Health & Physical Assessment, Head-to-Toe Exam, and Documentation | Chapter 13 from Saunders Comprehensive Review for the NCLEX-PN Examination (7th Edition)

Health & Physical Assessment, Head-to-Toe Exam, and Documentation | Chapter 13 from Saunders Comprehensive Review for the NCLEX-PN Examination (7th Edition)

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Welcome to Chapter 13 of the Saunders Comprehensive Review for the NCLEX-PN Examination (7th Edition) by Linda Anne Silvestri and Angela E. Silvestri. This comprehensive chapter is your go-to guide for conducting holistic health and physical assessments, integrating subjective and objective data, and documenting findings with accuracy. It empowers practical nursing students with the knowledge and skills to gather critical data for effective clinical care and NCLEX-PN success.

Watch the video summary below, and subscribe to Last Minute Lecture for detailed breakdowns of every NCLEX-PN chapter:

Health History and Mental Status Assessment

  • Health History: Collect chief complaint, present illness, past medical/surgical history, family/social history, and screen for domestic violence.
  • Mental Status Exam: Assess appearance, behavior, cognition, mood, affect, and thought processes.
  • Establish a comfortable, private setting and use culturally competent communication to build trust.

Physical Exam Techniques: Inspection, Palpation, Percussion, Auscultation

  • Use inspection for observation; palpation for touch and texture; percussion for sound and density; and auscultation for listening to heart, lung, and bowel sounds.
  • Always follow a head-to-toe, organized approach for consistency and safety.

Systematic Head-to-Toe Assessment

  • Vital Signs & Pain: Measure temperature, pulse, respirations, BP, SpO2, and use pain scales. Assess BMI.
  • Integumentary: Inspect turgor, color, capillary refill, lesions, and note differences in dark skin.
  • HEENT (Head, Eyes, Ears, Nose, Throat): Cranial nerve checks, visual acuity, oral inspection, otoscopic exam, and thyroid palpation.
  • Respiratory: Evaluate breath sounds, percussion, tactile fremitus, and note adventitious sounds.
  • Cardiovascular: Identify S1, S2, murmurs, pulses, cap refill, edema, and auscultation landmarks.
  • Abdominal: Inspect contour, auscultate bowel sounds, percuss for tympany/dullness, and palpate for tenderness or masses.
  • Musculoskeletal: Assess posture, ROM, joint tenderness, muscle tone, and strength grading.
  • Neurological: Evaluate cranial nerves, level of consciousness, coordination, reflexes (Babinski, Brudzinski, Kernig), and perform Romberg test.
  • Breast & Reproductive: Teach breast and testicular self-exam; assess for lesions, discharge, or abnormal findings.
  • Rectal & Prostate: Inspect for hemorrhoids, perform palpation, and screen for cancer signs.

Documentation, Teaching, and Safety Protocols

  • Document findings promptly, clearly, and legally—use accepted medical terminology and avoid subjective language.
  • Teach clients about self-exams, abnormal findings, and the importance of regular assessment for early detection.
  • Always follow infection control and safety protocols with assessment tools and during invasive procedures.

Cultural Competence and Focused Assessment

  • Be aware of normal variations related to age, ethnicity, and gender in all systems.
  • Adapt your approach for language barriers, cultural beliefs, and privacy needs.

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Conclusion: Confident, Culturally Sensitive Nursing Assessment

Chapter 13 of Saunders Comprehensive Review for the NCLEX-PN Examination (7th Edition) equips you with a systematic approach to health and physical assessment, from mental status to head-to-toe exam. With an emphasis on documentation, teaching, and cultural sensitivity, you’ll be ready for both NCLEX-PN and real-world client care.

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Explore the full YouTube playlist for Saunders Comprehensive Review for the NCLEX-PN Examination (7th Edition) here: Complete Playlist

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