnoses
APPENDIX B Health History Using Functional Health Patterns
APPENDIX C Conversion Tables
TABLE C-1 Length
TABLE C-2 Weight
TABLE C-3 Temperature: Fahrenheit and Celsius Equivalents in the Body Temperature Range
APPENDIX D Abbreviations
Symbols:
APPENDIX E Answer Key
Chapter 1
REVIEW QUESTIONS
Case Study 1
Case Study 2
Chapter 2
REVIEW QUESTIONS
Chapter 3
REVIEW QUESTIONS
Case Study
Chapter 4
REVIEW QUESTIONS
Chapter 5
REVIEW QUESTIONS
Chapter 6
REVIEW QUESTIONS
Case Study
Chapter 7
REVIEW QUESTIONS
Case Study
Chapter 8
REVIEW QUESTIONS
Case Study
Chapter 9
REVIEW QUESTIONS
Case Study
Chapter 10
REVIEW QUESTIONS
Case Study
Chapter 11
REVIEW QUESTIONS
Case Study
Chapter 12
REVIEW QUESTIONS
Case Study
Chapter 13
REVIEW QUESTIONS
Case Study
Chapter 14
REVIEW QUESTIONS
Case Study
Chapter 15
REVIEW QUESTIONS
Case Study
Chapter 16
REVIEW QUESTIONS
Case Study
Chapter 17
REVIEW QUESTIONS
Case Study
Chapter 18
REVIEW QUESTIONS
Case Study
Chapter 19
REVIEW QUESTIONS
Case Study
Chapter 20
REVIEW QUESTIONS
Case Study
Chapter 21
REVIEW QUESTIONS
Case Study
Chapter 22
REVIEW QUESTIONS
Case Study
Glossary
A
B
C
D
E
F
G
H
I
J
K
L
M
N
O
P
R
S
T
U
V
W
X
Illustration Credits
References
Chapter 1
Chapter 2
Chapter 3
Chapter 4
Chapter 5
Chapter 6
Chapter 7
Chapter 8
Chapter 9
Chapter 10
Chapter 11
Chapter 12
Chapter 13
Chapter 14
Chapter 15
Chapter 16
Chapter 17
Chapter 18
Chapter 19
Chapter 20
Chapter 21
Chapter 22

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