Health Assessment and Physical Examination, 4th Edition
By Pauline Calleja, Karen Theobald, Theresa Harvey and Mary Ellen Zator Estes
Contents:
Guide to the text xiii
Guide to the online resources xvii
Preface to this edition xix
Acknowledgements xxi
About the authors xxiii
UNIT 1
Laying The Foundation 1
01 The nursing role in health assessment
and physical examination 2
Background 2
Critical thinking and clinical reasoning 3
Applying standards for critical thinking 4
Components of critical thinking and clinical reasoning 5
Critical thinking and the nursing process 6
Critical thinking, cultural considerations for
healthcare practice 8
Culture 8
Defining cultural competence and cultural safety 8
Cultural competence 9
Cultural safety 10
Assessment: Taking the patient’s health history 11
Planning for physical examination 12
Implementation: Conducting the physical examination 12
Physical examination findings 12
Diagnostic and laboratory data 12
Evaluation of health assessment and physical
examination findings 13
Putting it all together 13
Prioritisation for consumer acuity 14
Evidence-based practice 15
Clinical (or critical) pathways 15
Chapter resources 15
02 The health consumer interview approaches
incorporating developmental considerations 17
Background 17
The consumer interview 18
The nurse 18
The consumer 18
The nurse’s role in assessing a consumer’s spiritual needs 20
General approach to planning for the health assessment
interview 21
Considerations for interviewing 22
Stages of the interview process 24
Factors affecting communication 25
Effective communication techniques 27
Using open-ended questions 27
Using closed questions 28
Facilitating 28
Using silence 28
Grouping communication techniques 28
Communication: Techniques to avoid 34
Requesting an explanation 34
Probing 34
Offering false reassurance 35
Giving approval 36
Defending 36
Advising 36
Questioning techniques which may be problematic 37
Interviewing the consumer with special needs 39
The consumer with impaired hearing 39
The consumer with impaired vision 39
The consumer with impaired speech or aphasia 40
The consumer with a low literacy level 40
The consumer who is culturally or linguistically diverse 41
The consumer who has a low level of understanding 41
The consumer who is emotional and upset 42
Behaviour that may be sexually inappropriate or
threatening 42
The consumer who is under the influence of
alcohol or drugs 43
Developmental theories 43
Transitional developmental theories 44
Ages and stages developmental theories 44
Developmental stages, tasks and life events 44
Developmental tasks of infants (birth to 1 year) 45
Developmental tasks of toddlers (1 to 3 years) 47
Developmental tasks of preschoolers (3 to 6 years) 49
Developmental tasks of school-age children
(6 to 12 years) 50
Developmental tasks of adolescents (12 to 18 years) 51
Developmental tasks of young adults (18 to 30 years) 52
Developmental tasks of early middle adulthood
(30 to 50 years) 52
Developmental tasks of late middle adulthood
(50 to 70 years) 53
Developmental tasks of late adulthood (70 years to death) 54
Developmental assessment tools 54
Chapter resources 56
03 The complete health history including documentation 58
Background 58
Types of health history 59
Preparing for the health history 59
General approach to the health history 60
Identifying information 61
Today’s date 61
Demographic data 61
The complete health history assessment tool 61
Source and reliability of information 62
Consumer profile 63
Reason for seeking health care and chief complaint 63
Present health and history of the present illness 63
Past health history 66
Family health history 72
Social history 72
Health maintenance and education activities 82
Review of systems 86
Concluding the health history 87
Supportive equipment 87
Documentation 87
Chapter resources 90
04 Aboriginal and Torres Strait Islander
peoples’ health 93
Background 94
Introduction to culturally safe and responsive practice 94
Cultural safety 94
Cultural responsiveness 96
Strengths-based communication 96
Diversity and identity 97
History 100
Truth-telling 100
Barriers to access: health care 103
Strength in partnerships 105
Respect 106
Holistic health 107
Connection and belonging to family, kinships
and communities 108
Connection and belonging to Country 109
Reflexivity 109
Communication in clinical practice for health
assessment and physical examination 112
Shared decision making 113
Dadirri: deep listening 114
Yarning: cultural communication 114
Keeping track of culturally safe practice 115
Chapter resources 118
UNIT 2
Physical Examination 121
05 Physical examination techniques 122
Background 122
Considerations prior to commencing physical
examination 123
Standard precautions 123
Transmission-based precautions 127
Legal considerations 128
Physical examination techniques 129
General approach to physical examination 129
Inspection 132
Palpation 132
Percussion 134
Auscultation 136
Equipment 138
Chapter resources 140
06 Examination requirements for
every consumer 142
Background 142
Planning for physical examination 143
Environment 143
Equipment 143
Implementation: Conducting the general survey 144
Examination of physical status 144
Examination of psychological status 147
Examination of vital signs 152
General approach to vital signs assessment 152
Respiration 153
Pulse 154
Temperature 158
Blood pressure 161
Oxygen saturation (SpO2) 167
Pain 171
Perception of pain 171
Source of pain 171
Types of pain 173
Variables affecting pain 173
Effects of pain on the body 174
Pain assessment 174
Pain management 176
Chapter resources 177
07 Mental status and neurological techniques 179
Background 179
Anatomy and physiology 181
Macrostructure 181
Meninges 181
Central nervous system 182
Blood supply 186
Peripheral nervous system 186
Reflexes 189
Assessment: Taking the consumer’s
health history 189
Person-centred health education 195
Planning for physical examination 195
Evaluating subjective data to focus physical examination 196
Environment 196
Equipment 196
Implementation: Conducting the physical examination 196
General approach to neurological assessment 197
Examination of mental status 199
Sensory examination 215
Examination of cranial nerves 216
Examination of motor system 223
Examination of cerebellar function (coordination
and gait) 223
Evaluation of health assessment and physical
examination findings 225
Case study 1: The consumer with delirium 226
Case study 2: The consumer with early onset dementia 230
Case study 3: The consumer with depression and anxiety 233
Chapter resources 236
08 Integumentary 240
Background 240
Anatomy and physiology 241
Skin 241
Hair 244
Nails 244
Function of skin 245
Function of hair 245
Function of nails 245
Assessment: Taking the consumer’s health history 246
Person-centred health education 250
Planning for physical examination 251
Environment 251
Equipment 251
Implementation: Conducting the physical examination 252
General approach to examination of the skin 252
Examination of the skin 252
Examination of the hair 277
Examination of the nails 280
Evaluation of health assessment and physical
examination findings 283
Case study: The consumer with herpes zoster 284
Chapter resources 288
09 Head, neck and regional lymph nodes 290
Background 290
Anatomy and physiology 291
Skull 291
Face 291
Neck 291
Thyroid 292
Lymph nodes 293
Blood supply 293
Assessment: Taking the consumer’s health history 294
Person-centred health education 297
Planning for physical examination 298
Evaluating subjective data to focus physical assessment 299
Environment 299
Equipment 299
Implementation: Conducting the physical examination 299
General approach to examination of head, neck and
regional lymph nodes 300
Examination of the head 300
Examination of the scalp 301
Examination of the face 301
Examination of the mandible 304
Examination of the neck 304
Examination of regional lymphatics: the thyroid gland 306
Examination of regional lymphatics: the lymph nodes 309
Evaluation of health assessment and physical
examination findings 311
Case study: The consumer with hyperthyroidism,
Graves’ disease 311
Chapter resources 315
10 Eyes 317
Background 317
Leading eye health related concerns 318
Anatomy and physiology 319
External structures 319
Internal structures 320
Visual pathway 322
Assessment: Taking the consumer’s health history 322
Person-centred health education 325
Planning for physical examination 326
Environment 326
Equipment 326
Implementation: Conducting the physical
examination 326
General approach to examination of the eyes 327
Examination of visual acuity 327
Examination of visual fields 330
Examination of external eye and lacrimal apparatus 331
Examination of extraocular muscle function 333
Examination of anterior segment structures 336
Evaluation of health assessment and physical
examination findings 342
Case study: The consumer with senile cataract 342
Chapter resources 346
11 Ears, nose, mouth and throat 349
Background 349
Anatomy and physiology 351
Ear 351
Nose 352
Sinuses 353
Mouth and throat 353
Assessment: Taking the consumer’s health history 356
Person-centred health education 361
Planning for physical examination 362
Evaluating subjective data to focus physical examination 362
Environment 362
Equipment 362
Implementation: Conducting the physical examination 363
General approach to examination of the ears,
nose and sinuses, mouth and throat 363
Examination of the ear 364
Examination of the nose 371
Examination of the sinuses 373
Examination of the mouth and throat 375
Examination of breath 375
Examination of the lips 375
Examination of the tongue 376
Examination of buccal mucosa 378
Examination of the gums 380
Examination of the teeth 381
Examination of the palate 381
Examination of the throat 382
Evaluation of health assessment and physical
examination findings 383
Case study: The consumer with acute rhinosinusitis 384
Chapter resources 389
12 Breasts and regional nodes 391
Background 391
Anatomy and physiology 392
Breasts 393
Regional nodes 395
Breast development 395
Assessment: Taking the consumer’s health history 396
Person-centred health education 399
Planning for physical examination 400
Evaluating subjective data to focus physical examination 400
Environment 401
Equipment 401
Implementation: Conducting the physical examination 401
General approach to examination of female breasts and
regional nodes 401
Examination of female breasts and regional nodes 402
Diagnostic techniques 413
Evaluation of health assessment and physical
examination findings 414
Case study: The consumer with fibrocystic
breast changes 415
Chapter resources 418
13 Respiratory 421
Background 421
Anatomy 422
Thorax 422
Sternum 422
Ribs 423
Intercostal spaces 424
Lungs 424
Pleura 427
Mediastinum 427
Bronchi 427
Alveoli 428
Diaphragm and muscles of respiration 428
Physiology 429
Ventilation 429
External respiration 429
Internal respiration 430
Control of breathing 430
Assessment: Taking the consumer’s health history 430
Person-centred health education 434
Planning for physical examination 436
Evaluating subjective data to focus physical assessment 436
Environment 436
Equipment 436
Implementation: Conducting the physical examination 438
General approach to respiratory assessment 439
Examination of the respiratory system 439
Examination of respirations 444
Assessing consumers with respiratory
supportive equipment 467
Evaluation of health assessment and physical
examination findings 468
Case study: The consumer with COVID-19 (moderate
disease with deterioration) 469
Chapter resources 473
14 Cardiovascular 476
Background 476
Anatomy and physiology 479
Heart 479
Coronary circulation 480
Cardiac cycle 482
Conduction system of the heart 483
Blood vessels 483
Assessment: Taking the consumer’s health history 491
Calculating target heart rate zone 495
Person-centred health education 496
Planning for physical examination 498
Evaluating subjective data to focus physical examination 498
Environment 498
Equipment 499
Implementation: Conducting the physical examination 499
General approach to heart assessment 500
Examination of the precordium 500
General approach to blood vessels examination 511
Examination of the blood vessels 512
Examination of the venous system 517
Examination of the arterial system 518
Evaluation of health assessment and physical
examination findings 520
Case study: The consumer with hypertension 521
Chapter resources 526
15 Gastrointestinal 529
Background 529
Abdomen and nutrition assessment 530
Nutrients 530
Nutrition through the life cycle 536
Cultural differences 536
Anatomy and physiology 536
Abdominal cavity 536
Abdominal viscera (organs) 538
Assessment: Taking the consumer’s health history 542
Person-centred health education 548
Planning for physical examination 550
Evaluating subjective data to focus physical assessment 550
Environment 550
Equipment 550
Implementation: Conducting the physical examination 550
General approach to abdomen and nutrition assessment 551
Examination of nutrition and abdomen 552
Examination of the abdomen 556
Examining consumers with abdominal tubes and drains 567
Evaluation of health assessment and physical
examination findings 568
Case study: The consumer with inflammatory
bowel disease 568
Chapter resources 572
16 Musculoskeletal 575
Background 575
Anatomy and physiology 577
Bones 577
Muscles 578
Tendons 579
Cartilage 579
Ligaments 579
Bursae 579
Joints 579
Assessment: Taking the patient’s health history 581
Person-centred health education 585
Planning for physical examination 586
Evaluating subjective data to focus physical assessment 586
Environment 586
Equipment 587
Implementation: Conducting the physical examination 587
General approach to the musculoskeletal
system assessment 588
Examination of the musculoskeletal system 589
Examination of joints 599
Assessing consumers with musculoskeletal supportive equipment 632
Evaluation of health assessment and physical
examination findings 633
Case study: The consumer with musculoskeletal
pain related to osteoarthritis 634
Chapter resources 638
17 Genitourinary and reproductive genitalia 641
Background 641
Female genitalia 641
Male genitalia 642
Urinary system 643
Anatomy and physiology 644
Female 644
The female reproductive cycle 647
Male reproductive system 650
Sexual development 652
Spermatogenesis 652
Male sexual function 652
Anatomy and physiology of the urinary system 654
Assessment: Taking the consumer’s health history 654
Person-centred health education 663
Planning for physical examination 665
Evaluating subjective data to focus physical assessment 665
Environment 665
Equipment 665
Implementation: Conducting the physical examination of
the female 666
General approach to female genitalia assessment 667
Examination of the bladder 668
Examination of the external genitalia 669
Collecting specimens for cytological smears and cultures 680
Classifications 682
Culture specimens 682
Examination of the vaginal wall 683
Bimanual examination 684
Rectovaginal examination 686
Examining consumers with urinary diversions 687
Implementation: Conducting the physical examination
of the male 688
General approach to examination of the male genitalia 688
Examination of the bladder 689
Examination of the male genitalia 689
Examining consumers with urinary diversions 702
Evaluation of health assessment and physical examination findings 702
Case study 1: The consumer with endometriosis 703
Case study 2: The male patient – emergency
department presentation, renal calculi 707
Chapter resources 711
18 Anus, rectum and prostate 714
Background 714
Anatomy and physiology 716
Rectum 716
Anus 716
Prostate 717
Assessment: Taking the consumer’s health history 718
Person-centred health education 722
Planning for physical examination 723
Evaluating subjective data to focus physical examination 723
Environment 723
Equipment 723
Implementation: Conducting the physical examination 723
General approach to assessment of the anus, rectum
and prostate 724
Examination of the anus, rectum and prostate 724
Evaluation of health assessment and physical
examination findings 730
Case study: The consumer with haemorrhoids and
rectal bleeding 730
Chapter resources 733
UNIT 3
Specific Lifespan Populations 737
19 The pregnant woman 738
Background 738
Anatomy and physiology 741
Skin and hair 741
Head and neck 741
Eyes, ears, nose, mouth and throat 741
Breasts 742
Thorax and lungs 742
Heart and blood vessels 742
Abdomen 744
Urinary system 745
Musculoskeletal system 746
Neurological system 747
Female genitalia 747
Anus and rectum 748
Haematological system 748
Endocrine system 748
Assessment: Taking the woman’s health history 748
Person-centred health education 753
Planning for physical examination 754
Evaluating subjective data to focus physical assessment 754
Environment 754
Equipment 755
Implementation: Conducting the physical examination 755
General approach to examination of the pregnant woman 756
Examination of the pregnant woman 756
Examination of the anus, perineum and rectum 768
Assessment of the haematological system 768
Examination of the endocrine system 768
Nutritional assessment 768
Psychosocial assessment 768
Subsequent or return antenatal visits 772
Evaluation of health assessment and physical
examination findings 773
Case study: The pregnant woman 773
Chapter resources 776
20 The paediatric consumer 779
Background 779
Physical growth 781
Anatomy and physiology 783
Structural and physiological variations 783
Growth and development 788
Assessment: Taking the consumer’s health history 789
Person-centred health education 794
Planning for physical examination 795
Evaluating subjective data to focus physical examination 795
Environment 796
Equipment 796
Implementation: Conducting the physical examination 796
General approach to paediatric physical examination 797
Developmental assessment 798
Paediatric pain assessment 802
Physical examination 802
Vital signs 804
Physical growth 805
Skin 808
Hair 810
Head 811
Eyes 813
Ears 815
Nose 817
Mouth and throat 818
Neck 820
Breasts 821
Thorax and lungs 821
Heart and blood vessels 822
Abdomen 826
Musculoskeletal system 827
Neurological system 830
Female genitalia 834
Male genitalia 835
Anus 837
Evaluation of health assessment and physical
examination findings 838
Case study: The paediatric consumer with acute tonsillitis 838
Chapter resources 842
21 The older adult 845
Background 845
Key health challenges for older adults 846
Anatomy and physiology 847
Structural and physiological variations 847
Assessment: Taking the consumer’s health history 858
Interview of the older adult 858
Special assessments 859
Planning for physical examination 862
Evaluating subjective data to focus physical examination 862
Environment 862
Equipment 863
Implementation: Conducting the physical examination 863
General approach to older adult assessment 864
Physical examination 865
Vital signs 866
Height and weight 867
Skin 867
Hair 867
Nails 868
Head and neck 868
Eyes 868
Ears 870
Nose 871
Mouth and throat 871
Breasts 871
Thorax and lungs 872
Heart and blood vessels 872
Abdomen 872
Musculoskeletal system 872
Mental status and neurological techniques 874
Female genitalia 875
Male genitalia 876
Anus, rectum and prostate 876
Evaluation of health assessment and physical
examination findings 877
Case study: The older adult 877
Chapter resources 883
UNIT 4
Putting It All Together 887
22 Health assessment and physical examination
in context 888
Background 888
Legal considerations 889
Ethical considerations 889
Approach to comprehensive health assessment and
physical examination 890
Assessment: Taking the consumer’s health history 890
Approach to physical examination 890
Implementation: Conducting the physical examination 891
General appearance 891
Measurements and vital signs 892
Mental status and neurological assessment 892
Skin 892
Head and face 892
Eyes 893
Ears 893
Nose and sinuses 893
Mouth and throat 893
Neck 893
Jugular veins 894
Back, posterior and lateral thoraxes 894
Anterior thorax 894
Heart 894
Female and male breasts 895
Abdomen 895
Inguinal area 895
Musculoskeletal system 895
Upper extremities 895
Lower extremities 895
Female genitourinary, reproductive, anus and rectum 896
Male genitourinary, reproductive, anus, rectum and prostate 896
Laboratory and diagnostic data 896
The process of pulling it together 897
Technology and documentation 897
Case study (comprehensive): The consumer with
unstable angina 897
Case study (focused): The consumer with a Colles
fracture 903
Conclusion 905
Chapter resources 906
Appendix: Functional assessments 907
Answers to review questions 909
Glossary 910
Index 923