the complete health assessment: putting it all together

Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc.

The CompleteThe CompleteHealth Assessment:Health Assessment:

Putting It All TogetherPutting It All Together

Chapter 27Chapter 27


Chapter 27: The Complete Health Assessment: Putting It All TogetherChapter 27: The Complete Health Assessment: Putting It All Together

Complete Health AssessmentComplete Health Assessment

The art of arranging all the steps you have The art of arranging all the steps you have learned so farlearned so far You may have to pause and think of what comes You may have to pause and think of what comes

next rather than just gather datanext rather than just gather data• Repeated rehearsals will make it smootherRepeated rehearsals will make it smoother

• You will come to the point at which the procedure flows You will come to the point at which the procedure flows naturallynaturally

• Even if you forget a step, you will be able to insert it Even if you forget a step, you will be able to insert it gracefully into next logical placegracefully into next logical place

• The following sequence is one suggested routeThe following sequence is one suggested route

• It is intended to minimize the number of position changes It is intended to minimize the number of position changes for the patient and for youfor the patient and for you

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Complete Health AssessmentComplete Health Assessment (cont.)(cont.)

Perform all the steps listed here for a Perform all the steps listed here for a complete examinationcomplete examination

• With experience, you will learn to strike a balance With experience, you will learn to strike a balance between which steps you must retain to be thorough and between which steps you must retain to be thorough and which corners you may safely cut when time is pressingwhich corners you may safely cut when time is pressing

• Have all equipment prepared and accessible before Have all equipment prepared and accessible before examinationexamination

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SequenceSequence

Patient walks into room, sits; the examiner Patient walks into room, sits; the examiner sits facing the patient; the patient is in street sits facing the patient; the patient is in street clothesclothes

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The Health HistoryThe Health History

Collect the history, complete or limited as visit Collect the history, complete or limited as visit warrantswarrants While obtaining the history and throughout the While obtaining the history and throughout the

examination, note data on person’s general examination, note data on person’s general appearanceappearance

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Seated TogetherSeated Together

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Physical ExaminationPhysical Examination

General appearanceGeneral appearance Appears stated ageAppears stated age Level of consciousnessLevel of consciousness Skin colorSkin color Nutritional statusNutritional status Posture and position comfortably erectPosture and position comfortably erect Obvious physical deformitiesObvious physical deformities

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Physical ExaminationPhysical Examination (cont.)(cont.)

General appearance (cont.)General appearance (cont.) MobilityMobility

• GaitGait

• Use of assistive devicesUse of assistive devices

• Range of motion (ROM) of jointsRange of motion (ROM) of joints

• No involuntary movementNo involuntary movement

• Able to rise from a seated position easilyAble to rise from a seated position easily

Facial expressionFacial expression Mood and affectMood and affect Speech: articulation, pattern, content appropriate, Speech: articulation, pattern, content appropriate,

native languagenative language

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General appearance (cont.)General appearance (cont.) HearingHearing Personal hygienePersonal hygiene

MeasurementMeasurement WeightWeight HeightHeight Compute body mass indexCompute body mass index Vision using Snellen’s eye chartVision using Snellen’s eye chart

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StandingStanding

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SkinSkin Examine both hands and inspect nailsExamine both hands and inspect nails For the rest of the examination, examine skin with For the rest of the examination, examine skin with

corresponding regional examinationcorresponding regional examination

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Vital signsVital signs Radial pulseRadial pulse RespirationsRespirations Blood pressureBlood pressure Temperature, if indicatedTemperature, if indicated

Head and faceHead and face Inspect and palpate scalp, hair, and craniumInspect and palpate scalp, hair, and cranium Inspect face: expression, symmetry, CN VIIInspect face: expression, symmetry, CN VII

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Seated, Changed into GownSeated, Changed into Gown

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Head and face (cont.)Head and face (cont.) Palpate temporal artery, then temporomandibular Palpate temporal artery, then temporomandibular

joint as person opens and closes mouthjoint as person opens and closes mouth Palpate maxillary sinuses and frontal sinusesPalpate maxillary sinuses and frontal sinuses

• If tender, transilluminate the sinusesIf tender, transilluminate the sinuses

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EyeEye Test visual fields by confrontation, CN IITest visual fields by confrontation, CN II Test extraocular muscles: corneal light reflex, six Test extraocular muscles: corneal light reflex, six

cardinal positions of gaze, CN III, IV, VIcardinal positions of gaze, CN III, IV, VI Inspect external eye structuresInspect external eye structures Inspect conjunctivae, sclerae, corneas, and iridesInspect conjunctivae, sclerae, corneas, and irides Test pupil size for light and accommodationTest pupil size for light and accommodation Darken roomDarken room Using an ophthalmoscope, inspect ocular fundus, Using an ophthalmoscope, inspect ocular fundus,

including red reflex, disc, vessels, and retinal including red reflex, disc, vessels, and retinal backgroundbackground

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EarEar Inspect external ear: position and alignment, skin Inspect external ear: position and alignment, skin

condition, and auditory meatuscondition, and auditory meatus Move auricle and push tragus for tendernessMove auricle and push tragus for tenderness With an otoscope, inspect canal, then tympanic With an otoscope, inspect canal, then tympanic

membrane for color, position, landmarks, and membrane for color, position, landmarks, and integrityintegrity

Test hearing using voice test; tuning fork tests, Test hearing using voice test; tuning fork tests, Weber and Rinne testsWeber and Rinne tests

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NoseNose Inspect external nose for symmetry and lesionsInspect external nose for symmetry and lesions Inspect facial symmetry, CN VIIInspect facial symmetry, CN VII Test the patency of each nostrilTest the patency of each nostril With a speculum, inspect the nares, including With a speculum, inspect the nares, including

nasal mucosa, septum, and turbinatesnasal mucosa, septum, and turbinates

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Mouth and throatMouth and throat With a penlight, inspect mouth, including buccal With a penlight, inspect mouth, including buccal

mucosa, teeth and gums, tongue, floor of mouth, mucosa, teeth and gums, tongue, floor of mouth, palate, and uvulapalate, and uvula

Grade tonsils, if presentGrade tonsils, if present Note mobility of uvula as person phonates “ahh,” Note mobility of uvula as person phonates “ahh,”

and test gag reflex, CN IX, and CN Xand test gag reflex, CN IX, and CN X Ask the person to stick out tongue, check CN XIIAsk the person to stick out tongue, check CN XII With a gloved hand, bimanually palpate mouth, if With a gloved hand, bimanually palpate mouth, if

indicatedindicated

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NeckNeck Inspect neck for symmetry, lumps, and pulsationsInspect neck for symmetry, lumps, and pulsations Palpate cervical lymph nodesPalpate cervical lymph nodes Inspect and palpate carotid pulse, one side at a Inspect and palpate carotid pulse, one side at a

time; if indicated, listen for carotid bruitstime; if indicated, listen for carotid bruits Palpate trachea in midlinePalpate trachea in midline Test ROM and muscle strength against your Test ROM and muscle strength against your

resistance: head forward and back, head turned to resistance: head forward and back, head turned to each side, and shoulder shrug, CN XIeach side, and shoulder shrug, CN XI• Step behind person, taking your stethoscope, ruler, and Step behind person, taking your stethoscope, ruler, and

marking pen with youmarking pen with you

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Neck (cont.)Neck (cont.) Palpate thyroid gland from posterior approachPalpate thyroid gland from posterior approach Open person’s gown to expose all of back for Open person’s gown to expose all of back for

examination of thorax, but leave gown on examination of thorax, but leave gown on shoulders and anterior chestshoulders and anterior chest

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Chest, posterior and lateralChest, posterior and lateral Inspect the posterior chest: configuration of Inspect the posterior chest: configuration of

thoracic cage, skin characteristics, and symmetry thoracic cage, skin characteristics, and symmetry of shoulders and musclesof shoulders and muscles

Palpate: symmetric expansion; tactile fremitus; Palpate: symmetric expansion; tactile fremitus; lumps or tendernesslumps or tenderness

Palpate length of spinous processesPalpate length of spinous processes Percuss over all lung fields, percuss using Percuss over all lung fields, percuss using

diaphragmatic excursiondiaphragmatic excursion

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Chest, posterior and lateral (cont.)Chest, posterior and lateral (cont.) Percuss costovertebral angle, noting tendernessPercuss costovertebral angle, noting tenderness Auscultate breath sounds; note any adventitious Auscultate breath sounds; note any adventitious

soundssounds• Move around to face patient; patient remains sittingMove around to face patient; patient remains sitting

• For a female breast examination, ask permission to lift For a female breast examination, ask permission to lift gown to drape on shoulders, exposing anterior chestgown to drape on shoulders, exposing anterior chest

• For male, lower gown to the lapFor male, lower gown to the lap

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Chest, anteriorChest, anterior Inspect respirations and skin characteristicsInspect respirations and skin characteristics Palpate for tactile fremitus, lumps, or tendernessPalpate for tactile fremitus, lumps, or tenderness Percuss anterior lung fieldsPercuss anterior lung fields Auscultate breath soundsAuscultate breath sounds

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HeartHeart Ask person to lean forward and exhale briefly; Ask person to lean forward and exhale briefly;

auscultate cardiac base for any murmursauscultate cardiac base for any murmurs Upper extremitiesUpper extremities

Test ROM and muscle strength of hands, arms, Test ROM and muscle strength of hands, arms, and shouldersand shoulders

Palpate epitrochlear nodesPalpate epitrochlear nodes

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Female breastsFemale breasts Inspect for symmetry, mobility, and dimpling as Inspect for symmetry, mobility, and dimpling as

woman lifts arms over head, pushes hands on woman lifts arms over head, pushes hands on hips, and leans forwardhips, and leans forward

Inspect supraclavicular and infraclavicular areasInspect supraclavicular and infraclavicular areas Help woman to lie supine with head at a flat to 30-Help woman to lie supine with head at a flat to 30-

degree angle degree angle • Stand at person’s right sideStand at person’s right side

• Drape gown up across shoulders and place an extra Drape gown up across shoulders and place an extra sheet across lower abdomensheet across lower abdomen

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Female breasts (cont.)Female breasts (cont.) Palpate each breast, lifting same side arm up over Palpate each breast, lifting same side arm up over

headhead• Include the tail of Spence and areolaInclude the tail of Spence and areola

Palpate each nipple for dischargePalpate each nipple for discharge Support person’s arm and palpate axilla and Support person’s arm and palpate axilla and

regional lymph nodesregional lymph nodes Teach breast self-examinationTeach breast self-examination

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Male breastsMale breasts Inspect and palpate while palpating anterior chest Inspect and palpate while palpating anterior chest

wallwall Supporting each arm, palpate axilla and regional Supporting each arm, palpate axilla and regional

nodesnodes Neck vesselsNeck vessels

Inspect each side of neck for a jugular venous Inspect each side of neck for a jugular venous pulse, turning person’s head slightly to other sidepulse, turning person’s head slightly to other side

Estimate jugular venous pressure, if indicatedEstimate jugular venous pressure, if indicated

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HeartHeart Inspect precordium for any pulsations or heave Inspect precordium for any pulsations or heave

(lift)(lift) Palpate apical impulse and note locationPalpate apical impulse and note location Palpate precordium for any abnormal thrillPalpate precordium for any abnormal thrill Auscultate apical rate and rhythmAuscultate apical rate and rhythm Auscultate with the diaphragm of stethoscope to Auscultate with the diaphragm of stethoscope to

study heart sounds, inching from apex up to base, study heart sounds, inching from apex up to base, or vice versaor vice versa

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Heart (cont.)Heart (cont.) Auscultate heart sounds with the bell of Auscultate heart sounds with the bell of

stethoscope, again inching through all locationsstethoscope, again inching through all locations Turn person over to left side while again Turn person over to left side while again

auscultating apex with bellauscultating apex with bell• Person should be supine, with bed or table flat; arrange Person should be supine, with bed or table flat; arrange

drapes to expose abdomen from chest to pubisdrapes to expose abdomen from chest to pubis

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Person SupinePerson Supine

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AbdomenAbdomen Inspect for contour, symmetry, skin Inspect for contour, symmetry, skin

characteristics, umbilicus, and pulsationscharacteristics, umbilicus, and pulsations Auscultate bowel soundsAuscultate bowel sounds Auscultate for vascular sounds over aorta and Auscultate for vascular sounds over aorta and

renal arteriesrenal arteries Percuss all quadrantsPercuss all quadrants Percuss height of liver span in right midclavicular Percuss height of liver span in right midclavicular

lineline

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Abdomen (cont.)Abdomen (cont.) Percuss location of spleenPercuss location of spleen Palpate using light palpation in all quadrants, then Palpate using light palpation in all quadrants, then

deep palpation in all quadrantsdeep palpation in all quadrants Palpate for liver, spleen, kidneys, and aortaPalpate for liver, spleen, kidneys, and aorta Test abdominal reflexes, if indicatedTest abdominal reflexes, if indicated

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Inguinal areaInguinal area Palpate each groin for femoral pulse and inguinal Palpate each groin for femoral pulse and inguinal

nodes; lift drape to expose legsnodes; lift drape to expose legs Lower extremitiesLower extremities

Inspect for symmetry, skin characteristics, and Inspect for symmetry, skin characteristics, and hair distributionhair distribution

Palpate pulses, including popliteal, posterior tibial, Palpate pulses, including popliteal, posterior tibial, and dorsalis pedis pulsesand dorsalis pedis pulses

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Inguinal area (cont.)Inguinal area (cont.) Palpate for temperature and pretibial edemaPalpate for temperature and pretibial edema Separate toes and inspectSeparate toes and inspect Test ROM and muscle strength of hips, knees, Test ROM and muscle strength of hips, knees,

ankles, and feetankles, and feet• Ask person to sit up and to dangle legs off bed or table; Ask person to sit up and to dangle legs off bed or table;

keep gown on and drape over lapkeep gown on and drape over lap

MusculoskeletalMusculoskeletal Note muscle strength as person sits upNote muscle strength as person sits up

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NeurologicNeurologic Test sensation in selected areas on face, arms, Test sensation in selected areas on face, arms,

hands, legs, and feet: superficial pain, light touch, hands, legs, and feet: superficial pain, light touch, and vibrationand vibration

Test position sense of finger, one handTest position sense of finger, one hand Test stereognosisTest stereognosis Test cerebellar function of the upper extremities Test cerebellar function of the upper extremities

using finger-to-nose test or rapid-alternating-using finger-to-nose test or rapid-alternating-movements testmovements test

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Patient Sits Up and Dangles LegsPatient Sits Up and Dangles Legs

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Neurologic (cont.)Neurologic (cont.) Test cerebellar function of lower extremities by Test cerebellar function of lower extremities by

asking person to run each heel down opposite asking person to run each heel down opposite shinshin

Elicit deep tendon reflexes: biceps, triceps, Elicit deep tendon reflexes: biceps, triceps, brachioradialis, patellar, and Achillesbrachioradialis, patellar, and Achilles

Test the Babinski reflexTest the Babinski reflex• Ask person to stand with gown on; stand close to personAsk person to stand with gown on; stand close to person

Lower extremitiesLower extremities Inspect legs for varicose veinsInspect legs for varicose veins

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MusculoskeletalMusculoskeletal Ask person to walk across room in his or her Ask person to walk across room in his or her

regular walk, turn, then walk back toward you, in regular walk, turn, then walk back toward you, in heel-to-toe fashionheel-to-toe fashion

Ask person to walk on toes for a few steps, then to Ask person to walk on toes for a few steps, then to walk on heels for a few stepswalk on heels for a few steps

Stand close and check Romberg’s signStand close and check Romberg’s sign Ask person to hold edge of bed and to perform a Ask person to hold edge of bed and to perform a

shallow knee bend, one for each legshallow knee bend, one for each leg

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Male genitaliaMale genitalia Inspect penis and scrotumInspect penis and scrotum Palpate the scrotal contents; if a mass exists, Palpate the scrotal contents; if a mass exists,

transilluminatetransilluminate Check for inguinal herniaCheck for inguinal hernia Teach testicular self-examinationTeach testicular self-examination

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Male GenitaliaMale Genitalia

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Patient Stands UpPatient Stands Up

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Musculoskeletal (cont.)Musculoskeletal (cont.) Stand behind and check the spine as person Stand behind and check the spine as person

touches toestouches toes Stabilize pelvis and test ROM of spine as person Stabilize pelvis and test ROM of spine as person

hyperextends, rotates, and laterally bendshyperextends, rotates, and laterally bends For male patient, sit on a stool in front of him; For male patient, sit on a stool in front of him;

person standsperson stands

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Male rectumMale rectum Inspect the perianal areaInspect the perianal area With a gloved lubricated finger, palpate the rectal With a gloved lubricated finger, palpate the rectal

walls and prostate glandwalls and prostate gland Save a stool specimen for an occult blood testSave a stool specimen for an occult blood test

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Female genitaliaFemale genitalia Inspect perineal and perianal areasInspect perineal and perianal areas With a vaginal speculum, inspect cervix and With a vaginal speculum, inspect cervix and

vaginal wallsvaginal walls Procure specimensProcure specimens Perform a bimanual examination; check cervix, Perform a bimanual examination; check cervix,

uterus, and adnexauterus, and adnexa Continue bimanual examing, checking rectum and Continue bimanual examing, checking rectum and

rectovaginal wallsrectovaginal walls

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Lithotomy Position, Female GenitaliaLithotomy Position, Female Genitalia

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Female genitalia (cont.)Female genitalia (cont.) Save a stool specimen for an occult blood testSave a stool specimen for an occult blood test Provide tissues for female to wipe perineal area, Provide tissues for female to wipe perineal area,

and help her up to a sitting positionand help her up to a sitting position

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Physical Examination (cont.)(cont.)

Tell patient you are finished with examination Tell patient you are finished with examination and that you will leave room as he or she gets and that you will leave room as he or she gets dresseddressed

Return to discuss examination and further Return to discuss examination and further plans and to answer any questionsplans and to answer any questions

Thank person for his or her timeThank person for his or her time For hospitalized person, return bed and any For hospitalized person, return bed and any

room equipment to way you found itroom equipment to way you found it Make sure call light and telephone are within Make sure call light and telephone are within

easy reacheasy reach

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the complete health assessment: putting it all together

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