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Information

  1. GENERAL—provides information on the client as a whole.
    1. Race, sex, apparent age in relation to stated age.
    2. Nutritional status—well hydrated and developed or obesity, cachexia—include weight.
    3. Apparent health status—general good health or mild, moderate, severe debilitation.
    4. Posture and motor activity—erect, symmetrical, balanced gait and muscle development, or ataxic, circumducted, scissor, or spastic gait; slumped or bent-over posture; scoliosis, lordosis, kyphosis; mild, moderate, or hyperactive motor responses.
    5. Behavior—alert; oriented to person, time, place; hears and comprehends instructions, or tense, anxious, angry; uses abusive language; slightly or largely unresponsive; delusions, hallucinations.
    6. Odors—noncontributory, or acetone, alcohol, fetid breath, incontinent of urine or feces.
  2. PHYSICAL ASSESSMENT—requires knowledge of normal findings, organization, and keen senses (i.e., visual, auditory, touch, smell). For abnormal findings, refer to the Assessment section of each health problem discussed.
    1. Components
      1. Inspection—uses observations to detect deviations from normal.
      2. Auscultation—used to perceive and interpret sounds arising from various organs, particularly heart, lungs, and bowel.
      3. Palpation—used to assess for discomfort, temperature, pulsations, size, consistency, and texture.
      4. Percussion—technique used to elicit vibrations produced by underlying organ structures; used less frequently in nursing practice.
        1. Flat—normal percussion; note over muscle or bone.
        2. Dull—normal percussion; note over organs such as liver.
        3. Resonance—normal percussion; note over lungs.
        4. Tympany—normal percussion; note over stomach or bowel.
    2. Approach—head to toe
      1. General appearance—well or poorly developed or nourished. Color (black, white, jaundiced, pale). In distress (acutely or chronically)?
      2. Vital signs—blood pressure (which arm or both, orthostatic change); pulse (regular or irregular, orthostatic change); respirations (labored or unlabored, wheeze); temperature (axillary, rectal, temporal [forehead], tympanic membrane, or oral); weight; height (Table 6.1. Factors Affecting Vital Signs).
      3. Skin, hair, and nails—pigmentation, scars, lesions, bruises, turgor. Describe or draw rashes.
        1. Skin color:
          1. Red—fever, allergic reaction, carbon monoxide (CO) poisoning, burn.
          2. White (pallor)—excessive blood loss, fright.
          3. Blue (cyanosis)—hypoxemia, peripheral vasoconstriction, shock.
          4. Mottled—cardiovascular embarrassment, shock.
        2. Skin temperature:
          1. Hot, dry—excessive body heat (heatstroke).
          2. Hot, wet—reaction to increased internal or external temperature.
          3. Cool, dry—exposure to cold.
          4. Cool, clammy—shock.
      4. Head—scalp, skull (configuration), scars, tenderness, bruits.
      5. Neck—suppleness. Trachea, larynx, thyroid, blood vessels (jugular veins, carotid arteries).
      6. Nodes—any cervical, supraclavicular, axillary, epitrochlear, inguinal lymphadenopathy? If so, size of nodes (in centimeters), consistency (firm, rubbery, tender), mobile or fixed.
      7. Eyes:
        1. External eye.Conjunctivae, sclerae, lids, cornea, pupils (including reflexes), visual fields, extraocular motions.
        2. Fundus.Disk, blood vessels, pigmentation.
      8. Ears—shape of pinnae, external canal, discharge, tympanic membrane, acuity, air conduction versus bone conduction (Rinne test), lateralization (Weber test).
      9. Nose—nares (symmetry), septum, mucosa, polyps, discharge, flaring.
      10. Mouth and throat—lips, teeth (loose, dental hygiene, odor), tongue (size, papillation, position), buccal mucosa, palate, tonsils, oropharynx.
      11. Chest
        1. Inspection.Contour, symmetry, expansion, retractions.
        2. Palpation.Expansion, rib tenderness, tactile fremitus.
        3. Percussion.Diaphragmatic excursion, dullness.
        4. Auscultation.Crackles, rubs, wheezes, egophony, pectoriloquy.
          1. Use diaphragm or bell. Normal sounds over alveoli—vesicular. Large airway or abnormal sounds—bronchial or bronchovesicular. Adventitious sounds—crackles or wheezes.
          2. Crackles—discontinuous noises heard on auscultation; caused by popping open of air spaces; usually associated with increased fluid in the lungs; formerly called rales and rhonchi.
          3. Wheezes—high-pitched, whistling sounds made by air flowing through narrowed airways.
          4. Stridor—harsh, high-pitched, heard during inspiration and expiration; life threatening.
      12. Breasts—symmetry, retraction, lesions, nipples (inverted, everted), masses, tenderness, discharge.
      13. Heart:
        1. Inspection.Point of maximal impulse (PMI), chest contour.
        2. Palpation.Point of maximal impulse (PMI), thrills, lifts, thrusts.
        3. Auscultation.Heart sounds, gallops, murmurs, rubs. Use diaphragm for highpitched sounds of normal heart sounds (S1 and S2) and bell for abnormal sounds (S3 and S4).
      14. Abdomen:
        1. Inspection.Scars (draw these), contour, masses, vein pattern.
        2. Auscultation.Bowel sounds, rubs, bruits. Use diaphragm. Auscultate after inspection and before palpation and percussion. Listen to each quadrant for at least 1 minute. If bowel sounds are present, they will be heard in lower right quadrant (area of ileocecal valve). Hypoactivity—every minute; normal—every 15 to 20 seconds; hyperactivity—about every 3 seconds.
        3. Percussion—organomegaly, hepatic dullness.
        4. Palpation—tenderness, masses, rigidity, liver, spleen, kidneys.
        5. Hernia—femoral, inguinal, ventral, umbilical.
      15. Genitalia:
        1. Male.Penile lesions, discharge, scrotum, testes. Circumcised?
        2. Female.Labia, discharge, odor, Bartholin's and Skene's glands, vagina, cervix. Bimanual examination of internal genitalia.
      16. Rectum—perianal lesions, sphincter tone, tenderness, masses, prostate, stool color, occult blood.
      17. Extremities—pulses (symmetry, bruits, perfusion). Joints (mobility, deformity). Cyanosis, edema. Varicosities. Muscle mass. Grips equal.
      18. Back—contour of spine, tenderness. Sacral edema.
      19. Neurological:
        1. Mental status.Alertness, memory, judgment, mood.
        2. Cranial nerves (I–XII) (Figure. 6.1. Cranial Nerves and Their Distributions).
        3. Cerebellum.Gait, finger-nose, heel-shin, tremors.
        4. Motor.Muscle mass, strength; deep tendon reflexes. Pathological or primitive reflexes.
        5. Sensory.Touch, pain, vibration. Heat and cold as indicated.
  3. ROUTINE LABORATORY STUDIES—see Appendix A for normal ranges.
    1. Hematology:
      1. Complete blood count—detects presence of anemia, infection, allergy, and leukemia.
      2. Prothrombin time—increase may indicate liver disease or cancer.
      3. Serology (Venereal Disease Research Laboratories [VDRL])—determines presence of syphilis; false-positive result may indicate collagen dysfunction.
    2. Urinalysis:
      1. Specific gravity—measures ability of kidney to concentrate urine. Fixed specific gravity indicates renal tubular dysfunction.
      2. Protein—indicates glomerular dysfunction.
      3. Albumin, white blood cells (WBCs), and pus—indicate renal infection.
      4. Sugar and acetone—presence indicates metabolic disorder.
    3. Chest x-ray—detects tuberculosis or other pulmonary dysfunctions, as well as changes in size or configuration of heart.
    4. Electrocardiogram (ECG or EKG)—detects rhythm and conduction disturbances, presence of myocardial ischemia or necrosis, and ventricular hypertrophy.
    5. Blood chemistries—detect deviation in electrolyte balance, presence of tissue damage, and adequacy of glomerular filtration.
  4. PREVENTIVE CARE
    1. Checkup visits recommended every 1 to 3 years until age 65 and then yearly thereafter. Table 6-2. Preventive Care Timelines lists suggested timelines.
    2. Individuals with special risk factors may need more frequent and additional types of preventive care.
      1. Diabetes—eye, foot examinations; urine, blood sugar tests.
      2. pillImage Drug abuse—AIDS, tuberculosis (TB) tests; hepatitis immunization.
      3. pillImage Alcoholism—influenza, pneumococcal immunizations; TB test.
      4. Overweight—blood sugar test, triglycerides, blood pressure.
      5. Homeless, recent refugee or immigrant—TB test.
      6. High-risk sexual behavior—AIDS, syphilis, gonorrhea, chlamydia (every year for women who are sexually active), hepatitis tests.
      7. Pregnancy—rubella blood test (prior to first pregnancy).
      8. Cancer—colonoscopy, mammography, x-ray.
    3. pillImageAdult immunizations—prevention of disease and reduction in the severity of disease (Table 6.3. 2011 Recommended Adult Immunization Schedule).

Assessment is followed by analysis of data and formulation of a nursing diagnosis. Possible nursing diagnoses are given in the following sections.