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 CONTENTS vii

Family health history 61 Contact and mobilise the patient’s important

Social history 62 spiritual resources 128
Health maintenance and promotion activities 70 Allow patients to pray 128
Review of systems 73 Make appropriate referrals to the hospital chaplain 128
Concluding the health history 74 Evaluation of spiritual assessment 129
Supportive equipment 74
Documentation 75
UNIT 02

04 Physical examination techniques 81 PHYSICAL EXAMINATION 135

Background 81
06 Examination requirements for every patient 136
Considerations prior to commencing
physical examination 81 Background 136
Standard Precautions 81 Assessment 136
Transmission-Based Precautions 85 Assessment in brief: General survey, vital signs
Legal considerations 86 and pain 136
Assessment 86 Planning 137
Assessment in brief: Physical assessment techniques 86 Environment 137
Physical examination techniques 86 Equipment 137
Inspection 87 General survey 137
Palpation 87 Physical presence 137
Percussion 88 Psychological presence 139
Auscultation 91 Vital signs 142
Equipment 92 Respiration 142
Pulse 143
05 Cultural and spiritual assessment 99 Temperature 148
Blood pressure 150
Background 99
Oxygen saturation (SpO2) 156
Cultural assessment 99
Pain 159
Cultural background 99
Perception of pain 159
Nursing and cultural competence 101
Source of pain 159
Culturally competent assessments:
Types of pain 161
concepts to consider 102
Variables affecting pain 161
Culture 102
Effects of pain on the body 162
Subculture 103
Assessing pain 162
Cultural identity and characteristics 103
Pain management 164
Minority groups 106
Values, norms and value orientations 106
07 Mental status and neurological techniques 167
Beliefs 107
Customs and rituals 111 Background 167
Self-assessment for cultural competency 117 Anatomy and physiology 169
Planning for cultural assessments 117 Macrostructure 169
Implementation of cultural assessments 117 Meninges 169
Evaluation of culturally competent assessments 119 Central nervous system 169
Spiritual assessment 119 Blood supply 173
Spiritual background 119 Peripheral nervous system 173
Religion and spirituality – concepts to consider 120 Reflexes 175
The health effects of religion and spirituality 122 Assessment 176
Role of the nurse and considerations for spiritual care 123 Assessment in brief: Mental status assessment
Assessment for spirituality 124 and neurological techniques 176
Planning for spiritual assessment 126 Subjective data 176
Implementing spiritual assessment 127 Health promotion 181
Show respect for the patient’s religious Planning 181
and spiritual beliefs 127 Evaluating subjective data to focus physical examination 181
Allow patients to practise their religion and spirituality Objective data 181
if they wish to do so 127
viii CONTENTS

Environment 181 Subjective data 264

Equipment 182 Health promotion 267
Implementation 182 Planning 268
Mental status 183 Evaluating subjective data to focus physical assessment 268
Sensory examination 198 Objective data 268
Assessment in brief: Assessing sensation 199 Environment 268
Cranial nerves 200 Equipment 268
Motor system 206 Implementation 269
Cerebellar function (coordination, station and gait) 207 Assessment of the head 269
Evaluation 209 Inspection of the shape of the head 269
Evaluation of health assessment data 209 Palpation of the head 270
Case study: The patient with delirium 209 Inspection and palpation of the scalp 270
Inspection of the face 271
08 Skin, hair and nails 216 Palpation and auscultation of the mandible 273
Background 216 Assessment of the neck 273
Anatomy and physiology 217 Inspection of the neck 273
Skin 217 Palpation of the neck 274
Hair 219 Inspection of regional lymphatics 275
Nails 220 Inspection of the thyroid gland 275
Function of skin 220 Palpation of the thyroid gland 275
Function of hair 221 Auscultation of the thyroid gland 277
Function of nails 221 Inspection of the lymph nodes 278
Assessment 221 Palpation of the lymph nodes 278
Assessment in brief: Skin, hair and nails 221 Evaluation 279
Subjective data 221 Evaluation of health assessment data 279
Health promotion 225 Case study: The patient with hyperthyroidism,
Planning 226 Graves’ disease 279
Evaluating subjective data to focus
physical examination 226 10 Eyes 286
Objective data 226 Background 286
Environment 226 Anatomy and physiology 288
Equipment 226 External structures 288
Implementation 227 Internal structures 288
Inspection of the skin 228 Visual pathway 289
Bleeding, ecchymosis and vascularity 231 Assessment 290
Palpation of the skin 245 Subjective data 290
Inspection of the hair 248 Assessment in brief: Eye 290
Palpation of the hair 250 Health promotion 293
Inspection of the nails 250 Planning 293
Palpation of the nails 252 Evaluating subjective data to focus physical examination 293
Evaluation 253 Objective data 293
Evaluation of health assessment data 253 Environment 293
Case study: The patient with herpes zoster 253 Equipment 293
Implementation 294
09 Head, neck and regional lymph nodes 260
Visual acuity 294
Background 260 Visual fields 296
Anatomy and physiology 261 External eye and lacrimal apparatus 297
Skull 261 Extraocular muscle function 300
Face 262 Anterior segment structures 303
Neck 262 Evaluation 308
Thyroid 262 Evaluation of health assessment data 308
Lymph nodes 262 Case study: The patient with senile cataract 309
Blood supply 263
Assessment 263 11 Ears, nose, mouth and throat 315
Assessment in brief: Head, neck and regional
Background 315
lymphatics 263
 CONTENTS ix

Anatomy and physiology 316 Sternum 383

Ear 316 Ribs 384
Nose 318 Intercostal spaces 384
Sinuses 319 Lungs 384
Mouth and throat 319 Pleura 387
Assessment 321 Mediastinum 387
Assessment in brief: Ears, nose, mouth and throat 321 Bronchi 387
Subjective data 321 Alveoli 388
Health promotion 325 Diaphragm and muscles of respiration 388
Planning 326 Physiology 389
Evaluating subjective data to focus physical examination 326 Ventilation 389
Objective data 326 External respiration 389
Environment 326 Internal respiration 389
Equipment 326 Control of breathing 389
Implementation 327 Assessment 390
Examination of the ear – auditory screening 327 Assessment in brief: Thorax and lung 390
External ear 328 Subjective data 391
Otoscopic assessment 330 Health promotion 394
Examination of the nose 334 Planning 395
Examination of the sinuses 336 Evaluating subjective data to focus
Examination of the mouth and throat 337 physical examination 395
Evaluation 345 Objective data 395
Evaluation of health assessment data 345 Environment 395
Case study: The patient with acute rhinosinusitis 345 Equipment 395
Implementation 396
12 Breasts and regional nodes 355 Inspection 397
Background 355 Respirations 401
Anatomy and physiology 356 Palpation 407
Breasts 356 Thoracic expansion 408
Regional nodes 358 Percussion 412
Breast development 358 Auscultation 415
Assessment 359 Assessing patients with respiratory
Assessment in brief: Breasts and supportive equipment 424
regional nodes 359 Evaluation 424
Subjective data 359 Evaluation of health assessment data 424
Health promotion 362 Case study: The patient with asthma 425
Planning 363
Evaluating subjective data to focus 14 Heart and blood vessels 432
physical examination 363 Background 432
Objective data 363 Anatomy and physiology 433
Environment 363 Heart 433
Equipment 363 Coronary circulation 435
Implementation 363 Cardiac cycle 436
Inspection 364 Conduction system of the heart 437
Palpation 368 Blood vessels 438
Diagnostic techniques 375 Assessment 445
Evaluation 375 Assessment in brief: Heart and blood vessel 445
Evaluation of health assessment data 375 Subjective data 445
Case study: The patient with fibrocystic breast Calculating target heart rate zone 449
changes to the left breast 376 Health promotion 449
Planning 451
13 Thorax and lungs 382 Evaluating subjective data to focus physical examination 451
Background 382 Objective data 451
Anatomy 383 Environment 451
Thorax 383 Equipment 451
x CONTENTS

Implementation 452 Planning 536

Assessment of the precordium 452 Evaluating subjective data to focus physical assessment 536
Assessment of the blood vessels 463 Objective data 536
Evaluation 472 Environment 536
Evaluation of health assessment data 472 Equipment 537
Case study: The patient with hypertension 472 Implementation 537
General assessment 538
15 Abdomen and nutrition 480 Posture 539
Background 480 Gait and mobility 540
Abdomen and nutrition assessment: Inspection 542
concepts to consider 481 Palpation 544
Nutrients 481 Muscle strength 548
Anatomy and physiology 487 Examination of joints 548
Abdominal cavity 487 Assessing patients with musculoskeletal
Abdominal viscera (organs) 490 supportive equipment 577
Assessment 492 Evaluation 579
Assessment in brief: Nutritional and abdominal 492 Evaluation of health assessment data 579
Subjective data 493 Case study: The patient with musculoskeletal trauma 579
Health promotion 498
Planning 500 17 Female genitalia 585
Evaluating subjective data to focus physical assessment 500 Background 585
Objective data 500 Anatomy and physiology 586
Environment 500 External female genitalia 586
Equipment 500 Internal female genitalia 587
Implementation 500 The female reproductive cycle 589
Physical examination of nutrition and abdomen 501 Assessment 592
Abdominal inspection 506 Assessment in brief: Female genitalia 592
Auscultation 509 Subjective data 592
Percussion 511 Health promotion 594
Palpation 513 Planning 596
Assessing for abdominal inflammation: Evaluating subjective data to focus physical assessment 596
rebound tenderness 517 Objective data 596
Assessing for appendicitis: Rovsing’s sign 518 Environment 596
Assessing for appendicitis: Iliopsoas muscle test 518 Equipment 596
Assessing patients with abdominal tubes and drains 519 Implementation 598
Evaluation 520 Inspection of the external genitalia 599
Evaluation of health assessment data 520 Palpation of the external genitalia 604
Case study: The patient with inflammatory Speculum examination of the internal genitalia 607
bowel disease 520 Classifications 612
Culture specimens 612
16 Musculoskeletal system 527 Inspection of the vaginal wall 613
Background 527 Bimanual examination 614
Anatomy and physiology 528 Rectovaginal examination 616
Bones 528 Evaluation 617
Muscles 528 Evaluation of health assessment data 617
Tendons 529 Case study: The patient with uterine fibroids 617
Cartilage 529
Ligaments 529 18 Male genitalia 624
Bursae 529 Background 624
Joints 529 Anatomy and physiology 625
Assessment 531 Essential organs 625
Assessment in brief: Musculoskeletal 531 Accessory organs 626
Subjective data 532 Ducts 626
Health promotion 535 Supporting structures 627
Sexual development 627
 CONTENTS xi

Spermatogenesis 627 Abdomen 680

Male sexual function 629 Urinary system 681
Assessment 629 Musculoskeletal system 681
Assessment in brief: Male genitalia 629 Neurological system 682
Subjective data 629 Female genitalia 682
Health promotion 632 Anus and rectum 683
Planning 633 Haematological system 683
Evaluating subjective data to focus physical assessment 633 Endocrine system 684
Objective data 633 Assessment 684
Environment 633 Assessment in brief: Assessment of
Equipment 633 the pregnant patient 684
Implementation 634 Subjective data 684
Inspection 634 Health promotion 689
Palpation 641 Planning 690
Auscultation 647 Evaluating subjective data to focus physical assessment 690
Evaluation 648 Objective data 690
Evaluation of health assessment data 648 Environment 690
Case study: The male patient – sexual health screening 648 Equipment 690
Implementation 691
19 Anus, rectum and prostate 655 General assessment, vital signs and weight 692
Background 655 Skin and hair 694
Anatomy and physiology 656 Head and neck 695
Rectum 656 Eyes, ears, nose, mouth and throat 695
Anus 657 Breasts 695
Prostate 657 Thorax and lungs 696
Assessment 658 Heart and blood vessels 696
Assessment in brief: Anus, rectum Abdomen 696
and prostate Assessment 658 Urinary system 696
Subjective data 658 Musculoskeletal system 697
Health promotion 661 Neurological system 697
Planning 662 Female genitalia 697
Evaluating subjective data to focus physical assessment 662 Foetal heart rate 700
Objective data 663 Leopold’s manoeuvre 701
Environment 663 Anus, perineum and rectum 702
Equipment 663 Haematological system 703
Implementation 663 Endocrine system 703
Inspection 664 Nutritional assessment 703
Evaluation 668 Additional antepartum tests and evaluations 703
Evaluation of health assessment data 668 Psychosocial assessment 704
Case study: The patient with haemorrhoids Subsequent or return prenatal visits 707
and rectal bleeding 669 Evaluation 708
Evaluation of health assessment data 708
Case study: The pregnant patient 708
UNIT 03

SPECIFIC LIFESPAN POPULATIONS 675 21 The paediatric patient 715

Background 715
20 The pregnant patient 676 Physical growth 716
Background 676 Anatomy and physiology 717
Anatomy and physiology 677 Structural and physiological variations 717
Skin and hair 677 Growth and development 721
Head and neck 678 Assessment 722
Eyes, ears, nose, mouth and throat 678 Assessment in brief: Paediatric patient* 722
Breasts 678 Subjective data 723
Thorax and lungs 678 Health promotion 727
Heart and blood vessels 678
xii CONTENTS

Planning 728 Nails 793

Evaluating subjective data to focus physical assessment 728 Head and neck 793
Objective data 728 Eyes 794
Environment 728 Ears 795
Equipment 729 Nose 796
Implementation 729 Mouth and throat 796
Developmental assessment 730 Breasts 797
Paediatric pain assessment 734 Thorax and lungs 797
Physical examination 734 Heart and blood vessels 797
Vital signs 735 Abdomen 797
Physical growth 736 Musculoskeletal system 798
Skin 739 Mental status and neurological techniques 799
Hair 741 Female genitalia 800
Head 741 Male genitalia 801
Eyes 743 Anus, rectum and prostate 801
Ears 745 Evaluation 802
Nose 747 Evaluation of health assessment data 802
Mouth and throat 747 Case study: The older adult 802
Neck 749
Breasts 750
UNIT 04
Thorax and lungs 750
Heart and blood vessels 751 PUTTING IT ALL TOGETHER 811
Abdomen 755
Musculoskeletal system 757 23 The complete health assessment
Neurological system 759 and physical examination 812
Female genitalia 763 Background 812
Male genitalia 765 Legal considerations 813
Anus 767 Ethical considerations 813
Evaluation 767 Approach to comprehensive health assessment
Evaluation of health assessment data 767 and physical examination 814
Case study: The paediatric patient with acute tonsillitis 768 Health history 815
Physical examination 815
22 The older adult 774 General survey 815
Background 774 Mental status and neurological system 816
Epidemiology 774 Measurements and vital signs 816
Issues in disease presentation 775 Skin 816
Anatomy and physiology 776 Head and face 817
Structural and physiological variations 776 Eyes 817
Assessment 783 Ears 817
Assessment in brief: Assessment of the older adult 783 Nose and sinuses 817
Subjective data 784 Mouth and throat 817
Interview of the older adult 784 Neck 817
Special assessments 785 Musculoskeletal system 818
Planning 787 Upper extremities 818
Evaluating subjective data to focus physical assessment 787 Lower extremities 818
Objective data 788 Back, posterior and lateral thoraxes 818
Environment 788 Anterior thorax 819
Equipment 788 Heart 819
Implementation 788 Female and male breasts 819
Functional testing 789 Jugular veins 819
Cognition 790 Heart 819
Vital signs 791 Abdomen 819
Height and weight 792 Inguinal area 819
Skin 792 Female genitalia, anus and rectum 820
Hair 793 Male genitalia 820
Male anus, rectum and prostate 820
 CONTENTS xiii

Laboratory and diagnostic data 820 Appendix A: Functional assessments 831

The process of pulling it together 820 Answers to review questions 833
Technology and documentation 821 Glossary 834
Case study (Comprehensive): The patient with unstable angina 821 Index 847
Case study (Focused): The patient with a Colles fracture 826 Assessment in brief cards
Conclusion 829
 PREFACE TO THIS EDITION

Health assessment forms the foundation of all nursing care. Assessment is an

ongoing process that evaluates the whole person as a physical, psychosocial and
functional being, whether they are young or old, well or ill. Health Assessment
and Physical Examination, 2nd edition for Australia and New Zealand, provides a
well-illustrated approach to the process of holistic assessment, including health
history interview, physical examination techniques, and health promotional
guidelines.
The text is clearly presented and moves the learner through foundation to
more advanced health assessment. Beginning to advanced level nurses will find
the book helpful as it takes a scaffolded approach that moves the learner through
a contextualised introduction to the chapter focus (body system) and overviews
including anatomy and physiology. Following this, the chapters explore health
history assessment and physical examination of the particular body system or
content area. Through this process abnormal findings are highlighted and the
chapter concludes with assessment applied to practice through a case study
exemplar.

CONCEPTUAL APPROACH
This text is designed to teach readers to holistically assess a patient as a foundation
of nursing care. The skills of interviewing, inspection, palpation, percussion,
auscultation and documentation are refined to support the reader to make more
accurate clinical judgments and promote healthy patient outcomes.
The concept for Health Assessment and Physical Examination is based on a
straightforward, well-organised assessment approach that could be easily read
and assimilated into clinical practice. Further, this text focuses the reader on a
transparent clinical reasoning cycle for ongoing care of the patient as a result of the
health assessment outcome. The text is organised using a quality framework called
APIE (Assess, Plan, Implement, Evaluate 5 APIE). This framework is applicable to
nursing in all contexts.
Health Assessment and Physical Examination, 2nd edition, embraces a strong
emphasis on the underpinning knowledge of anatomy, physiology and assessment,
while highlighting clinically relevant information. Emphasis on a holistic patient
approach is displayed through the themes of assessment of the whole person:
cultural, spiritual, familial, and environmental considerations; patient dignity; and
health promotion.
Health Assessment and Physical Examination, 2nd edition, offers a user-friendly
approach that delivers a wealth of information. The consistent, easy-to-follow
format with recurring pedagogical features is based on two formats:
1 The IPPA method of physical examination (Inspection, Palpation, Percussion,
Auscultation) is consistently applied to body systems for a complete, detailed
physical assessment.
2 The ENAP format (Examination, Normal findings, Abnormal findings,
Pathophysiology) is followed for every IPPA examination, providing a useful
and valuable collection of information. Pathophysiology is included to support
understanding of each abnormal finding, acknowledging that nurses’ clinical
decisions need to be based on scientific rationale. It also enables the reader to
study the content specifically relevant to his or her own health care practice.
xiv
 PREFACE xv

ORGANISATION
Health Assessment and Physical Examination, 2nd edition, consists of 23 chapters
which are organised into four units.
Unit 1 lays the foundation for the entire assessment process by guiding the
reader through the nursing process, the critical thinking and clinical reasoning
cycle, the patient interview including developmental considerations, the health
history including documentation, physical assessment techniques, and cultural and
spiritual assessment. Specific tips on professionalism, approaching patients, and
discussing sensitive topics help the reader understand the importance of the nurse–
patient relationship in the assessment process.
Unit 2 opens with a description of fundamental assessment techniques,
including measuring vital signs and assessing pain, and then details assessment
procedures and findings for specific body systems. The format used for all applicable
physical assessment chapters in this unit includes:

Learning outcomes
++ Background
–– Anatomy and physiology
++ Assessment
++ Subject data
–– Health history
–– Health promotion
++ Planning
–– Evaluation of subjective data to focus physical examination
–– Objective data
–– Environment
–– Equipment
–– Approach to physical examination
++ Implementation
–– Inspection
–– Palpation
–– Percussion
–– Auscultation
++ Evaluation
–– Evaluation of health assessment data
–– Case study
–– Evaluation and clinical reasoning for case study
The examination techniques presented are described for adults. Because
assessment techniques and findings may differ in pregnant women, children and
the older adult, these populations are discussed in separate chapters in Unit 3.
Unit 4 helps the reader assimilate and synthesise the wealth of information
presented in the text in order to perform a thorough, accurate and efficient health
assessment and physical examination. Specific guidelines and reminders on gaining
patients’ cooperation, being sensitive to legal and ethical considerations, and
documenting accurately make this unit a complete health assessment resource tool.
 ACKNOWLEDGEMENTS

We would like to acknowledge and sincerely thank our families and friends who have
shared ‘us’ on the weekends with this manuscript. We value and appreciate your
generous support and tolerance of our journey in completing this second edition.
We would like to thank all the chapter contributors who so enthusiastically
involved themselves in contextualising and writing some of the case studies
including: Sharon Bourgeois, Denise Blanchard, Sharon Laver, Kolleen Miller-Rosser,
Lisa Stewart and Amanda Wylie.
We would also like to thank our colleagues who gave valuable input into
particular areas of our writing, including Belynda Abbott, Helen Donovan and
Elizabeth Forster.
Thanks also go to the reviewers from universities in Australia and New Zealand
who provided valuable feedback on the chapter drafts.

A final thank you goes to the Cengage production team, specifically Jessica Brennan
and Fiona Hammond for their continued support. The authors and Cengage
Learning would like to thank the following reviewers for their incisive and helpful
feedback:
++ Lynne Chaffey – Manukau Institute of Technology
++ Bernadette Watson – Griffith University
++ Tanya Langtree – James Cook University
++ Lisa Hee – Central Queensland University
++ Allison Moloney – Gold Coast Institute of TAFE
++ Ann Framp – University of Sunshine Coast
++ Jan Alderman – University of Adelaide
++ Marie-Claire Seeley – Monash University
++ John Cooper – University of Tasmania
++ Peter Wall – Murdoch University
++ Ben Hay – University of Notre Dame
++ Alex Chan – University of Tasmania.

xvi
ABOUT THE AUTHORS

Pauline Calleja
Griffith University
RN, PhD, BNSc, MANP, FCENA
Lecturer, School of Nursing and Midwifery

Pauline’s nursing background has spanned many specialty areas over the past
18 years and included teaching students health assessment, physical examination
and clinical reasoning in clinical and academic settings. Pauline has just
transitioned from a senior nursing management and clinical support role in remote
central Queensland, back into academic teaching, and convenes the post-graduate
emergency program. Her experience in special projects includes teaching
Indigenous primary health care workers, developing capacity for clinical teaching
in Vietnam and developing leadership skills in Australian clinical teachers. Pauline
has taught at Queensland University of Technology, University of the Sunshine
Coast, James Cook University and within various clinical and vocational education
settings. Professional associations include College of Emergency Nursing Australasia,
CRANAplus, and the Australian College of Nursing.

Karen Theobald
Queensland University of Technology (QUT)
RN, PhD (Griff), MHSc (Nursing), GCert (HigherEd), BAppSc (QUT)
Senior Lecturer, Director of Academic Programs, Study Area Coordinator for
Emergency Nursing in the School of Nursing, Queensland University of Technology

Karen has over 30 years as a nursing lecturer and clinician, teaching across a variety
of clinical, undergraduate and postgraduate settings. The majority of Karen’s
teaching is in the areas of acute care nursing, health assessment, advanced life
support, and supporting the teaching of students and staff. Her focus in recent
times has been on enhancing innovation in curriculum design and learning
materials. Karen has spent the greater part of her time in various leadership roles at
the Queensland University of Technology, School of Nursing. She also supervises
higher degree research students. Her research areas are learning and teaching and
cardiovascular disease and she also serves in leadership and advisory capacities with
professional organisations such as the Australian College of Critical Care Nurses and
the Australian Resuscitation Council (Queensland Branch).

Theresa Harvey
Queensland University of Technology (QUT)
RN, CM, FRCNA BHlthSc (Nurs), Grad Dip (FurtherEdTraining),
MN (Women’s Health)
A/Senior Lecturer, Director of Clinical Partnerships, School of Nursing, Queensland
University of Technology

Theresa has over 35 years of clinical and nursing education experience. Her clinical
experience incorporates varied nursing and midwifery practice. In recent years her
education focus has been teaching health assessment and physical examination

xvii
xviii A B O U T T H E A U T H O R S

in undergraduate programs and supporting students’ clinical learning in their

transition to practice. Theresa has had a large role in development of clinical
teachers from multidisciplinary health areas, supporting students on practicum
both in Australia and Vietnam. Theresa has taught at Queensland University of
Technology, Australian Catholic University (Brisbane), and Northern Sydney Area
Midwifery School/Ryde Hospital. Professional associations include Australian
Society for Simulation in Health Care and Theresa is also a Fellow of the Australian
College of Nursing.

Mary Ellen Zator Estes

Ball State University, Muncie, Indiana
RN, MSN, FNP, APRN-BC, NP-C
Family Nurse Practitioner in Internal Medicine, Fairfax, Virginia Clinical Faculty,
Nurse Practitioner Track, School of Nursing, Ball State University, Muncie, Indiana

With over 25 years’ experience as a clinician and academician, Ms Estes has

taught health assessment and physical examination courses to nurses and nursing
students from a variety of backgrounds. Her hands-on approach in the classroom,
clinical laboratory and health care setting has consistently led to positive learning
experiences for her students. She has taught at the University of Virginia,
Marymount University, Northern Virginia Community College, and The George
Washington University Medical Centre. She has also served as Clinical Faculty for
Ball State University.
 Guide to the text
As you read this text you will find a number of features in every chapter to
enhance your study of health assessment and physical examination.

FEATURES WITHIN CHAPTERS: T H E PAT I E N T I N T E R V I E W A N D D E V E L O P M E N TA L C O N S I D E R AT I O N S 35

The patient who is under the influence of alcohol or drugs

The patient who is under the influence of alcohol or drugs presents a unique

CHAPTER 02
LEARNING OUTCOMES
challenge to the nurse. Depending on the quantity of alcohol consumed and

Review a concise outline of the important steps

ASSESSMENT IN BRIEF
the type of drugs ingested, the patient can have central nervous system (CNS)
depression, or the patient can be very disruptive with CNS stimulation. The
patient’s judgment may be impaired, which can lead to physical harm to those in

for performing each type of assessment and

the immediate environment. For this reason, when you have a violent or agitated
274 P H Y S I C A L E X A M I N AT I O N patient, security personnel should be alerted and stationed nearby.
Patients under the influence of some drugs have been known to exhibit

Learning outcomes give you a clear sense of physical examination using the Assessment in
superhuman strength and are capable of inflicting serious physical harm on
themselves and others. To care for this person, place yourself at a safe distance,
remain calm, and provide care in a nonthreatening manner.

what topics each chapter will cover and what you brief boxes. Assessment in brief Tear-out Cards
3 Have the patient touch the chin to the chest, to each side, and to each E
shoulder. CLINICAL REASONING
UNIT 0 2

4 Assess for limitation of motion.

should be able to do after
5 Note the
reading
theor tracheostomy.
presence of a stoma chapter. are included in pocket-sized form at the back of
ASSESSING ALCOHOL WITHDRAWAL
Excessive alcohol consumption is one of the more prominent health risks in Australian
society (ABS, 2013). Alcohol and drug use in patients presenting to health care settings,
The muscles of the neck are symmetrical with the head in a central position. The
the book for clinical reference and easy revision.
N particularly to emergency departments has risen dramatically. Of concern are the negative
consequences that might arise from abuse of such substances and the withdrawal
patient is able to move the head through a full range of motion without symptoms that may become evident as the patient is assessed and managed in the
complaint of discomfort or noticeable limitation. The patient may be breathing healthcare setting. The alcohol withdrawal scale (Ciwa-ar) is an assessment tool which is
sensitive to the person experiencing alcohol withdrawal. The tool (Trathen, 2006) contains 10

09
through a stoma or tracheostomy. criteria to assess, rate and calculate an overall score to guide patient management. Policies
will vary among individual health care agencies however, and intervention is based on the
A Asymmetry of the neck is abnormal (see Figure 9.17). final score calculated for the patient. For further information refer to the following website
CHAPTER P Asymmetrical masses can be benign or malignant, but they all must be evaluated
for the Ciwa-ar – Alcohol withdrawal scale by Trathen:
http://www.dryoutnow.com/alcohol-treatment/alcohol-treatment_xaf1.shtml
further.
A The patient complains of pain with flexion or rotation of the head.
INTERVIEWING CONSIDERATIONS

ASSESSMENT IN BRIEF
HEAD, NECK AND REGIONAL LYMPH
P Pain with flexion NODES
can be associated with the pain and muscle spasm caused + Be aware of personal beliefs and how these were + Do not assume that you understand the meaning of all patient
by meningeal irritation of meningitis (see Chapter 7). Generalised discomfort acquired. Avoid imposing your beliefs on those you communications. Clarify frequently.
interview. + Paraphrase and summarise occasionally to help patients
may be related to trauma, spasm, inflammation of muscles or diseases of the + Listen and observe. Attend to verbal and affective content as organise their thinking, clarify issues, and begin to explore
LEARNING OUTCOMES vertebrae. well as to nonverbal cues. specific concerns more deeply.
+ Keep your attention focused on the patient. Do not listen with + Allow for periods of silence.
At the end of this chapter you will be able to:
A There is a slight or prominent lateral deviation of the patient’s neck. The ‘half an ear.’ Do not think about other things when you are + Remember that attitudes and feelings may be conveyed
1 Identify the anatomic structures of the head and neck.
interviewing. nonverbally.
2 Identify the lymph nodes of the head and neck. sternocleidomastoid muscles, and to a lesser extent the trapezii and scalene + Maintain eye contact with the patient as is appropriate for the + Consistently monitor your reactions to the patient’s verbal and
3 Describe the health history for the head, neck and regional lymph
muscles, maynodes.
also be prominent on the affected side. The muscles frequently patient’s culture. nonverbal messages.
4 Demonstrate the physical examination of the head, neck and regional lymph nodes. + Notice the patient’s speech patterns and any recurring + Avoid being judgmental or critical. Avoid preaching.
5 Describe normal findings, common abnormalities hypertrophy as of
and pathophysiology the result
these of powerful
abnormalities in the contractions. themes. Note any extra emphasis that the patient places on + Avoid the use of nontherapeutic interviewing techniques.
FIGURE 9.17 This physical
right neck mass of
assessment was
the head, neck and regional lymph nodes. certain words or topics.
P This condition is called torticollis (Figure 9.18). Causes can be:
identified as squamous
6 Discusscell carcinoma.
the critical reasoning in evaluating outcomes of health assessment and physical examination,
1 Congenital:
including documentation, health education provision resulting
and relevant health referral. from a haematoma or partial rupture at birth of the
sternocleidomastoid, causing a shortening of the muscle.
DEVELOPMENTAL THEORIES
2
Ocular: a head posture assumed to correct for ocular muscle palsy and
BACKGROUND Express Once you have mastered the basic interview techniques, you will need to consider ASSESSMEN
resulting diplopia. the developmental level of your patient to undertake your assessment. A variety
T IN BRIEF
The most common head, neck and regional lymph node disorders are lymphoid
3 Acuteofspasm:the mouth. commonly associated with the inflammation of viral myositis of theories have been developed that depict and predict growth and development.
INTERVIEW ASSESSM

CHAPTER 2
cancers; headache; thyroid cancer; and malignant neoplasms The Visit http://login.cengagebrain
most common forms of lymphoid cancer are lymphoma, myeloma and lymphoid .com and use the access code
The theories most widely used for clinical assessment of patients are the ‘ages ING
CONSIDERAT
or trauma such as sleeping
leukaemia (AIHW, 2012). This cancer is ranked fifth out of the top five most that comes with
with thisthe
book head in an unusual position. and stages’ theories of Piaget (1952), Freud (1946), Erikson (1974) and Kohlberg + Be aware
of personal IONS
Avoid impo beliefs and
common causes of death for all cancers, which 4 how these wer
Other:
account phenothiazine
for 49 per cent of all deaths therapy and Parkinson’s disease, as the result of
for a 24 month access to the sing your belie PHYSICAL

CHAPTER 4
+ Listen and fs on those e acquired.
from cancer (AIWH, 2012). CourseMate Express Study observe. Atte you interview
increased cholinergic activity
Guide resources inforthe brain.
this chapter, well as to nonv nd to verbal .
Headache is one of the most common health problems experienced by erbal cues. and affective Inspection
including quizzes, videos, games content as

TEAR-OUT CARD >>

Australians and New Zealanders. Individuals aged between 25 and 44 years are more + Keep your + Vision
and more. attention focu
likely than others to encounter headaches A (Better health Channel, 2014). Cancer of Range of motion of the neck is reduced. ‘half an ear.’
Do not think
sed on the patie
nt. Do not liste + Smell
the thyroid gland is a significant health problem with an annual incidence of 2039 interviewing. about other n with

URGENT FINDING
things when
P per cent (Australian Institute of Health
cases in 2012, and a low mortality rate of 0.5 Degenerative changes of osteoarthritis may result in decreased ability for full + Maintain
eye contact
you are Palpation
and Welfare & Australasian Association of Cancer Registries, 2012). Approximately patient’s cultu with the patie + Light palp
one in every 1000 Australians is affected by thyroid cancer. range of motion. This condition is usually painless unless nerve root irritation + Notice the
re. nt as is appr
opriate for the + Deep palp
ati
patient’s spee ati
In the Australian Indigenous male population, the most common oral has occurred. Crepitus, or a crunching sound on hyperextension of the neck, Note any extr ch patterns
and any recu Percussion
health problems are dental caries and periodontal disease (Northern Territory a emphasis rring themes.
words or topic that the patie
Department of Health, 2011). Gingivitis and periodontitis are the most common may also be observed. + Do not assu
s. nt places on
certain
+ Direct, or
imm
type of periodontal disease, seen more commonly in the Indigenous child and me that you + Indirect,

Identify serious or life-threatening signs or

understand or me
adult populations than non-Indigenous counterparts (Australian Indigenous A There is an acute localised inflammation, tenderness and redness, with the communicati
ons. Clarify the meaning
of all patient
Palpation of the neck HealthInfoNet, 2014, Jamieson, Armfield, Roberts-Thomson, 2007, Australian
Institute of Health and Welfare, 2012). patient complaining of pain in the infected area. This is called a hordeolum.
+ Paraphra
se and sum
organise their
frequently.
marise occa
sion
Auscultatio
+ Direct, or
n
thinking, clar ally to help patients imme
1 Stand in front of the patient.
critical assessment findings that need immediate
The major cause of periodontal disease Ein the Indigenous group relates to the specific conc ify issues, and + Indirect,
erns more deep begin to expl or med
FIGURE 9.18
2 With the finger pads, palpate
high prevalence of smoking, poor oral hygiene and limited dental visit assessment.
Torticollis
the sternocleidomastoid muscles.
(Australian Indigenous HealthInfoNet, 2014, Thomson et al., 2008). In Maori and
P Staphylococcus is generally the infecting organism that causes a hordeolum. + Allow for
periods of silen ly. ore Advanced tech
niqu
+ Rememb ce. + Direct fist
er that attitudes
3 Note the presence of masses or tenderness. adult Pacific people, poorer oral health and lower dental service attendance rates percu

attention with the Urgent finding boxes.

and feelings
There are two types of hordeolum: nonverbally.
+ Consiste
may be conv
eyed
+ Indirect
fist perc
4 Stand behind the patient. 257 ntly monitor
1 Internal: affects the meibomian glands, is usually large, may point to the skin nonverbal mes
sages.
your reactions
to the patie
nt’s verbal and
5 With the finger pads, palpate the trapezius. + Avoid bein
g judgmental
6 Note the presence of masses or tenderness.
or conjunctival side of the lid. + Avoid the
use of nont
or critical. Avo
id preachin
herapeutic g.
2 External: often called a ‘stye’, an infection of a sebaceous gland, usually interviewing
techniques.
N The muscles should be symmetrical without palpable masses or spasm.
points to the skin side of the lid, extending to the lid margin.
A A mass is palpated in the musculature.
URGENT FINDING Infections of the glands of the eyelid can be causedASbySESimproper removal
P A mass may be a tumour, either primary or metastatic. SMENT IN
BRIEF
of make-up, dry eyes or seborrhoea. There may be some connection between a
CHAP TER 6

NECK INJURY A A spasm may be felt in the muscles. GENERAsuch ASSESSMEN

hordeolum and increased handling of the lids in activities L SURVEasY, inserting
VITAL SIGNS and T IN B
If a neck injury is suspected, stabilise the neck and do not P Muscle spasm may be due to varied causes such as Physical pres AND PAIN
removing contact lenses.

CHAP TER 7
ence
+ Stated
proceed with the assessment. Refer the patient immediately to infections, trauma, chronic inflammatory processes or age versus MENTAL STA
NEUROLOGICTUS A
+ General apparent age
an experienced health specialist for further evaluation. There is a chronic inflammation of the meibomian gland in either the upper or appearance

REFLECTION IN PRACTICE
neoplasms. A + Body fat AL TE
+ Stature Mental statu
SKIN, HAIR AND NAILS 249 the lower lid. It generally forms over several weeks and, in many cases, points + Motor activ + Physical
s assessment
ity appearance
toward the conjunctival side of the lid, usually not on the lid margin. There is + Body and
breath odou
rs
behaviour an

Psychologica – Posture
and moveme
E Examination N Normal findings A Abnormal findings P Pathophysiology no redness or tenderness. + Dress, groo
l presence – Dress, groo
ming and

Reflection in practice
is referred to asboxes introduce realistic
ming and pers personal hygi
+ Mood and onal hygiene ene
This inflammation a chalazion and its cause is unknown.
CHAPTER 08

P manner
COURTESY OF THE CENTERS FOR DISEASE CONTROL AND PREVENTION.

+ Speech – Facial expr

ession
ASSOCIATE PROFESSOR, DEPARTMENT OF PEDIATRICS,

– Affect
COURTESY OF ROBERT A. SILVERMAN, M.D., CLINICAL

ASSOCIATE PROFESSOR, DEPARTMENT OF PEDIATRICS,

+ Facial expr
COURTESY OF ROBERT A. SILVERMAN, M.D., CLINICAL

The lids are inflamed bilaterally and are red-rimmed, with scales clinging to both ession + Commun

clinical situations and ethical controversies

of itching and burningto
A + Distress ication
+ Level of
consciousnes
the upper and the lower lids. The patient complains Vital signs + Cognitiv
e abilities and
s
+ Respirati mentation

allowalong
you to consider how you would react in
the lid margins. There may also be some loss of the eyelashes. on
GEORGETOWN UNIVERSITY.

PUTTING IN CONTEXT
GEORGETOWN UNIVERSITY.

+ Pulse – Attention
+ Tempera – Memory
ture
This is blepharitis, which may be either staphylococcal or seborrhoeic. Often a
P + Blood pres – Judgmen

various
patientsituations. TheseIfare to help you infections
relate
sure t
+ Oxygen – Insight
has both types simultaneously. the patient has seborrhoeic saturation
– Spatial perc
D. Trichotillomania E. Tinea capitis Pain assessm eption
elsewhere (scalp or eyebrows), it is more likely that the blepharitis is of the ent – Calculati

to the issues in a personal context as well as

on
F. Seborrhoeic dermatitis – Abstrac
t reasoning
seborrhoeic type. – Thought

Explore the application of health assessment and

A Areas of broken-off hairs in irregular patterns process and
with scaliness, but no infection, are abnormal (see Figure 8.18D). content

to assist you to develop your critical thinking,

Raised, yellow, nonpainful plaques are present on upper and lower lids near the
A – Suicidal
P Trichotillomania is the manipulation of the hair by twisting and pulling, leading ideation

physical examination theory in different clinical to reduced hair mass. This can be an unconscious action or a sign of psychiatric inner canthus.
effective decision making a form ofand problem solving
illness.
Broken-off hairs with scaliness and follicular inflammation are abnormal (see These lesions
P are xanthelasma, xanthoma frequently associated with
situations you may encounter in the real world
A
Figure 8.18E). The area may be painful and purulent with boggy nodules. hypercholesterolaemia.
P Tinea capitis (ringworm) is a fungal infection, frequently caused by
skills.
with NEW Putting it in context boxes.
dermatophytic trichomycosis. The eyebrows have scaling areas.
A
A The scalp is covered with yellow-brown scales and crusts. The scalp may be oily.
Oedema may be present (see Figure 8.18F).
G. Head lice P This is caused by seborrhoea.
FIGURE 8.18 (Continued)
P Seborrhoeic dermatitis is caused by increased production of sebum by the scalp.

PUTTING IT IN CONTEXT
REFLECTION IN PRACTICE
DEALING WITH IMPETIGO IN SCHOOL BASED POPULATIONS (SCHOOL SORES)
As the school nurse in a primary school, you are asked to bacteria that causes the infection and usually are treated with THE PATIENT WITH SUSPECTED PHYSICAL ABUSE
conduct an assessment of each first-grade student’s skin after topical or oral antibiotics.
a parent notifies the school their child has been diagnosed with + What information do you need to give to parents in this How would you react to a patient who has swollen and discoloured eyelids that you believe
school sores. You discover that seven children have blister like situation?
to be the result of physical abuse? What would be an appropriate verbal response? What
sores, some of which appear to be filled with pus, others with + What are your responsibilities for the wellbeing of the entire
extensive scab formation. As you are aware this condition is school? Children at many schools also have segregated lunch resources are available in your community or institution to support and assist victims of
extremely contagious you call the affected children’s parents and play areas.
to pick up their children and seek treatment. Many parents are + What are local methods of managing an impetigo outbreak in
physical abuse?
at a loss for how to manage this issue, particularly if their child your schools and child care centres?
has good hygiene practices. You know treatment is to kill the

Lesions Lacrimal apparatus

E 1 Don gloves and lift the scalp hair by segments. Inspection
2 Evaluate the scalp for lesions or signs of infestation.
N The scalp should be pale white to pink in light-skinned individuals and light
E 1 Have the patient sit facing you.
brown in dark-skinned individuals. There should be no signs of infestation or 2 Identify the area of the lacrimal gland. Note any swelling or enlargement of
lesions. Seborrhoea, commonly known as dandruff, may be present.
the gland or elevation of the eyelid. Note any enlargement, swelling, redness,
A Abnormal manifestations include head lice.
P Head lice (pediculosis capitis) may be distinguished from dandruff in that
dandruff can be easily removed from the scalp or hair, whereas nits (see 3
increased tearing or exudate in the area of the lacrimal sac at the inner canthus.
Compare to the other eye in order to determine whether there is unilateral or
xix
Figure 8.18G), which are the lice larvae, are attached to the hair shaft and are
difficult to remove. Both seborrhoea and head lice may cause itching. bilateral involvement.
E Examination N Normal findings A Abnormal findings P Pathophysiology N There should be no enlargement, swelling or redness; no large amount of
exudate; and minimal tearing.
xx GUIDE TO THE TE X T

T H E PA E D I AT R I C PAT I E N T 743

EYES 295
Surface characteristics

CLINICAL REASONING
Sagittal suture
1 With the finger pads, palpate the skull in the same manner as the fontanelles Scalp

CHAPTER 21
E

Advanced practice material is included to extend

Periosteum Blood
Distance vision and suture lines.
Torn blood
1 Ask the patient to stand or sit facing the Snellen chart at a distance of 2 Note surface oedema and contour of the cranium. vessels

CHAP TER 10
E
Skull bone

your understanding beyond basic assessment

6 metres. N The skin covering the cranium is flush against the skull and without oedema.
Temporo-
2 If the patient normally wears glasses, ask that they be removed. Contact A softening of the outer layer of the cranial bones behind and above the ears

Clinical reasoning boxes explain the decision-

A parietal suture
lenses may be left in the eyes, but you must note that vision is corrected combined with a ping pong ball sensation as the area is pressed in gently with

and is highlighted clearly throughout the text to

when documenting the results of the vision test. If possible also note the the fingers is indicative of craniotabes, an abnormal finding.
strength of the contact lenses that the patient is wearing.

making process to enable you to develop and

P Craniotabes is associated with rickets, syphilis, hydrocephaly or hypervitaminosis A. FIGURE 21.16 Cephalohaematoma (section)
3 Instruct the patient to cover the left eye with the occluder (Figure 10.4B) and
B. Assist the patient in occluding the eye

enable easy reading.

to read as many lines on the chart as possible. A A localised, subcutaneous swelling over one of the cranial bones of a newborn is
referred to as a cephalohaematoma (Figures 21.16 and 21.17) and is abnormal.

enhance your clinical judgement skills.

4 Note the number at the end of the last line the patient was able to read
(Figure 10.4C). This abnormality differs from other surface characteristics in that oedema does
5 If the patient is unable to read the letters at the top of the chart, move the not cross suture lines with this condition. Varying degrees of swelling can persist
up to 3 months.

INSERT NEW FIGURE SOURCE HERE

patient closer to the chart. Note the distance at which the patient is able to
read the top line. P Cephalohaematomas acquired during forceps deliveries are due to subperiosteal
6 Repeat the test, occluding the right eye. bleeding and usually resolve within a couple of weeks, but may persist longer.
7 Repeat the test, using both eyes. A Swelling over the occipitoparietal region of the skull is abnormal.
8 If the patient normally wears glasses, the test should be repeated with
P Caput succedaneum results from pressure over the occipitoparietal region
the patient wearing the glasses, and this should be so noted (corrected or
during a prolonged delivery. It usually resolves within 1 to 2 weeks after birth. FIGURE 21.17 Cephalohaematoma
uncorrected).
A Moulding can occur in conjunction with caput succedaneum.
P The parietal bone overrides the frontal bone as a result of induced pressure
CLINICAL REASONING during delivery. It should resolve within 1 week of delivery.

BLINDNESS VERSUS LEGAL BLINDNESS VERSUS VISION IMPAIRMENT Eyes

Be sure to describe visual loss correctly.
For example, many more people are legally blind than totally blind (i.e., having no light
perception). In Australia for example, ‘vision impaired’ is defined as visual acuity less than
6/18 but equal or better than 6/60 in the better eye with the best possible correction and/or a
visual field of less than 20º.
Blindness is defined as visual acuity with best possible correction of less than 3/60
and/or a corresponding visual field loss of less than 10º around central fixation or no light
perception.
Legal blindness in Australia is visual acuity after correction by suitable lenses as less
than 6/60 in both eyes OR constriction to within 10º of fixation in the better eye irrespective
of corrected visual acuity OR a combination of visual defects resulting in the same degree of
visual impairment as occurring in the above points (AIHW, 2009b).
N The patient who has a visual acuity of 6/6 is considered to have normal visual
acuity. This means that the patient is able to read the line indicated at 6 metres
in both eyes.
A The patient is unable to read the chart with an uncorrected visual acuity of 6/9 in
one eye, vision in both eyes is different by two lines or more, or acuity is absent.
P The patient may have a refractive error related to a difference in the refractive
power of the cornea. Figure 10.5A illustrates how light rays focus on the retina
in a normal eye. In myopia (near-sightedness), the axial length of the globe is
longer than normal, resulting in the image not being focused directly on the
retina; this condition can be changed with corrective lenses (see Figure 10.5B).
If the patient is amblyopic, no corrective lenses will improve vision. Amblyopia
is the permanent loss of visual acuity resulting from strabismus that was not
corrected in early childhood, or certain medical conditions (alcoholism,
General approach
1 From infancy until about 8 to 10 years, you should assess the eyes toward the
C. Assessing distance vision
end of the assessment, with the exception of testing vision, which should be
FIGURE 10.4 (Continued)
done first. Remember that the child’s attention span is short, and attentiveness
decreases the longer you evaluate. Children generally are not cooperative for
eyes, ears and throat assessments.
2 Place the young infant, preschool, school-age, or adolescent patient on the
examination table. The older infant or the toddler can be held by the caregiver.
3 Become proficient at performing fundoscopic assessments on adults prior to
assessing the paediatric patient.
Vision screening
General approach
1 The adult Snellen chart can be used on children as young as 6 years, provided
they are able to read the alphabet. The E chart is used for a patient over 3 years
of age or any child who cannot read the alphabet (Figure 21.18).
2 Test every 1 to 2 years through adolescence.
3 If the child resists wearing a cover patch over the eye, make a game out of FIGURE 21.18 Tumbling E chart
wearing the patch. For example, the young child could pretend to be a pirate
exploring new territory. Use your imagination to think of a fantasy situation.
Tumbling E chart
E 1 Ask the child to point an arm in the direction the E is pointing.
2 Observe for squinting.
N Vision is 6/12 from 2 to approximately 6 years of age, when it approaches the
normal 6/6 acuity. Refer the patient to an ophthalmologist if results are 6/12 or
greater in a child 3 years of age or 6/9 or greater in a child 6 years or older, or if
results vary by two or more lines between eyes even if in the passing range.

HEALTH PROMOTION CONSIDERATION

uraemia, diabetes mellitus).
CASE STUDY & HEALTH HISTORY
A P See Chapter 10.

E Examination N Normal findings A Abnormal findings P Pathophysiology

E Examination N Normal findings A Abnormal findings P Pathophysiology

Health promotion boxes provide you with Every physical assessment chapter contains a EYES 309

guidance to educate for healthy patient outcomes thorough Health history that details potential
patient profiles, common complaint descriptions,
and problem solving skills to make clinical decisions for the patient being assessed.

and to emphasise assessment of the whole If any abnormal data has been identified, the nurse ensures that this information

CHAP TER 10
is acted upon. This may include communicating to the medical officer, appropriate

person. important past health history information, as well

nursing personnel or allied health care professional. Documentation is required and
must include reference to the outcomes of the clinical decision(s) made (refer to

as relevant family and social histories that are

Chapter 3, which discusses in detail why documentation is so important and how
this may be undertaken in different health settings).
By using the following case study, you will be able to follow this process.

linked to that examination.

680 S P E C I F I C L I F E S PA N P O P U L AT I O N S

HEALTH PROMOTION THE PATIENT WITH SENILE CATARACT

CASE STUDY
UNIT 0 3

DECREASING LEG OEDEMA DURING PREGNANCY

Oedema of the lower extremities is common during This case study illustrates the application and the objective Mrs Joan Kade, a 76-year-old woman presents complaining of
late pregnancy. It is a result of hormone induced documentation of the eye assessment. gradually decreasing vision in both eyes.
sodium retention, and in late pregnancy can also
occur due to the enlarged uterus putting pressure
HEALTH HISTORY
on the pelvic veins and inferior vena cava, slowing
venous return. It may be especially noticeable after PATIENT PROFILE 76 year-old Caucasian female
prolonged periods of sitting or standing. To minimise
this, educate the woman to: FIGURE 20.4 Resting in the lateral position CHIEF COMPLAINT ‘Watching television and reading is not as easy as it used to be, even with my glasses.’ The patient
helps to alleviate pooling of blood in the complains she is finding it more difficult to carry out her daily activities and recognise people at a
+ rest on the left side to favour venous return,
lower extremities.
+ elevate the feet while sitting distance. She also complains of glare from oncoming headlights when driving at night.
+ avoid sitting for long periods – after 1 hour go for short walk (Figure 20.4).
HISTORY OF PRESENT ILLNESS The patient has noticed a gradual deterioration in vision over the last 12 months. Her symptoms
started with bilateral blurred distance vision. Consultations with her optometrist and new
Systolic pressure is not significantly different throughout pregnancy, whereas prescription glasses have improved but not resolved the problem. She also complains of increasing
the diastolic pressure may lower by 5 mmHg in the second trimester and then problems with glare, particularly in bright light or when driving at night which has been getting
rise to first-trimester levels after midpregnancy. The lower blood pressure in the progressively worse. The patient denies any pain or recent injury.
second trimester occurs as the body adjusts to the changes in the intravascular
volume and to the hormonal effects on the vascular walls. Monitoring of blood PAST HEALTH HISTORY
pressure during pregnancy is an important factor in determining complications
MEDICAL HISTORY Hypertension since age 40
such as pre-eclampsia. Many pregnant women also experience dependent
Mild hyperlipidaemia since age 60
oedema partially due to peripheral vasodilation and decreased vascular
resistance. This swelling is most commonly seen in the feet but can also occur in SURGICAL HISTORY Carpal tunnel surgery both wrists, age 69
the hands and face. Denies any previous ocular surgery

Abdomen ALLERGIES Morphine – severe nausea and vomiting

The growing uterus gradually displaces the abdominal contents, leading to
MEDICATIONS Hydrochlorothiazide 25 mg every morning
decreased tone and motility, decreased bowel sounds, and an increased emptying
Atorvastatin calcium 10 mg every day
time for the stomach and intestines (Figure 20.5). These changes often bring about
increased flatulence and constipation and can contribute to the development of Denies using any ocular medications
Stomach
compressed haemorrhoids. COMMUNICABLE DISEASES Denies
Liver
pushed up
Indigestion (heartburn) is often experienced by the pregnant woman due to
the relaxation of the oesophageal sphincter, subsequent reflux and slowed gastric INJURIES AND ACCIDENTS Denies
emptying. Nausea and vomiting are common early in pregnancy and may even lead

NURSING CHECKLIST
SPECIAL NEEDS Wears glasses for distance and near correction (bifocal lenses)
to weight loss in the first trimester.
294 P H Y S I C A L E X A M I N AT I O N
Increased emptying time and chemical changes in bile composition can put the BLOOD TRANSFUSIONS Denies
pregnant woman at increased risk for cholelithiasis, the presence or formation of
bilestones or calculi in the gall bladder or duct, and oestrogen may augment any CHILDHOOD ILLNESSES Chickenpox, age 5, without sequelae
Bladder largely in tendency to develop
+ Rosenbaum cholestasis
near vision (arrest
pocket of bilecard
screening excretion). Measles, age 7, without sequelae
pelvis therefore
+ Some
Visionwomen
occluderwill also experience a separation of the rectus muscle of

Review and revise useful lists of important

frequent urination IMMUNISATIONS All childhood vaccines completed; annual flu vaccine – not had this year’s yet
the abdominal wall, known as diastasis recti, which may be asymptomatic
UNIT 0 2

+ Cotton-tipped applicator
FIGURE 20.5 Crowding of abdominal and noticed only as a vertical protrusion midline. Diastasis requires no medical FAMILY HEALTH HISTORY No significant family history noted. No family history of eye disease, including glaucoma, retinal
contents by gravid uterus intervention. detachment and macular degeneration.
concepts in nursing, client teaching and the
IMPLEMENTATION
CLINICAL REASONING
Express
Go to CourseMate Express Study Guide
Implementation of the physical examination requires you to consider your scope of
SOCIAL HISTORY

nursing process with Nursing Checklist boxes.

practice as well. In this section, depending on your context you may be performing Married with 5 children
to watch an animation of the conduction
foundation
HYPEREMESIS assessment with aspects of advanced assessment if you are practising in
GRAVIDARUM
system (heart)
a specialised
Severe nauseaarea.
and vomiting in pregnancy is known as hyperemesis gravidarum. It is ALCOHOL USE Denies
Assessmentwithofrapid
the eyes should be carried out in an orderly fashion, moving from the
associated
extraocular structures
and may require
weight loss, malnutrition,
to the intraocular
hospitalisation.
dehydration
This couldstructures.
and electrolyte
Thematernal
have potential eye assessment
abnormalities
usually
and neonatal includes
adverse
»»
A Case study is included in each of the
testing of associated
consequences; cranial
therefore nerves
closely and can
monitor womenbe performed in the following
who are experiencing order:
excessive nausea
1 and
Determination of visual
vomiting, and refer acuity
as necessary.
2 Determination of visual fields

Express
Go to CourseMate Express Study Guide
3 Assessment of the external eye and lacrimal apparatus
4 Evaluation of extraocular muscle function
Please see online for advanced assessment techniques.
examination chapters to apply critical thinking
for advanced assessment techniques.

NURSING CHECKLIST
skills to real-life scenarios. These case studies
GENERAL APPROACH TO ASSESSMENT OF THE EYES
1 Greet the patient and explain the assessment techniques that you will be using.
use the structure of that chapter’s overall health
2 Use a quiet room that will be free from interruptions.
3 Ensure that the light in the room provides sufficient brightness to allow adequate
observation of the patient.
history and provide detailed patient profiles, then
4 Place the patient in an upright sitting position on the examination table.
5 Visualise the underlying structures during the assessment process to allow adequate
description of findings.
use the evaluation and clinical reasoning cycle
6 Always compare right and left eyes.
7 Use a systematic approach that is followed consistently each time the assessment is to demonstrate the process of approaching the
case.(See Chapter 1 for further explanation of the
performed.

Visual acuity
The assessment of visual acuity (cranial nerve II) is a simple,
noninvasive procedure that is carried out with the use of evaluation and clinical reasoning cycle.)
a Snellen chart and an occluder to cover the patient’s eye.
The Snellen chart contains letters of various sizes with
standardised visual acuity numbers at the end of each line
of letters (Figure 10.4A). The numbers indicate the degree
of visual acuity when the patient is able to read that line
of letters at a distance of 6 metres. For instance, a patient
who has a visual acuity of 6/24 can read at 6 metres what a
patient with 6/6 vision is able to read at 24 metres.
It is sometimes difficult to have a space of 6 metres)
available for the placement of the chart, but the distance can

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352 P H Y S I C A L E X A M I N AT I O N
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REVIEW QUESTIONS
For answers to these questions, see Answer section at the end of
the book.
1 Risk factors for oral cancer are tobacco use, excessive alcohol
use, and which of the following?
a Female gender
b Age ,55 years
c History of leukoplakia
d Aphthous ulcers
2 Acute otitis externa is a common infection among children and
adults. Which describes a typical examination finding of otitis
externa?
a Thickening and clouding of the tympanic membrane
b Erythema and oedema of the external auditory canal
c Bubbles and air-fluid levels are visible
d Retraction and immobility of tympanic membrane
3 Risk factors for hearing loss are noise exposure, ageing, and
which of the following:
a Male gender
b Amphetamine use
c Excessive alcohol use
d Recurrent ear infections
4 During examination of the nasal mucosa, you note that the
nasal mucosa is pale and oedematous with clear, watery
discharge. These findings are most consistent with:
a The common cold
b Acute sinusitis
c Allergies or hay fever
d Presence of cerebrospinal fluid
5 During internal inspection of the nose, you note that the
nasal mucosa is inflamed and friable and there is a septal
GUIDE TO THE TE X T xxi
E Examination
A Abnormal findings
Express N Normal findings
P Pathophysiology
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E A R S , N O S E , M O U T H A N D T H R O AT 353
9 During your assessment of a 17-year-old male, you note that 10 During examination of your patient’s lips, you note clusters of
his breath smells of acetone and has a ‘fruity’ odour. Acetone vesicles on erythematous bases with serous fluid. They are
C H A P T E R 11
breath is most commonly associated with the following painful. This finding is consistent with which of the following
condition: conditions?
a Foetor hepaticus a Herpes simplex lesions
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b Uraemia b Aphthous ulcers
Express c Diabetic ketoacidosis c Basal cell carcinoma
d Halitosis d Chancre
WEBSITES
Australasian Sleep Association: http://www.sleep.org.au Narcolepsy and Overwhelming Daytime Sleep Society of Australia: http://
website and Search Me! nursing
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Australian and New Zealand Academy of Periodontists: www.nodss.org.au/sleep_apnoeas.html
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Australian Dental Association Incorporated: http://www.ada New Zealand Dental Association: http://www.nzda.org.nz/pub/
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Deaf Aotearoa NZ – National Office: www.deaf.co.nz The Hearing House: http://www.hearinghouse.co.nz
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REFERENCES
opportunity to test your knowledge
perforation. These findings are most consistent with which of Access Economics (2006). Listen Hear! The economic impact and cost of Hearing Association of New Zealand. (n.d.a) HEAR HERE! Hearing loss at a
the following? Select all that apply. hearing loss in Australia. Retrieved 1 November 2011 from https://www glance. Information card 2: Losing your hearing. Retrieved 1 June 2011
a Presence of a foreign body .audiology.asn.au/public/1/files/Publications/ListenHearFinal.pdf from www.hearing.org.nz
b Nasal inhalation of cocaine AIHW, (2011). Allergic Rhinitis (‘hay fever’) in Australia. Cat. No. ACM 23. Hearing Association of New Zealand. (n.d.b) HEAR HERE! Hearing loss at a
and consolidate your learning.
c Allergies or hay fever Canberra: AIHW. Viewed 2.8.14 on http://www.aihw.gov.au/publication glance. Information card 3: Other hearing conditions. Retrieved 1 June
d Bacterial sinusitis -detail/?id=10737420595 2011 from www.hearing.org.nz
Auckland Allergy Clinic (n.d.) Allergic rhinitis. Retrieved 2 November 2011 Hill, S. (2012) Ear disease in Indigenous Australians: a literature review.
e Overdose of decongestant nasal spray
from http://www.allergyclinic.co.nz/rhinitis.aspx Australian Medical Student Journal, 3 (1): 1–5.
f Nasal inhalation of amphetamines
Answers to review questions can be
Australian Tinnitus Association. (n.d.). Tinnitus – what is it? Retrieved Meniere’s Australia. (n.d.) What is Meniere’s disease. Retrieved 2 November 2011
6 The paranasal sinuses are air-filled cavities lined with mucous
2 November 2011 from http://www.tinnitus.asn.au/ from http://www.menieres.org.au/menieres-disease.php
membranes that lighten the weight of the skull and add Burns, J. & Thomson, N. (2013). Review of ear health and hearing O’Donoghue, G. M., Narula, A. A. & Bates, G. J. (2000). Clinical ENT:
resonance to the quality of the voice. The sinuses that can be among Indigenous Australians. Retrieved 2.8.14 from http://www An illustrated textbook. San Diego, CA: Singular.
found at the back of the book
assessed on physical examination include: .healthinfonet.ecu.edu.au/other-health-conditions/ear/reviews Southern Cross Healthcare Group, (2013). Hay fever (allergic
a Frontal and sphenoid sinuses /our-review rhinitis). Accessed 2 August 2014 from https://www.southerncross.
b Frontal and ethmoid sinuses DermNet NZ. (2011). Oral cancer. Retrieved 2 November 2011 from co.nz/AboutTheGroup/HealthResources/MedicalLibrary/tabid/178/vw/1
c Maxillary and frontal sinuses http://dermnetnz.org/site-age-specific/oral-cancer.html /ItemID/167/Hay-fever-allergic-rhinitis.aspx
d Maxillary and sphenoid sinuses
7 During your assessment of a 68-year-old male, you note that
• W
 ebsites and References are listed
his breath smells musty. The musty smell of breath is most BIBLIOGRAPHY
commonly associated with which of the following conditions? Collins, R. D. (2008). Differential diagnosis in primary care (4th ed.). Hayden, M. L. & Womack, C. R. (2007). Caring for patients with allergic
a Foetor hepaticus Philadelphia: Lippincott Williams & Wilkins. rhinitis. Journal of the American Academy of Nurse Practitioners,
b Pseudomonas infection Daugherty, J. (2007). The latest buzz on tinnitus. The Nurse Practitioner: The 19 (6), 290–298.
for further reading.
c Diabetic ketoacidosis American Journal of Primary Healthcare, 32 (10), 42–47. Kamienski, M. (2007). When sore throat gets serious: Three different
d Halitosis Giles, M. & Asher, I. (1991). Prevalence and natural history of otitis media cases, three very different causes. American Journal of Nursing,
8 During examination of your patient’s throat, you note that the patient with perforation in M ori school children. Journal of Laryngology & 107(10), 35–38.
has difficulty opening her mouth and has 31 swelling of the right Otology, 105 (4), 257–260. Labuguen, R. (2006). Initial evaluation of vertigo. American Family Physician,
tonsil with exudate. These findings are commonly associated with: Goolsby, M. & Grubbs, L. (2006). Advanced assessment: Interpreting 73 (2), 244–251, 254.
findings and formulating differential diagnosis. Philadelphia: F. A. Davis. Lowinger, D. (n.d.). Ear infection and blocked ear. Accessed 2 August 2014
a Infectious mononucleosis
Hart, A. (2007). An evidence-based approach to the diagnosis and from entcare.com.au
b Peritonsillar abscess
management of acute respiratory infections. The Journal for Nurse McCarter, D., Courtney, U. & Pollart, S. (2007). Cerumen impaction.
c Viral pharyngitis
Practitioners, 3 (9), 607–611. American Family Physician, 75 (10), 1523–1528, 1530.
d Diphtheria
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C

ORD

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ONCUSSION OF THE

908

Definition and morbid anatomy,

908

Diagnosis,

909

Symptoms,

908

Mental state,

908

Pulse and temperature in,

909

Pupils, state of,

909

Treatment, bromide of potassium, heat and cold, use,

911

912

of reaction,

911

Stimulants, use of,

911

RAIN

,A
TROPHY AND

YPERTROPHY OF

993

Atrophy

during childhood,

993

Causes, symptoms, and treatment,

994

of the fully-developed,

994

Causes, morbid anatomy, and symptoms,

995
 Treatment,

996

Hypertrophy

996

Course, diagnosis, prognosis, symptoms, and treatment,

998

Etiology and morbid anatomy,

997

Brain and its envelopes, tumors of,

1028

and membranes, changes in, in acute simple meningitis,

719
 in alcoholism,

617

in cerebral meningeal hemorrhage,

713

714

in external pachymeningitis,

705

in general paralysis of the insane,

196

in hæmatoma of the dura mater,

708

in tubercular meningitis,

730-732
 and spinal cord, diseases of membranes of,

703

lesions of, in insanity,

121

microcephalic, size of,

139

softening of,

918

989

in children,

990

state of, in chronic hydrocephalus,

944
 syphilis of,

1003

Brain-cortex, syphilis of (see

Syphilitic Affections of Nerve-centres

).

Brain, gross appearances of, in brain tumors,

1050

Brain-tire, treatment of,

358

Breathing, hysterical,

245
Bright's disease as a cause of intracranial hemorrhage and apoplexy,

930

Bromate of potassium, use of, in epilepsy,

501

Bromide of nickel, use of, in epilepsy,

500

Bromide of potassium, use of, in acute simple meningitis,

721

in acute spinal meningitis,

752
 in chronic cerebral meningitis,

722

in concussion of spine,

911

in hæmatoma of the dura mater,

710

in hystero-epilepsy,

313

in insanity,

136

in melancholia,

160

in migraine,

1232
 in tetanus,

558

in tumors of the brain,

1068

Bromides, use of, in alcoholism,

642

645

646

in cerebral anæmia,

789

hyperæmia,

773
 in chorea,

455

in epilepsy,

499

500

in insomnia,

380

381

382

in migraine,

414

415
 in spinal sclerosis,

905

906

in the opium habit,

674

676

in tubercular meningitis,

736

in vertigo,

427

Bronchi, disorders and lesions of, in chronic alcoholism,

608
 C.

Cachexia, alcoholic, characters,

616

Caffeine, use of, in migraine,

1232

in neuralgia,

1229

Caisson disease, a form of spinal hyperæmia,

804
Calabar bean, use of, in tetanus,

557

in tetanus neonatorum,

565

Cancer of the brain,

1049

Cannabis indica, habitual addiction to,

667

use of, in alcoholism,

645

in brain tumors,

1068
 in cerebral anæmia,

788

789

in migraine,

413

415

1232

in the opium habit,

676

in tetanus,

557

Capillary cerebral embolism,

979

Capsicum, use of, in alcoholism,

642

Carbuncles, as a cause of thrombosis of cerebral veins and sinuses,

985

Caries of teeth, as a cause of neuralgia,

1229

1233

Caries of temporal bone, as a cause of tubercular meningitis,

725
Carotids, ligation of, as a cause of cerebral anæmia,

777

ATALEPSY

314

Definition and synonyms,

314

Diagnosis,

334

from apoplexy and intoxication,

336

from epilepsy,
335

from simulation,

337

from tetanus,

336

Etiology,

315

Age, influence on causation,

315

Imitation, influence on causation,

319

Reflex irritation,

318
 Sex and puberty,

318

History,

315

Pathology and duration,

334

Prognosis,

337

Symptoms,

320

of cataleptoid phenomena in the insane,

327

of hypnotic catalepsy,

322
 of unilateral catalepsy,

324

Onset of seizures, mode of,

320

Pulse, respiration, and temperature in,

321

Reflex irritability, changes in,

321

Sensation, disturbances of,

321

Wax-like flexibility in,

321

337