Assessing a client’s health status is a major component of nursing care and has two aspects: (1) the nursing health history discussed in Chapter 10 oo010 \infty 0 and (2) the physical examination discussed in this chapter. A physical examination can be any of several types: (1) a comprehensive initial assessment (e.g., when a client is admitted to a healthcare agency), (2) a focused examination of a body system (e.g., the cardiovascular system) or body area (e.g., the lungs, when difficulty with breathing is observed), or (3) a functional assessment that examines one or more aspects of the client’s abilities (e.g., nutrition and metabolism, elimination, or sleep and rest). Note: Some nurses consider assessment to be the broad term used in applying the nursing process to health data and examination to be the physical process used to gather the data. In this text, the terms assessment and examination are sometimes used interchangeably-both referring to a critical investigation and evaluation of client status. 評估客戶的健康狀況是護理護理的重要組成部分，具有兩個方面：（1）在第 10 oo010 \infty 0 章中討論的護理健康歷史，以及（2）在本章中討論的身體檢查。身體檢查可以是幾種類型中的任何一種：（1）全面的初步評估（例如，當客戶被接納到醫療機構時），（2）針對某一身體系統（例如，心血管系統）或身體區域（例如，當觀察到呼吸困難時的肺部）進行的重點檢查，或（3）功能評估，檢查客戶能力的某一或多個方面（例如，營養和新陳代謝、排泄或睡眠和休息）。注意：一些護士認為評估是應用護理過程於健康數據的廣泛術語，而檢查則是用於收集數據的具體過程。在本文本中，評估和檢查這兩個術語有時可以互換使用，均指對客戶狀況的關鍵調查和評估。
As described in Chapter 10 oo10 \infty, assessing is considered the first phase or step of the nursing process. Performing the health history and physical examination is part of assessing, which includes data collection, organization, validation, and documentation. The new nurse learns the detailed steps of assessment for each system and then can select only those aspects of the assessment needed in a particular practice situation. 如第 10 oo10 \infty 章所述，評估被視為護理過程的第一階段或步驟。進行健康歷史和身體檢查是評估的一部分，包括數據收集、組織、驗證和文檔記錄。新護士學習每個系統的詳細評估步驟，然後可以根據特定的實踐情況選擇僅需的評估方面。
Physical Health Assessment 身體健康評估
These are some purposes of the physical examination: 這些是身體檢查的一些目的：
To obtain baseline data about the client’s functional abilities 獲取有關客戶功能能力的基線數據
To supplement, confirm, or refute data obtained in the nursing history 補充、確認或駁斥在護理歷史中獲得的數據
To obtain data that will help establish nursing diagnoses and plans of care 獲取有助於建立護理診斷和護理計劃的數據
To evaluate the physiologic outcomes of healthcare and thus the progress of a client’s health problem 評估醫療的生理結果以及客戶健康問題的進展
To make clinical judgments about a client’s health status 對客戶的健康狀況做出臨床判斷
To identify areas for health promotion and disease prevention. 識別健康促進和疾病預防的領域。
Assessments are conducted using a framework or approach to gathering the data. The most common framework for a comprehensive assessment is the head-to-toe assessment. However, the procedure can vary according to the age of the individual, the health status of the individual, the preferences of the nurse, the location of the examination, and the agency’s priorities and procedures. The order of head-to-toe assessment is given in Box 29.1. Regardless of the procedure used, the client’s energy and time need to be considered. The health assessment is therefore conducted in a systematic and efficient manner that results in the fewest position changes for the client. 評估是使用一個框架或方法來收集數據。最常見的全面評估框架是從頭到腳的評估。然而，該程序可能會根據個體的年齡、健康狀況、護理人員的偏好、檢查地點以及機構的優先事項和程序而有所不同。從頭到腳評估的順序見於框 29.1。無論使用何種程序，都需要考慮客戶的精力和時間。因此，健康評估以系統和高效的方式進行，從而使客戶的體位變化最少。
With hospitalized clients, a quick assessment is done at the beginning of the shift to use as a baseline for comparing with later data. This shift assessment is focused on immediate needs and problems and includes evaluating the status of environmental factors such as tubes, devices, and dressings. One possible structure for this shift assessment is the following: 對於住院病人，班次開始時會進行快速評估，以作為與後續數據比較的基準。這次班次評估專注於即時需求和問題，並包括評估環境因素的狀態，例如管道、設備和敷料。這次班次評估的一種可能結構如下：
Observe 觀察
a. Level of consciousness 意識水平
b. Skin color b. 肤色
c. Respiratory effort 呼吸努力
BOX 29.1 Head-to-Toe Framework BOX 29.1 頭到腳框架
General survey 一般調查
Vital signs 生命徵象
Head 頭部
Hair, scalp, face 頭髮、頭皮、臉部
Eyes and vision 眼睛與視力
Ears and hearing 耳朵和聽力
Nose 鼻子
Mouth and oropharynx 口腔和口咽
Neck 頸部
Muscles 肌肉
Lymph nodes 淋巴結
Trachea 氣管
Thyroid gland 甲狀腺
Carotid arteries 頸動脈
Neck veins 頸靜脈
Upper extremities 上肢
Skin and nails 皮膚和指甲
Muscle strength and tone 肌肉力量和緊實度
Joint range of motion 關節活動範圍
Brachial and radial pulses 臂動脈和橈動脈脈搏
Sensation 感覺
Chest and back 胸部和背部
Skin 皮膚
Thorax shape and size 胸廓的形狀和大小
Lungs 肺部
Heart 心臟
Spinal column 脊柱
Breasts and axillae 乳房和腋下
Abdomen 腹部
Skin 皮膚
Abdominal sounds 腹部聲音
Femoral pulses 股動脈脈搏
External genitals 外生殖器
Anus 肛門
Lower extremities 下肢
Skin and toenails 皮膚和腳趾甲
Gait and balance 步態與平衡
Joint range of motion 關節活動範圍
Popliteal, posterior tibial, and dorsalis pedis pulses 膕窩、後脛動脈和足背動脈脈搏
Berman, A., Snyder, S., Frandsen, G., Berman, A., Snyder, S., Frandsen, G., Berman, A., Snyder, S., & Frandsen, G. (2021). Kozier and erb’s fundamentals of nursing, global edition. Pearson Education, Limited Created from polyu-ebooks on 2022-09-10 00:25:54. 伯曼，A.，斯奈德，S.，弗蘭登，G.，伯曼，A.，斯奈德，S.，弗蘭登，G.，伯曼，A.，斯奈德，S.，& 弗蘭登，G.（2021）。科茲爾和厄爾布的護理基本原則，全球版。培生教育有限公司。於 2022 年 9 月 10 日 00:25:54 從 poly-ebook 創建。
d. Nutritional status d. 營養狀況
e. Body position (e.g., does the client appear in pain?) e. 身體姿勢（例如，客戶看起來是否有痛苦？）
f. Speech f. 演講
g. Hygiene and grooming g. 衛生與美容
2. Check vital signs including pain. Include pedal pulses. 2. 檢查生命徵象，包括疼痛。包括足部脈搏。
3. Auscultate lungs and apical pulse 3. 聽診肺部和心尖脈搏
4. Check capillary refill and peripheral edema 4. 檢查毛細血管再充填和周邊水腫
5. Auscultate bowel sounds 5. 聆聽腸音
6. Observe skin turgor and surfaces for lesions (anterior and posterior, especially bony prominences) 6. 觀察皮膚的緊實度和表面是否有病變（前面和後面，特別是骨突起處）
7. Observe mobility (all four extremities, weight bearing) 7. 觀察活動能力（四肢，承重）
8. Examine drains, catheters, wound dressings or tubes: location, patency, and description of drainage, if any. 8. 檢查排水管、導尿管、傷口敷料或管道：位置、通暢性及排水情況的描述（如有）。
Frequently, nurses assess a specific body area instead of the entire body. These specific assessments are made in relation to client complaints, the nurse’s own observation of problems, the client’s presenting problem, nursing interventions provided, and medical therapies. Examples of these situations and assessments are provided in Table 29.1. 護理人員經常評估特定的身體部位，而不是整個身體。這些特定的評估是根據客戶的抱怨、護理人員對問題的觀察、客戶所呈現的問題、提供的護理介入以及醫療療法進行的。這些情況和評估的例子在表 29.1 中提供。
Nurses use national guidelines and evidence-based practice to focus health assessment on specific conditions. The nurse’s judgment is key when the evidence is inconclusive or conflicting. For example, when screening for cancer, nurses should remember the American Cancer Society’s guidelines for early detection (Box 29.2). However, whereas those guidelines call for mammography every year between ages 45 to 54, the U.S. Preventive Services Task Force (2016) recommends breast mammography only every 2 years for females ages 50 to 74 and none thereafter. 護士使用國家指導方針和基於證據的實踐，將健康評估集中在特定的病症上。當證據不確定或相互矛盾時，護士的判斷至關重要。例如，在進行癌症篩檢時，護士應該記住美國癌症協會的早期檢測指導方針（見框 29.2）。然而，雖然這些指導方針要求在 45 至 54 歲之間每年進行一次乳房攝影，但美國預防服務工作組（2016 年）建議 50 至 74 歲的女性每兩年進行一次乳房攝影，之後則不再進行。
Preparing the Client 準備客戶
Most people need an explanation of the physical examination. Often clients are anxious about what the nurse will find. They can be reassured during the examination by explanations at each step. The nurse should explain when and where the examination will take place, why it is important, and what will happen. Instruct the client that all information gathered and documented during the assessment is kept confidential under the Health Insurance Portability and Accountability Act (HIPAA). This means that only those who legitimately need to know the client’s information will have access to it. 大多數人需要對身體檢查的解釋。客戶通常對護士會發現什麼感到焦慮。在檢查過程中，護士可以通過每一步的解釋來安撫他們。護士應該解釋檢查將在何時何地進行、為什麼這很重要以及會發生什麼。告知客戶，在評估過程中收集和記錄的所有信息都根據《健康保險可攜性和責任法案》（HIPAA）保持機密。這意味著只有那些真正需要知道客戶信息的人才能訪問這些信息。
Health examinations are usually painless. Determine in advance any positions that are contraindicated for a particular 健康檢查通常是無痛的。事先確定對特定情況禁忌的任何姿勢。
Assess level of consciousness using Glasgow Coma Scale (see Table 29.10 later in this
chapter); assess pupils for reaction to light and accommodation; assess vital signs.
Assess level of consciousness using Glasgow Coma Scale (see Table 29.10 later in this
chapter); assess pupils for reaction to light and accommodation; assess vital signs.| Assess level of consciousness using Glasgow Coma Scale (see Table 29.10 later in this |
| :--- |
| chapter); assess pupils for reaction to light and accommodation; assess vital signs. |
客戶剛剛在小腿上打了石膏。
The client has just had a cast applied to
the lower leg.
The client has just had a cast applied to
the lower leg.| The client has just had a cast applied to |
| :--- |
| the lower leg. |
Assess peripheral perfusion of toes, capillary blanch test, pedal pulse if able, and vital signs. 評估腳趾的周邊灌注、毛細血管變白測試、如果能夠則檢查足部脈搏和生命體徵。
The client's fluid intake is minimal. 客戶的液體攝取量很少。
Assess tissue turgor, fluid intake and output, and vital signs. 評估組織膨脹度、液體攝入和排出以及生命徵象。
Situation Physical Assessment
Client complains of abdominal pain. Inspect, auscultate, percuss, and palpate the abdomen; assess vital signs.
Client is admitted with a head injury. "Assess level of consciousness using Glasgow Coma Scale (see Table 29.10 later in this
chapter); assess pupils for reaction to light and accommodation; assess vital signs."
"The client has just had a cast applied to
the lower leg." Assess peripheral perfusion of toes, capillary blanch test, pedal pulse if able, and vital signs.
The client's fluid intake is minimal. Assess tissue turgor, fluid intake and output, and vital signs.| Situation | Physical Assessment |
| :---: | :---: |
| Client complains of abdominal pain. | Inspect, auscultate, percuss, and palpate the abdomen; assess vital signs. |
| Client is admitted with a head injury. | Assess level of consciousness using Glasgow Coma Scale (see Table 29.10 later in this <br> chapter); assess pupils for reaction to light and accommodation; assess vital signs. |
| The client has just had a cast applied to <br> the lower leg. | Assess peripheral perfusion of toes, capillary blanch test, pedal pulse if able, and vital signs. |
| The client's fluid intake is minimal. | Assess tissue turgor, fluid intake and output, and vital signs. |
BOX 29.2 Cancer Screening Guidelines for Average-Risk, Asymptomatic People BOX 29.2 平均風險、無症狀人群的癌症篩檢指導方針
COLORECTAL CANCER (MALES AND FEMALES) 結腸直腸癌（男性和女性）
Beginning at age 45 and until age 75, one of the following: 從 45 歲開始直到 75 歲，以下任一項：
Fecal occult blood test or 糞便潛血測試或
Fecal immunochemical test annually or 糞便免疫化學檢測每年一次或
Stool DNA test every 3 years or 每三年進行一次糞便 DNA 檢測或
Flexible sigmoidoscopy every 5 years or 每五年進行一次靈活的乙狀結腸鏡檢查或
Colonoscopy every 10 years or 每十年進行一次結腸鏡檢查或
Computerized tomography colonography every 5 years. 每五年進行一次電腦斷層結腸攝影。
At age 76 to 85 , screening should be individualized based on patient preference, health status, and prior screenings. Screening after age 85 is discouraged. 在 76 至 85 歲之間，篩檢應根據患者的偏好、健康狀況和先前的篩檢結果進行個別化。85 歲後不建議進行篩檢。
BREAST CANCER (FEMALES) 乳腺癌（女性）
Beginning in their early 20s, females should be told about the benefits and limitations of breast self-examination (BSE) and the importance of reporting breast symptoms to a health professional. Those who choose to perform BSE should receive instruction and have their technique reviewed regularly. Females may perform BSE regularly, occasionally, or not at all. 從二十出頭開始，女性應該了解乳房自我檢查（BSE）的好處和限制，以及向健康專業人士報告乳房症狀的重要性。選擇進行 BSE 的女性應接受指導，並定期檢查她們的技術。女性可以定期、偶爾或根本不進行 BSE。
Females should have the opportunity to begin annual screening between ages 40 and 44. 女性應該有機會在 40 至 44 歲之間開始每年的篩檢。
Females with an average risk of breast cancer should undergo regular screening mammography starting at age 45. 具有平均乳腺癌風險的女性應從 45 歲開始定期接受乳房攝影檢查。
Females ages 45 to 54 should be screened annually. 45 至 54 歲的女性應每年進行篩檢。
Females aged 55 or older should transition to biennial screening or can continue screening annually. 55 歲或以上的女性應該轉為每兩年篩檢，或可以繼續每年篩檢。
Females should continue screening mammography as long as their overall health is good and they have a life expectancy of 10 or more years. 女性應該繼續進行乳房攝影檢查，只要她們的整體健康良好，且預期壽命為 10 年或以上。
CERVICAL AND UTERINE CANCER (FEMALES) 宮頸癌和子宮癌（女性）
For females ages 21 to 29, screening every 3 years with Pap tests. 對於 21 至 29 歲的女性，每 3 年進行一次子宮頸抹片檢查。
For females ages 30-65, screening every 5 years with both HPV test and the Pap test, or every 3 years with the Pap test alone. 對於 30 至 65 歲的女性，每 5 年進行一次 HPV 檢測和巴氏檢查，或每 3 年僅進行巴氏檢查。
Females ages 65 and older who have had 3 or more consecutive negative Pap tests or 2 or more consecutive negative HPV and Pap tests in the last 10 years, the most recent test in the last 5 years, and females who have had a total hysterectomy should stop cervical cancer screening. 65 歲及以上的女性，如果在過去 10 年內有 3 次或以上連續的陰道抹片檢查結果為陰性，或 2 次或以上連續的 HPV 和陰道抹片檢查結果為陰性，且最近一次檢查是在過去 5 年內，或已經接受全子宮切除手術的女性，應停止進行子宮頸癌篩檢。
PROSTATE CANCER (MALES) 前列腺癌（男性）
For men aged 50 and older who have at least a 10-year life expectancy, discussion with the primary care provider about the benefits, risks, and uncertainties associated with prostate cancer screening. 對於年齡在 50 歲及以上且預期壽命至少為 10 年的男性，應與主要醫療提供者討論前列腺癌篩檢的好處、風險和不確定性。
From “A Blueprint for Cancer Screening and Early Detection: Advancing Screening’s Contribution to Cancer Control” by R. C. Wender, O. W. Brawley, S. A. Fedewa, T. Gansler, & R. A. Smith, 2019, CA: A Cancer Journal for Clinicians, 69, pp. 50-79. doi:10.3322/caac. 21550 來自 R. C. Wender、O. W. Brawley、S. A. Fedewa、T. Gansler 和 R. A. Smith 於 2019 年發表的《癌症篩檢與早期發現藍圖：推進篩檢對癌症控制的貢獻》，刊於《CA: 臨床醫師的癌症期刊》，第 69 卷，第 50-79 頁。doi:10.3322/caac.21550
client. The nurse assists the client as needed to undress and put on a gown. Clients should empty their bladders before the examination. Doing so helps them feel more relaxed and facilitates palpation of the abdomen and pubic area. 客戶。護士根據需要協助客戶脫衣服並穿上醫療袍。客戶在檢查前應排空膀胱。這樣可以幫助他們感到更放鬆，並促進腹部和恥骨區域的觸診。
When assessing adults it is important to recognize that people of the same age differ markedly. Box 29.3 provides special considerations for assessing adults, especially older adults. 在評估成年人時，重要的是要認識到同齡人之間存在顯著差異。框 29.3 提供了評估成年人的特殊考量，特別是對於老年人。
The sequence of the assessment differs with children and adults. With children, always proceed from the least invasive or uncomfortable aspect of the exam to the more invasive. Examination of the head and neck, heart and lungs, and range of motion can be done early in the process, with the ears, mouth, abdomen, and genitals being left for the end of the exam. 評估的順序在兒童和成人之間有所不同。對於兒童，應始終從檢查中最不具侵入性或不適感的部分開始，然後再進入更具侵入性的檢查。頭部和頸部、心臟和肺部的檢查，以及活動範圍的評估可以在過程早期進行，而耳朵、口腔、腹部和生殖器的檢查則留到檢查的最後。
Preparing the Environment 準備環境
Prepare the environment before starting the assessment. The time should be convenient to both the client and the 在開始評估之前，請準備好環境。時間應該對客戶和評估者都方便。
BOX 29.3 Health Assessment of the Adult BOX 29.3 成人健康評估
Be aware of normal physiologic changes that occur with aging (see the Lifespan Considerations later in this chapter). 注意隨著年齡增長而發生的正常生理變化（請參見本章後面的生命週期考量）。
Be aware of stiffness of muscles and joints from aging or history of orthopedic surgery. The client may need modification of the usual positioning. 注意因老化或骨科手術歷史而導致的肌肉和關節僵硬。客戶可能需要對通常的定位進行調整。
Permit ample time for the client to answer your questions and assume the required positions. 允許客戶有充足的時間回答您的問題並採取所需的姿勢。
Be aware of cultural differences. The client may want a family member present during undressing. 注意文化差異。客戶可能希望在脫衣服時有家人陪伴。
Arrange for an interpreter if the client’s language differs from that of the nurse. 如果客戶的語言與護士的語言不同，請安排一位翻譯。
Ask clients how they wish to be addressed, such as “Mrs.” or “Miss.” 詢問客戶他們希望如何被稱呼，例如“夫人”或“小姐”。
Adapt assessment techniques to any sensory impairment; for example, have clients use their eyeglasses or hearing aids. 調整評估技術以適應任何感官障礙；例如，讓客戶使用他們的眼鏡或助聽器。
If clients are frail, it is wise to conduct the assessment in several segments in order to avoid overtiring them. nurse. The environment needs to be well lighted and the equipment should be organized for efficient use. The room should be warm enough to be comfortable for the client. Providing privacy is important. Most people are embarrassed if their bodies are exposed or if others can overhear or view them during the assessment. Culture, age, and gender of both the client and the nurse influence how comfortable the client will be and what special arrangements might be needed. Family and friends should not be present unless the client asks for someone. 如果客戶身體虛弱，最好將評估分成幾個部分進行，以避免使他們過度疲勞。環境需要有良好的照明，設備應該有序以便高效使用。房間應該保持足夠的溫暖，以使客戶感到舒適。提供隱私是很重要的。大多數人會感到尷尬，如果他們的身體暴露，或者在評估過程中其他人能夠聽到或看到他們。客戶和護士的文化、年齡和性別會影響客戶的舒適程度以及可能需要的特殊安排。除非客戶要求，否則家人和朋友不應在場。
Positioning 定位
Several positions are required during the physical assessment. The client’s physical condition, energy level, and age should be considered. Some positions are embarrassing and uncomfortable and therefore should not be maintained for long. The assessment is organized so several body areas can be assessed in one position, thus minimizing the number of position changes needed (Table 29.2). 在身體評估過程中需要採取幾個姿勢。應考慮客戶的身體狀況、能量水平和年齡。有些姿勢可能會讓人感到尷尬和不適，因此不應長時間保持。評估的安排使得可以在一個姿勢下評估多個身體部位，從而最小化所需的姿勢變換次數（表 29.2）。
Draping 披覆
Drapes should be arranged so that the area to be assessed is exposed and other body areas are covered. Exposure of the body is frequently embarrassing to clients. Drapes provide not only a degree of privacy but also warmth. Drapes are made of paper, cloth, or bed linen. 帷幕應該安排好，以便評估的區域暴露出來，而其他身體部位則要覆蓋。身體的暴露對客戶來說常常是尷尬的。帷幕不僅提供了一定程度的隱私，還能帶來溫暖。帷幕可以由紙、布或床單製成。
Instrumentation 儀器學
All equipment required for the health assessment should be clean, in good working order, and readily accessible. Equipment is frequently set up on trays, ready for use. Various instruments are shown in Table 29.3. If the assessment is being conducted outside of a healthcare setting, be sure you obtain all the needed equipment, including adequate lighting. 所有進行健康評估所需的設備應保持清潔、運行良好且易於取得。設備通常會放在托盤上，隨時可用。各種儀器見於表 29.3。如果評估是在醫療環境之外進行，請確保您獲得所有所需的設備，包括足夠的照明。
TABLE 29.2 Client Positions and Body Areas Assessed 表 29.2 客戶姿勢及評估的身體部位
Position 位置
Description 描述
Areas Assessed 評估範圍
Cautions 注意事項
Sitting 坐著
坐姿，背部不支撐，雙腿自由懸垂
A seated position, back
unsupported and legs hang-
ing freely
A seated position, back
unsupported and legs hang-
ing freely| A seated position, back |
| :--- |
| unsupported and legs hang- |
| ing freely |
Older adults and weak clients
may require support.| Older adults and weak clients |
| :--- |
| may require support. |
Position Description Areas Assessed Cautions
Sitting "A seated position, back
unsupported and legs hang-
ing freely" "Head, neck, posterior and
anterior thorax, lungs,
breasts, axillae, heart, vital
signs, upper and lower
extremities, reflexes" "Older adults and weak clients
may require support."| Position | Description | Areas Assessed | Cautions |
| :--- | :--- | :--- | :--- |
| Sitting | A seated position, back <br> unsupported and legs hang- <br> ing freely | Head, neck, posterior and <br> anterior thorax, lungs, <br> breasts, axillae, heart, vital <br> signs, upper and lower <br> extremities, reflexes | Older adults and weak clients <br> may require support. |
Berman, A., Snyder, S., Frandsen, G., Berman, A., Snyder, S., Frandsen, G., Berman, A., Snyder, S., & Frandsen, G. (2021). Kozier and erb’s fundamentals of nursing, global edition. Pearinued Education, Limited. Created from polyu-ebooks on 2022-09-10 00:25:54. 伯曼，A.，斯奈德，S.，弗蘭德森，G.，伯曼，A.，斯奈德，S.，弗蘭德森，G.，伯曼，A.，斯奈德，S.，& 弗蘭德森，G. (2021)。科茲爾和厄爾布的護理基本原則，全球版。佩林教育有限公司。於 2022 年 9 月 10 日 00:25:54 從 poly-ebooks 創建。
TABLE 29.2 Client Positions and Body Areas Assessed-continued 表 29.2 客戶位置及評估的身體區域-續
Position 位置
Areas Assessed 評估範圍
Cautions 注意事項
Semi-Fowler's 半坐臥位
仰臥，床頭抬高約 30^(@)-45^(@)30^{\circ}-45^{\circ}
Back-lying with head of the
bed elevated approximately
30^(@)-45^(@)30^{\circ}-45^{\circ}
Back-lying with head of the
bed elevated approximately
30^(@)-45^(@)| Back-lying with head of the |
| :--- |
| bed elevated approximately |
| $30^{\circ}-45^{\circ}$ |
可能會不舒服，除非腳或膝蓋稍微抬高。
May be uncomfortable unless
the foot or knee is elevated
slightly.
May be uncomfortable unless
the foot or knee is elevated
slightly.| May be uncomfortable unless |
| :--- |
| the foot or knee is elevated |
| slightly. |
Position Areas Assessed Cautions
Semi-Fowler's "Back-lying with head of the
bed elevated approximately
30^(@)-45^(@)" "May be uncomfortable unless
the foot or knee is elevated
slightly."| Position | Areas Assessed | Cautions |
| :--- | :--- | :--- |
| Semi-Fowler's | Back-lying with head of the <br> bed elevated approximately <br> $30^{\circ}-45^{\circ}$ | May be uncomfortable unless <br> the foot or knee is elevated <br> slightly. |
TABLE 29.3 Equipment and Supplies Used for a Health Examination 表 29.3 健康檢查所用的設備和用品
Supplies 用品
Purpose 目的
Flashlight or penlight 手電筒或筆燈
◻\square
協助觀察咽喉或判斷眼瞳的反應
To assist viewing of the pharynx or to determine the reactions of
the pupils of the eye
To assist viewing of the pharynx or to determine the reactions of
the pupils of the eye| To assist viewing of the pharynx or to determine the reactions of |
| :--- |
| the pupils of the eye |
Ophthalmoscope 眼底鏡
1 号10 1 號 10
A lighted instrument to visualize the interior of the eye 一種照明儀器，用於可視化眼睛的內部
Otoscope 耳鏡
一種照明儀器，用於可視化耳膜和外耳道（耳鏡可附加鼻鏡以檢查鼻腔）
A lighted instrument to visualize the eardrum and external audi-
tory canal (a nasal speculum may be attached to the otoscope to
inspect the nasal cavities)
A lighted instrument to visualize the eardrum and external audi-
tory canal (a nasal speculum may be attached to the otoscope to
inspect the nasal cavities)| A lighted instrument to visualize the eardrum and external audi- |
| :--- |
| tory canal (a nasal speculum may be attached to the otoscope to |
| inspect the nasal cavities) |
Percussion (reflex) hammer 敲打（反射）錘
An instrument with a rubber head to test reflexes 一種帶有橡膠頭的儀器，用於測試反射
Tuning fork 音叉
一種雙尖金屬工具，用於測試聽力敏銳度和振動感覺
A two-pronged metal instrument used to test hearing acuity and
vibratory sense
A two-pronged metal instrument used to test hearing acuity and
vibratory sense| A two-pronged metal instrument used to test hearing acuity and |
| :--- |
| vibratory sense |
Gloves 手套
To protect the nurse 保護護士
Tongue blades (depressors) 舌板（壓舌板）
在評估口腔和咽喉時壓下舌頭
To depress the tongue during assessment of the mouth and
pharynx
To depress the tongue during assessment of the mouth and
pharynx| To depress the tongue during assessment of the mouth and |
| :--- |
| pharynx |
Supplies Purpose
Flashlight or penlight ◻ "To assist viewing of the pharynx or to determine the reactions of
the pupils of the eye"
Ophthalmoscope 1 号10 A lighted instrument to visualize the interior of the eye
Otoscope https://cdn.mathpix.com/cropped/2024_09_22_165a6599d3c22557d2f0g-04.jpg?height=147&width=272&top_left_y=1551&top_left_x=669 "A lighted instrument to visualize the eardrum and external audi-
tory canal (a nasal speculum may be attached to the otoscope to
inspect the nasal cavities)"
Percussion (reflex) hammer An instrument with a rubber head to test reflexes
Tuning fork "A two-pronged metal instrument used to test hearing acuity and
vibratory sense"
Gloves https://cdn.mathpix.com/cropped/2024_09_22_165a6599d3c22557d2f0g-04.jpg?height=126&width=272&top_left_y=1984&top_left_x=669 To protect the nurse
Tongue blades (depressors) "To depress the tongue during assessment of the mouth and
pharynx"| Supplies | | Purpose |
| :---: | :---: | :---: |
| Flashlight or penlight | $\square$ | To assist viewing of the pharynx or to determine the reactions of <br> the pupils of the eye |
| Ophthalmoscope | 1 号10 | A lighted instrument to visualize the interior of the eye |
| Otoscope |  | A lighted instrument to visualize the eardrum and external audi- <br> tory canal (a nasal speculum may be attached to the otoscope to <br> inspect the nasal cavities) |
| Percussion (reflex) hammer | | An instrument with a rubber head to test reflexes |
| Tuning fork | | A two-pronged metal instrument used to test hearing acuity and <br> vibratory sense |
| Gloves |  | To protect the nurse |
| Tongue blades (depressors) | | To depress the tongue during assessment of the mouth and <br> pharynx |
Methods of Examining 檢查方法
Four primary techniques are used in the physical examination: inspection, palpation, percussion, and auscultation. These techniques are discussed throughout this chapter as 在身體檢查中使用了四種主要技術：視診、觸診、叩診和聽診。本章將討論這些技術。
Inspection 檢查
Inspection is the visual examination, which is assessing by using the sense of sight. It should be deliberate, purposeful, and systematic. The nurse inspects with the naked eye and with a lighted instrument such as an otoscope (used to view 檢查是視覺檢查，通過使用視覺來評估。它應該是有意識的、目的明確的和系統性的。護士用肉眼和如耳鏡等照明儀器進行檢查（用於觀察）。
the ear). In addition to visual observations, olfactory (smell) and auditory (hearing) cues are noted. Nurses frequently use visual inspection to assess moisture, color, and texture of body surfaces, as well as shape, position, size, color, and symmetry of the body. Lighting must be sufficient for the nurse to see clearly; either natural or artificial light can be used. When using the auditory senses, it is important to have a quiet environment for accurate hearing. Inspection can be combined with the other assessment techniques. 耳朵）。除了視覺觀察外，還注意嗅覺（嗅）和聽覺（聽）的線索。護士經常使用視覺檢查來評估身體表面的濕度、顏色和質地，以及身體的形狀、位置、大小、顏色和對稱性。照明必須足夠，讓護士能夠清楚地看到；可以使用自然光或人造光。在使用聽覺時，擁有安靜的環境對於準確聽取非常重要。檢查可以與其他評估技術結合使用。
There are two types of palpation: light and deep. Light (superficial) palpation should always precede deep palpation because heavy pressure on the fingertips can dull the sense of touch. For light palpation, the nurse extends the dominant hand’s fingers parallel to the skin surface and presses gently while moving the hand in a circle (Figure 29.1 ■). With light palpation, the skin is slightly depressed. If it is necessary to determine the details of a mass, the nurse presses lightly several times rather than holding the pressure. See Box 29.4 for the characteristics of masses. 有兩種觸診方式：輕觸和深觸。輕觸（表面觸診）應始終在深觸之前進行，因為用指尖施加重壓會使觸覺鈍化。進行輕觸時，護士將主導手的手指平行於皮膚表面輕輕按壓，同時將手以圓形移動（見圖 29.1 ■）。輕觸時，皮膚會稍微凹陷。如果需要確定腫塊的細節，護士應輕輕按壓幾次，而不是持續施加壓力。詳見框 29.4 有關腫塊的特徵。
Figure 29.1 ■ The position of the hand for light palpation. 圖 29.1 ■ 輕觸時手的位置。
BOX 29.4 Characteristics of Masses 盒子 29.4 大眾的特徵
Location-site on the body, dorsal or ventral surface 身體部位的位置，背面或腹面
Size-length and width in centimeters 尺寸-長度和寬度以厘米為單位
Shape-oval, round, elongated, irregular 形狀-橢圓、圓形、長形、不規則
Consistency-soft, firm, hard 一致性-柔軟、堅固、硬朗
Surface-smooth, nodular 表面光滑，結節狀
Mobility-fixed, mobile 移動固定，移動式
Pulsatility - present or absent 脈動性 - 存在或不存在
Tenderness - degree of tenderness to palpation 觸診的柔軟度 - 柔軟度的程度
Deep palpation is usually not done during a routine examination and requires significant practitioner skill. It is performed with extreme caution because pressure can damage internal organs. It is usually not indicated in clients who have acute abdominal pain or pain that is not yet diagnosed. 深層觸診通常不會在常規檢查中進行，並且需要相當高的醫療技能。這項檢查需極其小心，因為施加的壓力可能會損傷內部器官。對於有急性腹痛或尚未診斷的疼痛的患者，通常不建議進行此檢查。
Deep palpation is done with two hands (bimanually) or one hand. In deep bimanual palpation, the nurse extends the dominant hand as for light palpation, then places the finger pads of the nondominant hand on the dorsal surface of the distal interphalangeal joint of the middle three fingers of the dominant hand (Figure 29.2 ■). The top hand applies pressure while the lower hand remains relaxed to perceive the tactile sensations. For deep palpation using one hand, the finger pads of the dominant hand press over the area to be palpated. Often the other hand is used to support from below (Figure 29.3◻29.3 \square ). 深層觸診可以用雙手（雙手操作）或單手進行。在深層雙手觸診中，護士將主導手伸展，如同輕觸診，然後將非主導手的指尖放在主導手中三指的遠端指關節的背面（圖 29.2 ■）。上方的手施加壓力，而下方的手保持放鬆，以感知觸覺感受。對於單手深層觸診，主導手的指尖壓在要觸診的區域上。通常另一隻手會從下方支撐（圖 29.3◻29.3 \square ）。
To test skin temperature, it is best to use the dorsum (back) of the hand and fingers, where the examiner’s skin is thinnest. To test for vibration, the nurse should use the palmar surface of the hand. General guidelines for palpation include the following: 要測試皮膚溫度，最好使用手背和手指，因為檢查者的皮膚最薄。要測試震動，護士應使用手掌表面。觸診的一般指導方針包括以下幾點：
The nurse’s hands should be clean and warm, and the fingernails short. 護士的手應該乾淨且溫暖，指甲要短。
Areas of tenderness should be palpated last. 應該最後觸診觸痛區域。
Deep palpation should be done after superficial palpation. 深層觸診應在淺層觸診後進行。
Figure 29.2 ◻\square The position of the hands for deep bimanual palpation. 圖 29.2 ◻\square 雙手深層觸診的手部位置。
own hands are warm before beginning. During palpation, the nurse should be sensitive to the client’s verbal and facial expressions indicating discomfort. 雙手在開始之前是溫暖的。在觸診過程中，護士應該對客戶的言語和面部表情敏感，以便察覺不適的跡象。
Percussion 打擊樂器
Percussion is the act of striking the body surface to elicit sounds that can be heard or vibrations that can be felt. There are two types of percussion: direct and indirect. 敲擊是指打擊身體表面以產生可聽見的聲音或可感受到的震動。敲擊有兩種類型：直接和間接。
Figure 29.3 Deep palpation using the lower hand to support the body while the upper hand palpates the organ. 圖 29.3 深層觸診時，使用下手支撐身體，上手觸診器官。
In direct percussion, the nurse strikes the area to be percussed directly with the pads of two, three, or four fingers or with the pad of the middle finger. The strikes are rapid, and the movement is from the wrist. This technique is useful in percussing an adult’s sinuses (Figure 29.4■). 在直接叩診中，護士用兩根、三根或四根手指的指尖，或用中指的指尖直接敲擊要叩診的區域。敲擊動作迅速，並且是從手腕發力。這種技術在叩診成人的鼻竇時非常有用（圖 29.4■）。
Indirect percussion is the striking of an object (e.g., a finger) held against the body area to be examined. In this technique, the middle finger of the nondominant hand, referred to as the pleximeter, is placed firmly on the client’s skin. Only the distal phalanx and joint of this finger should be in contact with the skin. Using the tip of the flexed middle finger of the other hand, called the plexor, the nurse strikes the pleximeter, usually at the distal interphalangeal joint or a point between the distal and proximal joints (Figure 29.5◻29.5 \square ). The striking motion comes from the wrist; the forearm remains stationary. The angle between the plexor and the pleximeter should be 90^(@)90^{\circ}, and the blows must be firm, rapid, and short to obtain a clear sound. 間接叩診是指用一個物體（例如手指）敲擊要檢查的身體部位。在這種技術中，非主導手的中指稱為叩診器，穩固地放置在客戶的皮膚上。只有這根手指的遠端指骨和關節應與皮膚接觸。使用另一隻手的彎曲中指尖，稱為叩診槌，護士敲擊叩診器，通常在遠端指間關節或遠端與近端關節之間的某個點（圖 29.5◻29.5 \square ）。敲擊動作來自手腕；前臂保持靜止。叩診槌與叩診器之間的角度應為 90^(@)90^{\circ} ，敲擊必須堅固、迅速且短促，以獲得清晰的聲音。
Figure 29.4 Direct percussion using one hand to strike the surface of the body. 圖 29.4 使用一隻手直接敲擊身體表面。
Figure 29.5 Indirect percussion using the finger of one hand to tap the finger of the other hand. 圖 29.5 使用一隻手的手指輕敲另一隻手的手指進行間接敲擊。
Percussion is used to determine the size and shape of internal organs by establishing their borders. It indicates whether tissue is fluid filled, air filled, or solid. Percussion elicits five types of sound: flatness, dullness, resonance, hyperresonance, and tympany. Flatness is an extremely dull sound produced by very dense tissue, such as muscle or bone. Dullness is a thudlike sound produced by dense tissue such as the liver, spleen, or heart. Resonance is a hollow sound such as that produced by lungs filled with air. Hyperresonance is not produced in the normal body. It is described as booming and can be heard over an emphysematous lung. Tympany is a musical or drumlike sound produced from an air-filled stomach. On a continuum, flatness reflects the most dense tissue (the least amount of air) and tympany the least dense tissue (the greatest amount of air). A percussion sound is described according to its intensity, pitch, duration, and quality (Table 29.4). 叩診用於確定內臟的大小和形狀，通過建立其邊界。它指示組織是充滿液體、充滿空氣還是固體。叩診引發五種類型的聲音：平坦聲、鈍聲、共鳴聲、過度共鳴聲和鼓音。平坦聲是由非常密集的組織（如肌肉或骨骼）產生的極鈍聲。鈍聲是由密集組織（如肝臟、脾臟或心臟）產生的沉悶聲。共鳴聲是由充滿空氣的肺部產生的空心聲。過度共鳴聲在正常身體中不會產生。它被描述為轟鳴聲，可以在肺氣腫的肺部聽到。鼓音是由充滿空氣的胃產生的音樂或鼓聲。在一個連續體上，平坦聲反映出最密集的組織（最少的空氣），而鼓音則反映出最不密集的組織（最多的空氣）。叩診聲根據其強度、音高、持續時間和質量進行描述（表 29.4）。
Auscultation 聽診
Auscultation is the process of listening to sounds produced within the body. Auscultation may be direct or indirect. Direct auscultation is performed using the unaided ear, for example, to listen to a respiratory wheeze or the grating of a moving joint. Indirect auscultation is performed using a stethoscope, which transmits sounds to the nurse’s ears. A stethoscope is used primarily to listen to sounds from within the body, such as bowel sounds or valve sounds of the heart and blood pressure. 聽診是聆聽身體內部產生的聲音的過程。聽診可以是直接的或間接的。直接聽診是使用未輔助的耳朵進行的，例如，聆聽呼吸時的喘鳴聲或活動關節的摩擦聲。間接聽診則是使用聽診器進行的，聽診器將聲音傳遞到護士的耳朵。聽診器主要用於聆聽身體內部的聲音，例如腸道聲音或心臟和血壓的瓣膜聲音。
The stethoscope tubing should be 30 to 35 cm ( 12 to 14 in.) long, with an internal diameter of about 0.3 cm ( 1//8in1 / 8 \mathrm{in}.).) . It should have both a flat-disk diaphragm and a bellshaped amplifier (see Figure 4 in Skill 28.3 on page 549). The diaphragm best transmits high-pitched sounds (e.g., bronchial sounds), and the bell best transmits low-pitched sounds such as some heart sounds. The earpieces of the stethoscope should fit comfortably into the nurse’s ears, facing forward. The amplifier of the stethoscope is placed firmly but lightly against the client’s skin. If the client has excessive hair, it may be necessary to dampen the hairs with a moist cloth so that they will lie flat against the skin and not interfere with clear sound transmission. 聽診器的管長應為 30 至 35 厘米（12 至 14 英寸），內徑約為 0.3 厘米。它應該具有平盤式膜片和鈴形擴音器（見第 549 頁技能 28.3 中的圖 4）。膜片最能傳遞高音（例如，支氣管音），而鈴形擴音器最能傳遞低音，如某些心音。聽診器的耳塞應舒適地貼合護士的耳朵，面向前方。聽診器的擴音器應輕輕但穩固地放在客戶的皮膚上。如果客戶有過多的毛髮，可能需要用濕布將毛髮弄濕，以便它們平貼在皮膚上，不會干擾清晰的聲音傳輸。
TABLE 29.4 Percussion Sounds and Tones 表 29.4 敲擊聲音與音調
Sound 聲音
Intensity 強度
Pitch 音調
Duration 持續時間
Quality 品質
Example of Location 位置範例
Flatness 平坦性
Soft 柔軟
High 高
Short 短
Extremely dull 極其乏味
Muscle, bone 肌肉，骨頭
Dullness 遲鈍
Medium 中等
Medium 中等
Moderate 適度
Thudlike 沉重的聲音
Liver, heart 肝臟，心臟
Resonance 共鳴
Loud 大聲
Low 低
Long 長
Hollow 空心
Normal lung 正常肺部
Hyperresonance 超共振
Very loud 非常大聲
Very low 非常低
Very long 非常長
Booming 繁榮
Emphysematous lung 氣腫性肺
Tympany 鼓音
Loud 大聲
高（主要以音色為特徵）
High (distinguished mainly by
musical timbre)
High (distinguished mainly by
musical timbre)| High (distinguished mainly by |
| :--- |
| musical timbre) |
Moderate 適度
Musical 音樂劇
Stomach filled with gas (air) 胃部充滿氣體（空氣）
Sound Intensity Pitch Duration Quality Example of Location
Flatness Soft High Short Extremely dull Muscle, bone
Dullness Medium Medium Moderate Thudlike Liver, heart
Resonance Loud Low Long Hollow Normal lung
Hyperresonance Very loud Very low Very long Booming Emphysematous lung
Tympany Loud "High (distinguished mainly by
musical timbre)" Moderate Musical Stomach filled with gas (air)| Sound | Intensity | Pitch | Duration | Quality | Example of Location |
| :---: | :---: | :---: | :---: | :---: | :---: |
| Flatness | Soft | High | Short | Extremely dull | Muscle, bone |
| Dullness | Medium | Medium | Moderate | Thudlike | Liver, heart |
| Resonance | Loud | Low | Long | Hollow | Normal lung |
| Hyperresonance | Very loud | Very low | Very long | Booming | Emphysematous lung |
| Tympany | Loud | High (distinguished mainly by <br> musical timbre) | Moderate | Musical | Stomach filled with gas (air) |
Auscultated sounds are described according to their pitch, intensity, duration, and quality. The pitch is the frequency of the vibrations (the number of vibrations per second). Low-pitched sounds, such as some heart sounds, have fewer vibrations per second than high-pitched sounds, such as bronchial sounds. The intensity (amplitude) refers to the loudness or softness of a sound. Some body sounds are loud, for example, bronchial sounds heard from the trachea; others are soft, for example, normal breath sounds heard in the lungs. The duration of a sound is its length (long or short). The quality of sound is a subjective description of a sound, for example, whistling, gurgling, or snapping. 聽診聲音根據其音高、強度、持續時間和質量進行描述。音高是振動的頻率（每秒的振動次數）。低音的聲音，例如某些心音，每秒的振動次數少於高音的聲音，例如支氣管聲。強度（振幅）指的是聲音的響亮或柔和程度。一些身體聲音很響，例如從氣管聽到的支氣管聲；其他則較柔和，例如在肺部聽到的正常呼吸聲。聲音的持續時間是其長度（長或短）。聲音的質量是對聲音的主觀描述，例如口哨聲、咕嚕聲或啪嗒聲。
QSEN Teamwork and Collaboration: Interprofessional Practice QSEN 團隊合作與協作：跨專業實踐
Obtaining a health history and performing physical assessment of various aspects of the client are within the scope of practice of many healthcare providers other than nurses before, during, and after their treatments of clients. Although these providers may verbally communicate their findings and plan to other healthcare team members, the nurse must also know where to locate their documentation in the client’s medical record. The nursing care plan should incorporate interprofessional considerations when appropriate. 獲取健康歷史並對客戶的各個方面進行身體評估是許多醫療提供者（除了護士）在治療客戶的過程中、期間和之後的職業範疇。雖然這些提供者可能會口頭向其他醫療團隊成員傳達他們的發現和計劃，但護士也必須知道如何在客戶的醫療記錄中找到他們的文檔。護理計劃應在適當時納入跨專業考量。
General Survey 一般調查
Health assessment begins with a general survey that involves observation of the client’s general appearance, level of comfort, and mental status, and measurement of vital signs, height, and weight. Many components of the general survey are assessed while taking the client’s health history, such as the client’s body build, posture, hygiene, and mental status (see Chapter 10 oo10 \infty ). 健康評估始於一般調查，這包括觀察客戶的整體外觀、舒適程度和心理狀態，以及測量生命徵象、身高和體重。在進行客戶健康歷史時，許多一般調查的組成部分會被評估，例如客戶的體型、姿勢、衛生和心理狀態（見第 10 oo10 \infty 章）。
Appearance and Mental Status 外觀與心理狀態
The general appearance and behavior of an individual must be assessed in relationship to culture, educational level, socioeconomic status, and current circumstances. For example, an individual who has recently experienced a personal loss may appropriately appear depressed (sad expression, slumped posture). The client’s age, sex, and race are also useful factors in interpreting findings that suggest increased risk for known conditions. Skill 29.1 describes how to assess general appearance and mental status. Skill 29.17 later in this chapter describes a mental status examination in detail. 個體的一般外觀和行為必須與文化、教育水平、社會經濟地位和當前情況相關聯進行評估。例如，最近經歷個人損失的個體可能會適當地表現出抑鬱（悲傷的表情、駝背的姿勢）。客戶的年齡、性別和種族也是解釋顯示已知病症風險增加的發現時有用的因素。技能 29.1 描述了如何評估一般外觀和心理狀態。本章後面的技能 29.17 詳細描述了心理狀態檢查。
Assessing Appearance and Mental Status 評估外觀和心理狀態
PLANNING 規劃
Assignment 作業
Due to the substantial knowledge and skill required, assessment of general appearance and mental status is not assigned to assistive personnel (AP). However, many aspects are observed during usual care and may be recorded by individuals other than the nurse. Abnormal findings must be validated and interpreted by the nurse. 由於需要大量的知識和技能，對一般外觀和心理狀態的評估不會分配給輔助人員（AP）。然而，在日常護理中會觀察到許多方面，並且可以由護士以外的人員記錄。異常發現必須由護士進行驗證和解釋。
Equipment 設備
None 抱歉，您沒有提供任何文本進行翻譯。請提供要翻譯的內容
Perform hand hygiene and observe other appropriate infection prevention procedures. 執行手部衛生並遵守其他適當的感染預防程序。
3. Provide for client privacy. 3. 保障客戶隱私。
IMPLEMENTATION 實施
Performance 表現
Prior to performing the assessment, introduce self and verify the client’s identity using agency protocol. Explain to the client what you are going to do, why it is necessary, and how to participate. Discuss how the results will be used in planning further care or treatments. 在進行評估之前，介紹自己並根據機構的程序確認客戶的身份。向客戶解釋您將要做什麼、為什麼這是必要的以及如何參與。討論結果將如何用於規劃進一步的護理或治療。
Assessment 評估
4. Observe for signs of distress in posture or facial expression. 4. 觀察姿勢或面部表情中的痛苦跡象。
5. Observe general body build, height, and weight. 5. 觀察一般的體型、身高和體重。
Normal Findings 正常發現
No distress noted 未見困擾
Proportionate, varies with lifestyle 成比例，隨生活方式而異
Deviations from Normal 偏離正常範圍
Bending over because of abdominal pain, wincing, frowning, or labored breathing Excessively thin or obese 因腹痛而彎腰、皺眉、面露痛苦或呼吸困難，過於瘦弱或肥胖
Assessing Appearance and Mental Status-continued 評估外觀和心理狀態 - 繼續
Assessment
6. Observe client's posture and gait, 評估
觀察客戶的姿勢和步態，
standing, sitting, and walking.
Observe client’s overall hygiene and grooming. 觀察客戶的整體衛生和美容。
Note body and breath odor. 注意身體和呼吸的氣味。
Note obvious signs of health or illness (e.g., in skin color or breathing). 注意明顯的健康或疾病跡象（例如，皮膚顏色或呼吸）。
Assess the client’s attitude (frame of mind). 評估客戶的態度（心態）。
Note the client’s affect and mood; assess the appropriateness of the client’s responses. 注意客戶的情感和情緒；評估客戶反應的適當性。
Listen for quantity of speech (amount and pace), quality (loudness, clarity, inflection). 聆聽語音的數量（數量和速度）、質量（音量、清晰度、語調）。
Listen for relevance and organization of thoughts. of reality 聆聽思想的相關性和組織性。現實的。
Document findings in the client record using printed or electronic forms and checklists supplemented by narrative notes when appropriate. 在客戶記錄中使用印刷或電子表格和檢查清單記錄發現，並在適當時補充敘述性備註。
Normal Findings 正常發現
Relaxed, erect posture; coordinated movement 放鬆的直立姿勢；協調的動作
Clean, neat 乾淨、整齊
No body odor or minor body odor relative to work or exercise; no breath odor Well developed, well nourished, intact skin, easy breathing 無體味或相對於工作或運動的輕微體味；無口氣味。皮膚發育良好、營養充足、完整，呼吸順暢
Cooperative, able to follow instructions 合作，能夠遵循指示
Appropriate to situation 適合情況
Understandable, moderate pace; clear tone and inflection 可理解的，適中的語速；清晰的語調和重音
Logical sequence; makes sense; has sense 邏輯順序；有道理；有意義
Rapid or slow pace; overly loud or soft 快速或緩慢的步伐；過於響亮或柔和
Illogical sequence; flight of ideas; confusion; generalizations; vague 不合邏輯的順序；思想的飛躍；混亂；概括；模糊
EVALUATION 評估
Perform a detailed follow-up examination of specific systems based on findings that deviated from expected or normal for the client. Relate findings to previous assessment data if available. 根據客戶的預期或正常情況偏離的發現，對特定系統進行詳細的後續檢查。如果有可用的，將發現與先前的評估數據相關聯。
Report significant deviations from expected or normal findings to the primary care provider. 報告與預期或正常發現的重大偏差給主要照護提供者。
Clinical Alert! 臨床警報！
Review the agency charting form before beginning your assessment to ensure that you know which data you will need to collect, have all the equipment you require, and know how to perform the assessment in a systematic manner. 在開始評估之前，請先檢查機構的記錄表，以確保您知道需要收集哪些數據，擁有所需的所有設備，並知道如何以系統化的方式進行評估。
Vital Signs 生命徵象
Vital signs are measured (a) to establish baseline data against which to compare future measurements and (b) to detect actual and potential health problems. See Chapter 28 oo28 \infty for measurements of temperature, pulse, respirations, blood pressure, and oxygen saturation. See Chapter 30 oo30 \infty for pain assessment. 生命徵象的測量是為了 (a) 建立基準數據，以便與未來的測量進行比較，以及 (b) 偵測實際和潛在的健康問題。請參閱第 28 oo28 \infty 章以了解體溫、脈搏、呼吸、血壓和氧氣飽和度的測量。請參閱第 30 oo30 \infty 章以了解疼痛評估。
Height and Weight 身高和體重
In adults, the ratio of weight to height provides a general measure of health. By asking clients about their height and weight before actually measuring them, the nurse obtains some idea of the client’s self-image. Excessive discrepancies between the client’s responses and the measurements may provide clues to actual or potential problems in self-concept. Take note of any unintentional weight gain or loss lasting or progressing over several weeks. 在成年人中，體重與身高的比例提供了一個健康的基本指標。護士在實際測量客戶的身高和體重之前詢問客戶的身高和體重，可以獲得客戶自我形象的一些概念。客戶的回答與測量結果之間的過度差異可能提供有關自我概念的實際或潛在問題的線索。注意任何持續或在幾週內進展的無意識體重增加或減少。
The nurse measures height with a measuring stick attached to weight scales or to a wall. The client should remove the shoes and stand erect, with heels together, and the heels, buttocks, and back of the head against the measuring stick; eyes should be looking straight ahead. The nurse raises the L-shaped sliding arm until it rests on top of the client’s head, or places a small flat object such as a ruler or book on the client’s head. The edge of the flat object should abut the measuring guide. 護士使用附有體重秤或固定在牆上的量尺來測量身高。客戶應該脫掉鞋子，直立站立，腳跟並攏，腳跟、臀部和頭部後面緊貼量尺；眼睛應該直視前方。護士將 L 形滑臂抬起，直到其放在客戶的頭頂上，或在客戶的頭上放置一個小平物體，如尺子或書本。平物體的邊緣應該緊貼量測指導線。
Weight is usually measured when a client is admitted to a healthcare agency and then often regularly thereafter, for example, each morning before breakfast and after emptying the bladder. Scales measure in pounds ( lb ) or kilograms ( kg ), and the nurse may need to convert between the two systems. One kilogram is equal to 2.2 pounds. When accuracy is essential, the nurse should use the same scale each time (because every scale weighs slightly differently), take the measurements at the same time each day, and make sure the client has on a similar kind of clothing and no footwear. The weight is read from a digital display panel or a balancing arm. Clients who cannot stand are weighed on chair (Figure 29.6 ◻\square ) or bed scales. The bed scales (Figure 29.7■ ) have canvas straps or a stretcher-like apparatus to support the client. A machine lifts the client above the bed, and the weight is reflected either on a digital display panel or on a balance arm like that of a standing scale. Newer hospital beds have built-in scales. 體重通常在客戶入院時測量，之後通常會定期測量，例如每天早上早餐前和排空膀胱後。秤的單位是磅（lb）或公斤（kg），護士可能需要在這兩個系統之間進行轉換。一公斤等於 2.2 磅。當準確性至關重要時，護士應每次使用相同的秤（因為每個秤的重量略有不同），每天在相同的時間進行測量，並確保客戶穿著類似的衣物且不穿鞋。體重從數字顯示面板或平衡臂上讀取。無法站立的客戶則在椅子（圖 29.6 ◻\square ）或床秤上稱重。床秤（圖 29.7■）有帆布帶或類似擔架的裝置來支撐客戶。一台機器將客戶抬起，體重顯示在數字顯示面板或類似站立秤的平衡臂上。較新的醫院床有內建的秤。
Figure 29.6 ◻\square Chair scale. 圖 29.6 ◻\square 椅子比例尺。
Sian Bradfield/Pearson Education Australia Pty Ltd. 西安·布拉德菲爾德/皮爾森教育澳大利亞有限公司。
Figure 29.7 ■ Bed scale. 圖 29.7 ■ 床秤。
Integument 外皮
The integument includes the skin, hair, and nails. The examination begins with a generalized inspection using a good source of lighting, preferably indirect natural daylight. 皮膚系統包括皮膚、頭髮和指甲。檢查從使用良好光源的全面檢查開始，最好是間接的自然日光。
INFANTS 嬰兒
Observation of children’s behavior can provide important data for the general survey, including physical development, neuromuscular function, and social and interactional skills. 觀察兒童的行為可以為一般調查提供重要數據，包括身體發展、神經肌肉功能以及社交和互動技能。
It may be helpful to have parents hold older infants and very young children for part of the assessment. 在評估過程中，讓父母抱著較大的嬰兒和非常年幼的孩子可能會有所幫助。
Measure height of children under age 2 in the supine position with knees fully extended. 測量 2 歲以下兒童在仰臥位時的身高，膝蓋完全伸直。
Weigh without clothing. 脫衣稱重。
Include measurement of head circumference until age 2. Standardized growth charts include head circumference up to age 3. 包括在 2 歲之前測量頭圍。標準化生長圖表包括到 3 歲的頭圍。
CHILDREN 兒童
Anxiety in preschool-age children can be decreased by letting them handle and become familiar with examination equipment. 學齡前兒童的焦慮可以通過讓他們接觸並熟悉檢查設備來減少。
School-age children may be very modest and shy about exposing parts of the body. 學齡兒童可能對暴露身體的某些部位感到非常害羞和謙虛。
Adolescents should be examined without parents present. 青少年應在沒有父母在場的情況下接受檢查。
Weigh children without shoes and with as little clothing as possible. 在沒有鞋子和盡量少穿衣服的情況下稱量孩子。
OLDER ADULTS 老年人
Allow extra time for clients to answer questions. 允許客戶額外時間回答問題。
Adapt questioning techniques as appropriate for clients with hearing or visual limitations. 根據客戶的聽力或視力限制，調整提問技巧。
Older adults can lose several inches in height. Be sure to document height and ask if they are aware of becoming shorter in height. 老年人可能會失去幾英寸的身高。務必記錄身高並詢問他們是否意識到自己變矮了。
When asking about weight loss, be specific about amount and time frame, for example, “Have you lost more than five pounds in the last two months?” “How much did you weigh one year ago?” 當詢問減重時，請具體說明數量和時間範圍，例如：“你在過去兩個月內減了超過五磅嗎？” “你一年前的體重是多少？”
Skin 皮膚
Assessment of the skin involves inspection and palpation. The entire skin surface may be assessed at one time or as each aspect of the body is assessed. The nurse may also use the olfactory sense to detect unusual skin odors; these are usually most evident in the skinfolds or in the axillae. Pungent body odor is frequently related to poor hygiene, hyperhidrosis (excessive perspiration), or bromhidrosis (foul-smelling perspiration). 皮膚評估包括檢查和觸診。整個皮膚表面可以一次性評估，或在評估身體的每個部分時進行。護理人員也可以利用嗅覺來檢測異常的皮膚氣味；這些氣味通常在皮膚摺疊處或腋下最為明顯。刺鼻的體味通常與不良衛生、過度出汗（多汗症）或臭汗症（有異味的汗水）有關。
Pallor is the result of inadequate circulating blood or hemoglobin and subsequent reduction in tissue oxygenation. In clients with dark skin, it is usually characterized by the absence of underlying red tones in the skin and may be most readily seen in the buccal mucosa. In brownskinned clients, pallor may appear as a yellowish brown tinge; in black-skinned clients, the skin may appear ashen gray. Pallor in all people is usually most evident in areas with the least pigmentation such as the conjunctiva, oral mucous membranes, nail beds, palms of the hand, and soles of the feet. 蒼白是由於循環中的血液或血紅蛋白不足，隨之導致組織缺氧。在深色皮膚的客戶中，通常以皮膚缺乏底層紅色調為特徵，最容易在口腔黏膜中觀察到。在棕色皮膚的客戶中，蒼白可能呈現為黃褐色的色調；在黑色皮膚的客戶中，皮膚可能顯得灰白色。所有人的蒼白通常在色素最少的區域最為明顯，例如結膜、口腔黏膜、指甲床、手掌和腳底。
Cyanosis (a bluish tinge) is most evident in the nail beds, lips, and buccal mucosa. In dark-skinned clients, close inspection of the palpebral conjunctiva (the lining of the eyelids) and palms and soles may also show evidence of cyanosis. Jaundice (a yellowish tinge) may first be evident in the sclera of the eyes and then in the mucous membranes and the skin. Nurses should take care not to confuse jaundice with the normal yellow pigmentation in the sclera of a dark-skinned client. If jaundice is suspected, the posterior part of the hard palate should also be inspected for a yellowish color tone. Erythema is skin redness associated with a variety of rashes and other conditions. 紫紺（藍色調）在指甲床、嘴唇和口腔黏膜中最為明顯。在深色皮膚的客戶中，仔細檢查眼瞼結膜（眼瞼的內襯）以及手掌和腳底也可能顯示紫紺的跡象。黃疸（黃色調）可能首先在眼球的巩膜中顯現，然後在黏膜和皮膚中出現。護士應注意不要將黃疸與深色皮膚客戶的正常巩膜黃色素混淆。如果懷疑有黃疸，還應檢查硬顎的後部是否有黃色調。紅斑是與各種皮疹和其他情況相關的皮膚紅腫。
Localized areas of hyperpigmentation (increased pigmentation) and hypopigmentation (decreased pigmentation) may occur as a result of changes in the distribution of melanin (the dark pigment) or in the function of the melanocytes in the epidermis. An example of hyperpigmentation in a defined area is a birthmark; an example of hypopigmentation is vitiligo. Vitiligo, seen as patches of hypopigmented skin, is caused by the destruction of melanocytes in the area. Albinism is the complete or partial lack of melanin in the skin, hair, and eyes. Other localized color changes may indicate a problem such as edema or a localized infection. Dark-skinned clients normally have areas of lighter pigmentation, such as the palms, lips, and nail beds. 局部的色素沉著過多（色素增加）和色素沉著不足（色素減少）可能是由於黑色素（深色素）的分佈變化或表皮中黑色素細胞的功能變化所引起的。局部色素沉著過多的例子是胎記；色素沉著不足的例子是白癜風。白癜風表現為色素減少的皮膚斑塊，是由於該區域黑色素細胞的破壞所造成的。白化病是皮膚、頭髮和眼睛中黑色素的完全或部分缺乏。其他局部顏色變化可能表明存在問題，例如水腫或局部感染。深色皮膚的客戶通常在手掌、嘴唇和指甲床等部位有較淺的色素區域。
Edema is the presence of excess interstitial fluid. An area of edema appears swollen, shiny, and taut and tends to blanch the skin color or, if accompanied by inflammation, may redden the skin. Generalized edema is most often an indication of impaired venous circulation and in some cases reflects cardiac dysfunction or venous abnormalities. 水腫是指過多的間質液體存在。水腫區域看起來腫脹、光滑且緊繃，並且往往會使皮膚顏色變淺，或者如果伴隨炎症，可能會使皮膚變紅。全身性水腫最常表明靜脈循環受損，在某些情況下反映心臟功能障礙或靜脈異常。
A skin lesion is an alteration in a client’s normal skin appearance. Primary skin lesions are those that appear initially in response to some change in the external or internal environment of the skin (Figure 29.8 ■, (1-8). Secondary skin lesions are those that do not appear initially but result from modifications such as chronicity, trauma, or infection of the primary lesion. For example, a vesicle or blister (primary lesion) may rupture and cause an erosion (secondary lesion). Table 29.5 illustrates secondary lesions. Nurses are responsible for describing skin lesions accurately in terms of location (e.g., face), distribution (i.e., body regions involved), and configuration (the arrangement or position of several lesions) as well as color, shape, size, firmness, texture, and characteristics of individual lesions. Skill 29.2 describes how to assess the skin. 皮膚病變是客戶正常皮膚外觀的變化。原發性皮膚病變是指因皮膚外部或內部環境的某些變化而最初出現的病變（圖 29.8 ■，(1-8)）。繼發性皮膚病變則是指那些最初未出現，但由於原發性病變的慢性、創傷或感染等改變而產生的病變。例如，水泡或水疱（原發性病變）可能破裂並導致侵蝕（繼發性病變）。表 29.5 顯示了繼發性病變。護士負責準確描述皮膚病變，包括位置（例如，臉部）、分佈（即涉及的身體區域）和形狀（多個病變的排列或位置），以及顏色、形狀、大小、堅硬度、質地和個別病變的特徵。技能 29.2 描述了如何評估皮膚。
Clinical Alert! 臨床警報！
If you have not already gathered relevant information about the client’s history as it relates to the specific area being assessed, do so before beginning the physical examination. This allows you to focus the examination, customizing it to the individual client history and current status. 如果您尚未收集與客戶歷史相關的相關信息，特別是與正在評估的特定領域有關的信息，請在開始身體檢查之前進行收集。這樣可以使您專注於檢查，根據個別客戶的歷史和當前狀況進行定制。
Macule, Patch Flat, unelevated change in color. Macules are 1 mm to 1 cm ( 0.04 to 0.4 in .) in size and circumscribed. Examples: freckles, measles, petechiae, flat moles. Patches are larger than 1 cm ( 0.4 in .) and may have an irregular shape. Examples: port wine birthmark, vitiligo (white patches), rubella. 斑點、斑塊是平坦的、未隆起的顏色變化。斑點的大小為 1 毫米到 1 厘米（0.04 到 0.4 英寸），且邊界清晰。例子包括：雀斑、麻疹、出血點、平坦的痣。斑塊的大小大於 1 厘米（0.4 英寸），且可能具有不規則形狀。例子包括：葡萄酒色胎記、白癜風（白色斑塊）、風疹。
A café-au-lait macule 咖啡牛奶斑
Nodule, Tumor Elevated, solid, hard mass that extends deeper into the dermis than a papule. Nodules have a circumscribed border and are 0.5 to 2 cm ( 0.2 to 0.8 in .). Examples: squamous cell carcinoma, fibroma. Tumors are larger than 2 cm ( 0.8 in.) and may have an irregular border. Examples: malignant melanoma, hemangioma. 結節、腫瘤 隆起的、實心的、堅硬的腫塊，深入真皮層比丘疹更深。結節有明確的邊界，大小為 0.5 至 2 厘米（0.2 至 0.8 英寸）。例子：鱗狀細胞癌、纖維瘤。腫瘤的大小超過 2 厘米（0.8 英寸），可能有不規則的邊界。例子：惡性黑色素瘤、血管瘤。
(4) Chalazion (4) 眼瞼囊腫
Papule Circumscribed, solid elevation of skin. Papules are less than 1 cm (0.4 in.). Examples: warts, acne, pimples, elevated moles. (2 丘疹 是皮膚的局限性固體隆起。丘疹的大小小於 1 厘米（0.4 英寸）。例子：疣、痤瘡、粉刺、隆起的痣。
(2) Papular drug eruption (2) 常見藥物皮疹
Pustule Vesicle or bulla filled with pus. Examples: acne vulgaris, impetigo. 膿疱或充滿膿液的水泡。例子：青春痘、膿皰病。
(5) Acne pimple (5) 痘痘
Plaque Plaques are larger than 1 cm ( 0.4 in.). Examples: psoriasis, rubeola. 3 斑塊 斑塊的大小大於 1 厘米（0.4 英寸）。例子：牛皮癬、麻疹。 3
(3) Psoriasis (3) 牛皮癬
Vesicle, Bulla A circumscribed, round or oval, thin translucent mass filled with serous fluid or blood. 囊泡，水疱 一種圓形或橢圓形的圍繞性薄透明質量，內部充滿了漿液或血液。
Vesicles are less than 0.5 cm ( 0.2 in .). Examples: herpes simplex, early chicken pox, small burn blister. Bullae are larger than 0.5 cm ( 0.2 in .). Examples: large blister, seconddegree burn, herpes simplex. (6) 囊泡的大小小於 0.5 厘米（0.2 英寸）。例子：單純皰疹、早期水痘、小燒傷水泡。大水泡的大小大於 0.5 厘米（0.2 英寸）。例子：大水泡、二度燒傷、單純皰疹。
(6) Blister (6) 水泡
(7)(7) Digital mucous cyst 數位黏液囊腫
Wheal A reddened, localized collection of edema fluid; irregular in shape. Size varies. Examples: hives, mosquito bites. 8 蕁麻疹 一種紅腫的局部水腫液體聚集；形狀不規則。大小不一。例子：蕁麻疹、蚊子叮咬。
Figure 29.8◻29.8 \square Primary skin lesions. 圖 29.8◻29.8 \square 主要皮膚病變。
Figures (1) Dr. Marazzi/Science Source; (2) Scott Camazine/Alamy; (3 hriana/123RF; (4) Elena Shishkina/123RF; (5) Faiz Zaki/Shutterstock; (6) gajus/123RF; (7) Hercules Robinson/Alamy; 8 ipen/Shutterstock. 圖像 (1) Dr. Marazzi/Science Source; (2) Scott Camazine/Alamy; (3) hriana/123RF; (4) Elena Shishkina/123RF; (5) Faiz Zaki/Shutterstock; (6) gajus/123RF; (7) Hercules Robinson/Alamy; (8) ipen/Shutterstock.
TABLE 29.5 Secondary Skin Lesions 表 29.5 次級皮膚病變
Assessing the Skin 評估皮膚
PLANNING 規劃
Review characteristics of primary and secondary skin lesions if necessary (see Figure 29.8 and Table 29.5). 如有必要，檢查原發性和繼發性皮膚病變的特徵（見圖 29.8 和表 29.5）。
Ensure that adequate lighting is available. 確保有足夠的照明。
Assignment 作業
Due to the substantial knowledge and skill required, assessment of the skin is not assigned to AP. However, the skin is observed during usual care and AP should record their findings. Abnormal findings must be validated and interpreted by the nurse. 由於需要大量的知識和技能，因此皮膚的評估不會分配給助理護理人員。然而，在日常護理中會觀察皮膚，助理護理人員應該記錄他們的發現。異常發現必須由護士進行驗證和解釋。
Equipment 設備
Millimeter ruler 毫米尺
Clean gloves 清潔手套
Magnifying glass 放大鏡
Assessing the Skin-continued 評估皮膚-持續進行中
IMPLEMENTATION 實施
Performance 表現
Prior to performing the assessment, introduce self and verify the client’s identity using agency protocol. Explain to the client what you are going to do, why it is necessary, and how to participate. Discuss how the results will be used in planning further care or treatments. 在進行評估之前，介紹自己並根據機構的程序確認客戶的身份。向客戶解釋您將要做什麼、為什麼這是必要的以及如何參與。討論結果將如何用於規劃進一步的護理或治療。
Perform hand hygiene and observe other appropriate infection prevention procedures. 執行手部衛生並遵守其他適當的感染預防程序。
Provide for client privacy. 提供客戶隱私。
Inquire if the client has any history of the following: pain or itching; presence and spread of lesions, bruises, abrasions, pigmented spots; previous experience with skin problems; associated clinical signs; family history; presence of problems in other family members; related systemic conditions; use of medications, lotions, home remedies; excessively dry or moist feel to the skin; tendency to bruise easily; association of the problem to season of year, stress, occupation, medications, recent travel, housing, and so on; recent contact with allergens (e.g., metal paint). 詢問客戶是否有以下歷史：疼痛或癢感；病變、瘀傷、擦傷、色素斑點的存在和擴散；以往皮膚問題的經驗；相關的臨床徵兆；家族病史；其他家庭成員的問題；相關的全身性疾病；使用的藥物、乳液、家庭療法；皮膚過於乾燥或潮濕的感覺；容易瘀傷的傾向；問題與季節、壓力、職業、藥物、近期旅行、居住環境等的關聯；最近接觸過過敏原（例如，金屬漆）。
Assessment 評估
Inspect skin color (best assessed under natural light and on areas not exposed to the sun). 檢查皮膚顏色（最好在自然光下評估，並在未暴露於陽光的區域進行）。
Inspect uniformity of skin color. 檢查皮膚顏色的一致性。
Assess edema, if present (i.e., location, color, temperature, shape, and the degree to which the skin remains indented or pitted when pressed by a finger). Measuring the circumference of the extremity with a millimeter tape may be useful for future comparison. 評估水腫（如果存在），包括位置、顏色、溫度、形狀，以及在用手指按壓時皮膚凹陷或凹陷的程度。使用毫米卷尺測量肢體的周長可能對未來的比較有幫助。
Inspect, palpate, and describe skin lesions. Apply gloves if lesions are open or draining. Palpate lesions to determine shape and texture. Describe lesions according to location, distribution, color, configuration, size, shape, type, or structure (Box 29.5 on page 584). Use the millimeter ruler to measure lesions. 檢查、觸診並描述皮膚病變。如果病變是開放或流膿的，請戴上手套。觸診病變以確定形狀和質地。根據位置、分佈、顏色、形狀、大小、形狀、類型或結構描述病變（參見第 584 頁的框 29.5）。使用毫米尺測量病變。
Another method that can be used to record lesion size and shape is to lay clean double-thick clear plastic over the lesion or wound and trace the shape with a permanent marker. Dispose of the bottom layer that came in contact with the client and place the top layer in the client record. Use this method only if contact with the plastic does not contaminate the wound. 另一種可以用來記錄病變大小和形狀的方法是將乾淨的雙層透明塑料放在病變或傷口上，並用永久性標記筆描繪形狀。處理與客戶接觸的底層，並將頂層放入客戶記錄中。僅在與塑料接觸不會污染傷口的情況下使用此方法。
If gloves were applied, remove and discard gloves. 如果戴上手套，請脫下並丟棄手套。
Perform hand hygiene. 執行手部衛生。
Observe and palpate skin moisture. 觀察和觸診皮膚濕度。
Palpate skin temperature. Compare the two feet and the two hands, using the backs of your fingers. 觸診皮膚溫度。比較兩隻腳和兩隻手，使用手指的背面。
Note skin turgor (fullness or elasticity) by lifting and pinching the skin on an extremity or on the sternum. 注意皮膚的膨脹度（飽滿度或彈性），通過提起和捏住四肢或胸骨上的皮膚來觀察。
Normal Findings 正常發現
Varies from light to deep brown; from ruddy pink to light pink; from yellow overtones to olive Generally uniform except in areas exposed to the sun; areas of lighter pigmentation (palms, lips, nail beds) in darkskinned people 顏色從淺棕色到深棕色不等；從紅潤粉色到淺粉色；從黃色調到橄欖色。一般來說，顏色均勻，除了暴露在陽光下的區域；在深色皮膚的人中，手掌、嘴唇和指甲床等區域的色素較淺
No edema 無水腫
Deviations from Normal 偏離正常範圍
Pallor, cyanosis, jaundice, erythema 蒼白、青紫、黃疸、紅斑
Areas of either hyperpigmentation or hypopigmentation 超色素沉著或色素減少的區域
See the scale for describing edema. 請參閱描述水腫的標準。
Freckles, some birthmarks that have not changed since childhood, and some long-standing vascular birthmarks such as strawberry or port-wine hemangiomas, some flat and raised nevi; no abrasions or other lesions 雀斑、一些自童年以來未變的胎記，以及一些長期存在的血管性胎記，如草莓或波特酒色血管瘤，還有一些平坦和隆起的痣；沒有擦傷或其他病變
Various interruptions in skin integrity; irregular, multicolored, or raised nevi, some pigmented birthmarks such as melanocystic nevi, and some vascular birthmarks such as cavernous hemangiomas. Even these deviations from normal may not be dangerous or require treatment. 皮膚完整性的各種中斷；不規則的、多色的或隆起的痣，一些色素性胎記如黑色素囊腫痣，以及一些血管性胎記如海綿狀血管瘤。即使這些偏離正常的情況也可能不危險或不需要治療。
Assessment by an advanced-level practitioner is required. If skin lesions are suggestive of physical abuse, follow state regulations for follow-up and reporting. Signs of abuse may include bruises, unusual location of burns, or lesions that are not easily explainable. If lesions are present in adults or verbal-age children, conduct the interview and assessment in private. 需要由高級從業者進行評估。如果皮膚病變暗示身體虐待，請遵循州法規進行後續處理和報告。虐待的跡象可能包括瘀傷、燒傷的異常位置或不易解釋的病變。如果成年人或具言語能力的兒童有病變，請在私密環境中進行訪談和評估。
Excessive moisture (e.g., in hyperthermia); excessive dryness (e.g., in dehydration) 過多的濕氣（例如，在高熱中）；過度的乾燥（例如，在脫水中）
Generalized hyperthermia (e.g., in fever); generalized hypothermia (e.g., in shock); localized hyperthermia (e.g., in infection); localized hypothermia (e.g., in arteriosclerosis) 全身性高熱（例如，發燒）；全身性低溫（例如，休克）；局部高熱（例如，感染）；局部低溫（例如，動脈硬化）
Skin stays pinched or tented or moves back slowly (e.g., in dehydration). Count in seconds how long the skin remains tented. 皮膚保持捏住或隆起，或慢慢回彈（例如，在脫水的情況下）。計算皮膚保持隆起的時間，以秒為單位。
When pinched, skin springs back to previous state (is elastic); may be slower in older adults. 當被捏時，皮膚會回彈到之前的狀態（具有彈性）；在老年人中可能會較慢。
Moisture in skinfolds and the axillae (varies with environmental temperature and humidity, body temperature, and activity) Uniform; within normal range 皮膚摺疊處和腋下的濕度（隨環境溫度和濕度、體溫和活動而變化）均勻；在正常範圍內
Assessing the Skin-continued 評估皮膚-持續進行中
Assessment 評估
12. Document findings in the client record using printed or electronic forms or checklists supplemented by narrative notes when appropriate. 12. 在客戶記錄中使用印刷或電子表格或檢查清單記錄發現，並在適當時補充敘述性備註。
Draw location of skin lesions on body surface diagrams. (2) 在身體表面圖上繪製皮膚病變的位置。(2)
EVALUATION 評估
Compare findings to previous skin assessment data if available to determine if lesions or abnormalities are changing. 比較結果與先前的皮膚評估數據（如果有的話），以確定病變或異常是否有變化。
Report significant deviations from expected or normal findings to the primary care provider. 報告與預期或正常發現的重大偏差給主要照護提供者。
BOX 29.5 Describing Skin Lesions 盒子 29.5 描述皮膚病變
Type or structure. Skin lesions are classified as primary (those that appear initially in response to some change in the external or internal environment of the skin) and secondary (those that do not appear initially but result from modifications such as chronicity, trauma, or infection of the primary lesion). For example, a vesicle (primary lesion) may rupture and cause an erosion (secondary lesion). 類型或結構。皮膚病變分為原發性（那些最初因皮膚外部或內部環境的變化而出現的病變）和繼發性（那些最初未出現但由於原發性病變的慢性、創傷或感染等改變而產生的病變）。例如，水泡（原發性病變）可能破裂並導致侵蝕（繼發性病變）。
Size, shape, and texture. Note size in millimeters and whether the lesion is circumscribed or irregular; round or oval shaped; flat, elevated, or depressed; solid, soft, or hard; rough or thickened; fluid filled or has flakes. 大小、形狀和質地。注意以毫米為單位的大小，以及病變是否有明確邊界或不規則；圓形或橢圓形；平坦、隆起或凹陷；實心、柔軟或堅硬；粗糙或增厚；充滿液體或有片狀物。
Color. There may be no discoloration; one discrete color (e.g., Berman, A., Snyder, S., Frown, or black); or several colors, as with ecchymosis, Berman, A., Snyder, S., Frandsen, G., Berman, A., Snyder, S., Berman, A., Snyder, S., Frandsed from (a bruise), in which an initial dark red or blue color fades to a yellow color. When color changes are limited to the edges of a lesion, they are described as circumscribed; when spread over a large area, they are described as diffuse. 顏色。可能沒有變色；一種獨特的顏色（例如，伯曼，A.，斯奈德，S.，皺眉，或黑色）；或幾種顏色，如瘀斑，伯曼，A.，斯奈德，S.，弗蘭德森，G.，伯曼，A.，斯奈德，S.，伯曼，A.，斯奈德，S.，弗蘭德自（瘀傷），其中最初的深紅色或藍色逐漸變為黃色。當顏色變化僅限於病變的邊緣時，稱為局限性；當擴散到大面積時，稱為弥漫性。
Distribution. Distribution is described according to the location of the lesions on the body and symmetry or asymmetry of findings in comparable body areas. 分佈。分佈是根據病變在身體上的位置以及可比較身體區域的發現的對稱性或不對稱性來描述的。
Configuration. Configuration refers to the arrangement of lesions in relation to each other. Configurations of lesions may be annular (arranged in a circle), clustered together (grouped), linear (arranged in a line), arc or bow shaped, or merged (indiscrete); may follow the course of cutaneous nerves; or may be meshed in the form of a network. 配置。配置是指病變之間的排列方式。病變的配置可能是環狀（圍成一個圓圈）、聚集在一起（分組）、線性（排列成一條線）、弧形或弓形，或合併（不明顯）；可能沿著皮膚神經的走向；或可能以網絡的形式交織在一起。
INFANTS 嬰兒
Physiologic jaundice may appear in newborns 2 to 3 days after birth and usually lasts about 1 week. Pathologic jaundice, or that which indicates a disease, appears within 24 hours of birth and may last more than 8 days. 生理性黃疸可能在新生兒出生後 2 到 3 天出現，通常持續約 1 週。病理性黃疸，即指示疾病的黃疸，則在出生後 24 小時內出現，可能持續超過 8 天。
Newborns may have milia (whiteheads), small white nodules over the nose and face, and vernix caseosa (white cheesy, greasy material on the skin). 新生兒可能會有脂肪粒（白頭粉刺），在鼻子和臉部出現小白色結節，以及胎脂（皮膚上白色的奶酪狀油膩物質）。
Premature infants may have lanugo, a fine downy hair covering their shoulders and back. 早產嬰兒可能會有胎毛，這是一種細軟的絨毛，覆蓋在他們的肩膀和背部。
In dark-skinned infants, areas of hyperpigmentation may be found on the back, especially in the sacral area. 在深色皮膚的嬰兒中，背部可能會出現色素沉著過度的區域，特別是在骶骨區域。
Diaper dermatitis may be seen in infants. 尿布皮膚炎可能在嬰兒中出現。
If a rash is present, inquire in detail about immunization history. 如果有皮疹，請詳細詢問免疫接種歷史。
Assess skin turgor by pinching the skin on the abdomen. 通過捏住腹部的皮膚來評估皮膚的彈性。
CHILDREN 兒童
Children normally have minor skin lesions (e.g., bruising or abrasions) on arms and legs due to their high activity level. Lesions on other parts of the body may be signs of disease or abuse, and a thorough history should be taken. 兒童通常因為活動量大而在手臂和腿部有輕微的皮膚損傷（例如，瘀傷或擦傷）。身體其他部位的損傷可能是疾病或虐待的跡象，應進行詳細的病史詢問。
Secondary skin lesions may occur frequently as children scratch or expose a primary lesion to microbes. 次級皮膚病變可能會經常發生，因為孩子們會抓撓或將原發病變暴露於微生物中。
With puberty, oil glands become more productive, and children may develop acne. Most individuals ages 12 to 24 have some acne. 隨著青春期的到來，油脂腺變得更加活躍，孩子們可能會出現痤瘡。大多數 12 至 24 歲的個體都有一些痤瘡。
In dark-skinned children, areas of hyperpigmentation may be found on the back, especially in the sacral area. 在深色皮膚的兒童中，背部可能會出現色素沉著過度的區域，特別是在骶骨區域。
If a rash is present, inquire in detail about immunization history. 如果有皮疹，請詳細詢問免疫接種歷史。
OLDER ADULTS 老年人
Changes in lighter colored skin occur at an earlier age than in darker skin. 較淺色皮膚的變化發生在比深色皮膚更早的年齡。
The skin loses its elasticity, resulting in wrinkles. Wrinkles first appear on the skin of the face and neck, which are abundant in collagen and elastic fibers. 皮膚失去彈性，導致皺紋。皺紋首先出現在臉部和頸部的皮膚上，這些部位富含膠原蛋白和彈性纖維。
The skin appears thin and translucent because of loss of dermis and subcutaneous fat. 皮膚看起來薄且透明，因為真皮和皮下脂肪的流失。
The skin is increasingly dry and flaky because sebaceous and sweat glands are less active. Dry skin is more prominent on the extremities. 皮膚越來越乾燥和脫屑，因為皮脂腺和汗腺的活躍度降低。乾燥的皮膚在四肢上更為明顯。
The skin takes longer to return to its natural shape after being tented between the thumb and finger. 皮膚在被拇指和食指夾住後，恢復到自然形狀所需的時間更長。
Due to the normal loss of peripheral skin turgor in older adults, assess for hydration by checking skin turgor over the sternum or clavicle. 由於老年人周邊皮膚的正常張力損失，應通過檢查胸骨或鎖骨上的皮膚張力來評估水分狀態。
Flat tan to brown-colored macules, referred to as senile lentigines or melanotic freckles, are normally apparent on the back of the hand and other skin areas that are exposed to the sun. These macules may be as large as 1 to 2 cm ( 0.4 to 0.8 in.). 平坦的棕褐色斑點，稱為老年斑或黑色素雀斑，通常出現在手背和其他暴露在陽光下的皮膚區域。這些斑點的大小可達 1 到 2 厘米（0.4 到 0.8 英寸）。
Warty lesions (seborrheic keratosis) with irregularly shaped borders and a scaly surface often occur on the face, shoulders, and trunk. These benign lesions begin as yellowish to tan and progress to a dark brown or black. 疣狀病變（脂漏性角化症）具有不規則形狀的邊緣和鱗屑表面，常見於面部、肩部和軀幹。這些良性病變最初呈現為黃褐色，隨後發展為深棕色或黑色。
Vitiligo tends to increase with age and is thought to result from an autoimmune response. 白癜風隨著年齡增長而增加，並被認為是由自體免疫反應引起的。
Cutaneous tags (acrochordons) are most commonly seen in the neck and axillary regions. These skin lesions vary in size and are soft, often flesh colored, and pedicled. 皮膚贅生物（指狀贅生物）最常見於頸部和腋下區域。這些皮膚病變大小不一，質地柔軟，通常呈肉色，並且有蒂。
Visible, bright red, fine dilated blood vessels (telangiectasias) commonly occur as a result of the thinning of the dermis and the loss of support for the blood vessel walls. 可見的鮮紅色細小擴張血管（毛細血管擴張症）通常是由於真皮變薄和血管壁支撐喪失所引起的。
Pink to slightly red lesions with indistinct borders (actinic keratoses) may appear at about age 50, often on the face, ears, backs of the hands, and arms. They may become malignant if untreated. 粉紅色至微紅色的病變，邊界不明（光線性角化病）可能在約 50 歲時出現，通常位於臉部、耳朵、手背和手臂上。如果不加以治療，可能會變成惡性。
Normal hair is resilient and evenly distributed. In people with severe protein deficiency (kwashiorkor), the hair color is faded and appears reddish or bleached, and the texture is coarse and dry. Some therapies cause alopecia (hair loss), and some disease conditions and medications affect the coarseness of hair. For example, hypothyroidism can cause very thin and brittle hair. Skill 29.3 describes how to assess the hair. 正常的頭髮具有彈性且分佈均勻。在嚴重蛋白質缺乏（克瓦希奧科病）的人身上，頭髮顏色會變得暗淡，呈現紅色或漂白的樣子，質地粗糙且乾燥。一些療法會導致脫髮，而某些疾病狀況和藥物會影響頭髮的粗糙度。例如，甲狀腺功能低下可能會導致頭髮非常細且脆弱。技能 29.3 描述了如何評估頭髮。
Hair 頭髮
Assessing a client’s hair includes inspecting the hair, considering developmental changes and ethnic differences, and determining the individual’s hair care practices and factors influencing them. Much of the information about hair can be obtained by questioning the client. 評估客戶的頭髮包括檢查頭髮、考慮發展變化和種族差異，以及確定個人的護髮習慣和影響這些習慣的因素。關於頭髮的許多資訊可以通過詢問客戶來獲得。
Assessing the Hair 評估頭髮
PLANNING 規劃
Assignment 作業
Due to the substantial knowledge and skill required, assessment of the hair is not assigned to AP. However, many aspects are observed during usual care and may be recorded by individuals other than the nurse. Abnormal findings must be validated and interpreted by the nurse. 由於需要大量的知識和技能，因此不將頭髮的評估分配給助理護理人員。然而，在日常護理中會觀察到許多方面，並且可以由除護士以外的其他人員記錄。異常發現必須由護士進行驗證和解釋。
Equipment 設備
Clean gloves 清潔手套
IMPLEMENTATION 實施
Performance 表現
Prior to performing the assessment, introduce self and verify the client’s identity using agency protocol. Explain to the client what you are going to do, why it is necessary, and how to participate. Discuss how the results will be used in planning further care or treatments. 在進行評估之前，介紹自己並根據機構的程序確認客戶的身份。向客戶解釋您將要做什麼、為什麼這是必要的以及如何參與。討論結果將如何用於規劃進一步的護理或治療。
Perform hand hygiene, apply gloves, and observe other appropriate infection prevention procedures. 執行手部衛生，佩戴手套，並遵循其他適當的感染預防程序。
Provide for client privacy. 提供客戶隱私。
Inquire if the client has any history of the following: recent use of hair dyes, rinses, or curling or straightening preparations; recent chemotherapy (if alopecia is present); presence of disease, such as hypothyroidism, which can be associated with dry, brittle hair. 詢問客戶是否有以下歷史：最近使用染髮劑、沖洗劑或燙髮或拉直產品；最近接受化療（如果有脫髮的情況）；是否有疾病，如甲狀腺功能低下，這可能與乾燥、脆弱的頭髮有關。
Ask about the products and equipment (e.g., combs, brushes, dryers, irons) the client usually uses on the hair. Assist the client to determine if the products are appropriate for the client’s type of hair and scalp (e.g., for dry or oily hair). Provide education regarding hygiene of the hair and scalp. 詢問客戶通常使用的產品和設備（例如，梳子、刷子、吹風機、熨斗）。協助客戶判斷這些產品是否適合客戶的髮質和頭皮類型（例如，乾性或油性髮質）。提供有關頭髮和頭皮衛生的教育。
Assessing the Hair-continued 評估頭髮-持續中
Assessment 評估
Normal Findings 正常發現
Deviations from Normal 偏離正常範圍
6. Inspect the evenness of growth over the scalp. 6. 檢查頭皮上生長的均勻性。
Evenly distributed hair 均勻分佈的頭髮
Patches of hair loss (i.e., alopecia) 脫髮斑塊（即，脫髮症）
7. Inspect hair thickness or thinness. 檢查頭髮的粗細。
Thick hair 濃密的頭髮
Very thin hair (e.g., in hypothyroidism) 非常稀疏的頭髮（例如，在甲狀腺功能低下的情況下）
8. Inspect hair texture and oiliness. 8. 檢查髮質和油脂程度。
parting the hair in several areas, checking behind
the ears and along the hairline at the neck.
9. Note presence of infections or infestations by
parting the hair in several areas, checking behind
the ears and along the hairline at the neck.| 9. Note presence of infections or infestations by |
| :--- |
| parting the hair in several areas, checking behind |
| the ears and along the hairline at the neck. |
Hirsutism (excessive hairiness); naturally
absent or sparse leg hair (poor circulation)| Hirsutism (excessive hairiness); naturally |
| :--- |
| absent or sparse leg hair (poor circulation) |
11. 脫下並丟棄手套。 - 進行手部衛生。
11. Remove and discard gloves.
- Perform hand hygiene.
11. Remove and discard gloves.
- Perform hand hygiene.| 11. Remove and discard gloves. |
| :--- |
| - Perform hand hygiene. |
12. Document findings in the client record using printed or electronic forms or checklists supplemented by narrative notes when appropriate. 12. 在客戶記錄中使用印刷或電子表格或檢查清單記錄發現，並在適當時補充敘述性備註。
EVALUATION
偏離了客戶的預期或正常情況。如果有的話，請參考之前的評估數據。
deviated from expected or normal for the client.
to previous assessment data if available.
deviated from expected or normal for the client.
to previous assessment data if available.| deviated from expected or normal for the client. |
| :--- |
| to previous assessment data if available. |
報告標誌的主要內容
Report sign
fo the prim
Report sign
fo the prim| Report sign |
| :--- | :--- |
| fo the prim |
Report sign,fo the prim| Report sign <br> fo the prim |
| :--- |
偏離預期或正常發現的提供者。
viations from expected or normal findings
provider.
viations from expected or normal findings
provider.| viations from expected or normal findings |
| :--- |
| provider. |
Assessment Normal Findings Deviations from Normal
6. Inspect the evenness of growth over the scalp. Evenly distributed hair Patches of hair loss (i.e., alopecia)
7. Inspect hair thickness or thinness. Thick hair Very thin hair (e.g., in hypothyroidism)
8. Inspect hair texture and oiliness. Silky, resilient hair "Brittle hair (e.g., hypothyroidism);
excessively oily or dry hair"
"9. Note presence of infections or infestations by
parting the hair in several areas, checking behind
the ears and along the hairline at the neck." No infection or infestation "Flaking, sores, lice, nits (lice eggs), and
ringworm"
10. Inspect amount of body hair. Variable "Hirsutism (excessive hairiness); naturally
absent or sparse leg hair (poor circulation)"
"11. Remove and discard gloves.
- Perform hand hygiene."
12. Document findings in the client record using printed or electronic forms or checklists supplemented by narrative notes when appropriate.
EVALUATION
"deviated from expected or normal for the client.
to previous assessment data if available." "Report sign,fo the prim" "viations from expected or normal findings
provider."| Assessment | Normal Findings | Deviations from Normal |
| :---: | :---: | :---: |
| 6. Inspect the evenness of growth over the scalp. | Evenly distributed hair | Patches of hair loss (i.e., alopecia) |
| 7. Inspect hair thickness or thinness. | Thick hair | Very thin hair (e.g., in hypothyroidism) |
| 8. Inspect hair texture and oiliness. | Silky, resilient hair | Brittle hair (e.g., hypothyroidism); <br> excessively oily or dry hair |
| 9. Note presence of infections or infestations by <br> parting the hair in several areas, checking behind <br> the ears and along the hairline at the neck. | No infection or infestation | Flaking, sores, lice, nits (lice eggs), and <br> ringworm |
| 10. Inspect amount of body hair. | Variable | Hirsutism (excessive hairiness); naturally <br> absent or sparse leg hair (poor circulation) |
| 11. Remove and discard gloves. <br> - Perform hand hygiene. | | |
| 12. Document findings in the client record using printed or electronic forms or checklists supplemented by narrative notes when appropriate. | | |
| EVALUATION | | |
| deviated from expected or normal for the client. <br> to previous assessment data if available. | Report sign <br> fo the prim | viations from expected or normal findings <br> provider. |
LIFESPAN CONSIDERATIONS Assessing the Hair 壽命考量 評估頭髮
INFANTS 嬰兒
It is normal for infants to have either very little or a great deal of body and scalp hair. 嬰兒的身體和頭皮毛髮很少或很多都是正常的。
CHILDREN 兒童
As puberty approaches, axillary and pubic hair will appear (see Box 29.9 later in this chapter). 隨著青春期的來臨，腋毛和陰毛將會出現（見本章後面的 29.9 框）。
OLDER ADULTS 老年人
Older adults may experience a loss of scalp, pubic, and axillary hair. 老年人可能會經歷頭皮、陰毛和腋毛的脫落。
Hairs of the eyebrows, ears, and nostrils become coarse. 眉毛、耳朵和鼻孔的毛髮變得粗糙。
Nails 指甲
Nails are inspected for nail plate shape, angle between the fingernail and the nail bed, nail texture, nail bed color, and the intactness of the tissues around the nails. The parts of the nail are shown in Figure 29.9 . 指甲會檢查指甲板的形狀、指甲與指甲床之間的角度、指甲的質地、指甲床的顏色，以及指甲周圍組織的完整性。指甲的各部分如圖 29.9 所示。
The nail plate is normally colorless and has a convex curve. The angle between the fingernail and the nail bed is normally 160 degrees (Figure 29.10A ■). One nail abnormality is the spoon shape, in which the nail curves upward from the nail bed (Figure 29.10B). This condition, called koilonychia, may be seen in clients with iron deficiency anemia. Clubbing is a condition in which the angle between the nail and the nail bed is 180 degrees, or greater (Figures 29.10C and D). Clubbing may be caused by a long-term lack of oxygen. 指甲板通常是無色的，並且具有凸曲線。指甲與指甲床之間的角度通常為 160 度（圖 29.10A ■）。一種指甲異常是匙形指甲，指甲從指甲床向上彎曲（圖 29.10B）。這種情況稱為凹甲症，可能出現在缺鐵性貧血的客戶中。指甲肥厚是一種情況，指甲與指甲床之間的角度為 180 度或更大（圖 29.10C 和 D）。指甲肥厚可能是由於長期缺氧引起的。
Nail texture is normally smooth. Excessively thick nails can appear in older adults, in the presence of poor circulation, or in relation to a chronic fungal infection. Excessively thin nails or the presence of grooves or furrows can reflect prolonged iron deficiency anemia. Beau’s lines are horizontal depressions in the nail that can result from injury or severe illness (Figure 29.10E). The nail bed is highly vascular, a characteristic that accounts for its color. A bluish or purplish tint to the nail bed may reflect cyanosis, and pallor may reflect poor arterial circulation. Should the client report a history of nail fungus (onychomycosis), a referral to a podiatrist or dermatologist for treatment of nail fungus may be appropriate. Symptoms of nail fungus include brittleness, discoloration, thickening, distortion of nail shape, crumbling of the nail, and loosening (detaching) of the nail. 指甲的質地通常是光滑的。過厚的指甲可能出現在老年人身上，或因循環不良，或與慢性真菌感染有關。過薄的指甲或有溝槽或凹痕的存在可能反映出長期的缺鐵性貧血。博氏線是指甲上的橫向凹陷，可能由於受傷或重病引起（圖 29.10E）。指甲床血管豐富，這一特徵解釋了其顏色。指甲床呈藍色或紫色的色調可能反映出發紺，而蒼白可能反映出動脈循環不良。如果客戶報告有指甲真菌感染（甲癬）的病史，則可能需要轉診給足病醫生或皮膚科醫生進行治療。指甲真菌感染的症狀包括脆弱、變色、增厚、指甲形狀變形、指甲崩裂和指甲鬆動（脫落）。
Figure 29.9 圖 29.9
The parts of a nail. 指甲的部分。
Created from polyu-ebooks on 2022-09-10 00:25:54 由 polyu-ebooks 創建於 2022-09-10 00:25:54
Figure 29.10◻A29.10 \square A, A normal nail; BB, a spoon-shaped nail; CC, early clubbing; DD, late clubbing; EE, Beau’s lines. 圖 29.10◻A29.10 \square A ，正常的指甲； BB ，勺形指甲； CC ，早期杵狀指甲； DD ，晚期杵狀指甲； EE ，博氏線。
The tissue surrounding the nails is normally intact epidermis. Paronychia is an inflammation of the tissues surrounding a nail. The tissues appear inflamed and swollen, and tenderness is usually present. 指甲周圍的組織通常是完整的表皮。甲周炎是指指甲周圍組織的炎症。這些組織看起來發炎且腫脹，通常伴隨著觸痛。
A blanch test can be carried out to test the capillary refill, that is, peripheral circulation. Normal nail bed capillaries blanch when pressed, but quickly turn pink or their usual color when pressure is released. A slow rate of capillary refill may indicate circulatory problems. Skill 29.4 describes how to assess the nails. 可以進行蒸汽測試來檢查毛細血管充血，即周邊循環。正常的指甲床毛細血管在按壓時會變白，但在釋放壓力後會迅速變回粉紅色或其正常顏色。毛細血管充血的速度緩慢可能表明循環問題。技能 29.4 描述了如何評估指甲。
Assessing the Nails 評估指甲
PLANNING 規劃
Assignment 作業
Due to the substantial knowledge and skill required, assessment of the nails is not assigned to AP. However, many aspects are observed during usual care and may be recorded by individuals other than the nurse. Abnormal findings must be validated and interpreted by the nurse. 由於評估指甲需要相當的知識和技能，因此不會將此任務分配給助理護理人員。然而，在日常護理中會觀察到許多方面，並且可以由其他人員記錄。異常發現必須由護理人員進行驗證和解釋。
Equipment 設備
None 抱歉，您沒有提供任何文本進行翻譯。請提供要翻譯的內容
IMPLEMENTATION 實施
Performance 表現
Prior to performing the assessment, introduce self and verify the client’s identity using agency protocol. Explain to the client what you are going to do, why it is necessary, and how to participate. Discuss how the results will be used in planning further care or treatments. In most situations, clients with artificial nails or polish on fingernails or toenails are not required to remove these for assessment; however, if the assessment cannot 在進行評估之前，介紹自己並根據機構的程序確認客戶的身份。向客戶解釋您將要做什麼，為什麼這是必要的，以及如何參與。討論結果將如何用於計劃進一步的護理或治療。在大多數情況下，帶有假指甲或指甲油的客戶不需要在評估時去除這些；然而，如果評估無法進行，則...
be conducted due to the presence of polish or artificial nails, document this in the record. 因為有指甲油或人造指甲的存在，應進行記錄。
Perform hand hygiene and observe other appropriate infection prevention procedures. 執行手部衛生並遵守其他適當的感染預防程序。
Provide for client privacy. 提供客戶隱私。
Inquire if the client has any history of the following: presence of diabetes mellitus, peripheral circulatory disease, previous injury, or severe illness. 詢問客戶是否有以下病史：糖尿病、周邊循環疾病、以往受傷或重病。
Assessment 評估
Inspect fingernail plate shape to determine its curvature and angle. 檢查指甲板的形狀以確定其曲率和角度。
Inspect fingernail and toenail texture. 檢查指甲和腳趾甲的質地。
Inspect fingernail and toenail bed color. 檢查指甲和腳趾甲床的顏色。
Inspect tissues surrounding nails. 檢查指甲周圍的組織。
Perform blanch test of capillary refill. Press the nail bed between your thumb and index finger; look for blanching and return of pink color to nail bed. Perform on at least one nail on each hand and foot. 進行毛細血管充血測試。用拇指和食指按壓指甲床；觀察是否變白以及粉紅色是否回到指甲床。至少在每隻手和每隻腳上進行一次。
Normal Findings 正常發現
Convex curvature; angle of nail plate about 160^(@)160^{\circ} (Figure 29.10A) 凸曲率；指甲板的角度約為 160^(@)160^{\circ} (圖 29.10A)
Smooth texture 光滑的質地
Highly vascular and pink in light-skinned clients; dark-skinned clients may have brown or black pigmentation in longitudinal streaks Intact epidermis 高度血管化，對於淺膚色客戶呈粉紅色；深膚色客戶可能在縱向條紋中有棕色或黑色色素 完整的表皮
Prompt return of pink or usual color (generally less than 2 seconds) 迅速返回粉紅色或常見顏色（通常少於 2 秒）
Deviations from Normal 偏離正常範圍
Spoon nail (Figure 29.10B); clubbing ( 180^(@)180^{\circ} or greater) (Figures 29.10C and D) 勺形指甲（圖 29.10B）；杖狀指（ 180^(@)180^{\circ} 或更大）（圖 29.10C 和 D）
Excessive thickness or thinness or presence of grooves or furrows; Beau’s lines (Figure 29.10E); discolored or detached nail Bluish or purplish tint (may reflect cyanosis); pallor (may reflect poor arterial circulation) 過度的厚度或薄度，或有溝槽或凹痕；博氏線（圖 29.10E）；變色或脫落的指甲，藍色或紫色的色調（可能反映青紫症）；蒼白（可能反映動脈循環不良）
Hangnails; paronychia (inflammation). If indicated, teach the client or family member about proper nail care including how to trim and shape the nails to avoid paronychia. Delayed return of pink or usual color (may indicate circulatory impairment) 倒刺；甲周炎（炎症）。如有需要，教導客戶或家屬正確的指甲護理，包括如何修剪和塑形指甲以避免甲周炎。粉紅色或正常顏色的延遲回復（可能表示循環障礙）。
10. Document findings in the client record using printed or electronic forms or checklists supplemented by narrative notes when appropriate. 10. 在客戶記錄中使用印刷或電子表格或檢查清單記錄發現，並在適當時補充敘述性備註。
EVALUATION 評估
Perform a detailed follow-up examination of other systems based on findings that deviated from expected or normal for the client. Relate findings to previous assessment data if available. 根據客戶的預期或正常情況偏離的發現，對其他系統進行詳細的後續檢查。如果有可用的，將發現與先前的評估數據相關聯。
Report significant deviations from expected or normal to the primary care provider. 報告與預期或正常情況的重大偏差給主要護理提供者。
LIFESPAN CONSIDERATIONS Assessing the Nails 壽命考量 評估指甲
INFANTS 嬰兒
Newborns’ nails grow very quickly, are extremely thin, and tear easily. 新生兒的指甲生長得非常快，極其纖細，且容易撕裂。
CHILDREN 兒童
Bent, bruised, or ingrown toenails may indicate shoes that are too tight. 彎曲、瘀傷或內生指甲可能表示鞋子太緊。
Nail biting should be discussed with an adult family member because it may be a symptom of stress. 咬指甲應該與成年家庭成員討論，因為這可能是壓力的症狀。
OLDER ADULTS 老年人
The nails grow more slowly and thicken. 指甲生長得較慢且變厚。
Longitudinal bands commonly develop, and the nails tend to split. 縱向條紋通常會出現，指甲往往會裂開。
Bands across the nails may indicate protein deficiency; white spots, zinc deficiency; spoon-shaped nails may indicate iron deficiency. 指甲上的橫紋可能表示蛋白質缺乏；白點則可能表示鋅缺乏；匙狀指甲可能表示鐵缺乏。
Toenail fungus is more common and difficult to eliminate (although not dangerous to health). 趾甲真菌感染更常見且難以消除（儘管對健康沒有危險）。
Head 頭部
During assessment of the head, the nurse inspects and palpates simultaneously and also auscultates. The nurse examines the skull, face, eyes, ears, nose, sinuses, mouth, and pharynx. 在評估頭部時，護士同時進行檢查和觸診，並且還進行聽診。護士檢查顱骨、面部、眼睛、耳朵、鼻子、鼻竇、口腔和咽喉。
Skull and Face 頭骨和面部
There is a large range of normal shapes of skulls. A normal head size is referred to as normocephalic. If head size appears to be outside of the normal range, the circumference can be compared to standard size tables. Measurements more than two standard deviations from the norm for the age, sex, and race of the client are abnormal and should be reported to the primary care provider. Names of areas of the head are derived from names of the underlying bones: frontal, parietal, occipital, mastoid process, mandible, maxilla, and zygomatic (Figure 29.11 ■). 頭骨的正常形狀範圍很大。正常的頭部大小稱為正常頭型（normocephalic）。如果頭部大小似乎超出正常範圍，可以將周長與標準大小表進行比較。對於客戶的年齡、性別和種族，超過兩個標準差的測量值被視為異常，應報告給主要護理提供者。頭部各區域的名稱源自於其下方骨骼的名稱：額骨、頂骨、後頭骨、乳突、下頜骨、上頜骨和顴骨（圖 29.11 ■）。
Many disorders cause a change in facial shape or condition. Kidney or cardiac disease can cause edema of the eyelids. Hyperthyroidism can cause exophthalmos, a protrusion of the eyeballs with elevation of the upper eyelids, resulting in a startled or staring expression. Hypothyroidism, or myxedema, can cause a dry, puffy face with dry skin and coarse features and thinning of scalp hair and eyebrows. Increased adrenal hormone production or administration of steroids can cause a round face with reddened cheeks, referred to as moon face, and excessive hair growth on the upper lips, chin, and sideburn areas. Prolonged illness, starvation, and dehydration can result in sunken eyes, cheeks, and temples. Skill 29.5 describes how to assess the skull and face. 許多疾病會導致面部形狀或狀況的改變。腎臟或心臟疾病可能會引起眼瞼水腫。甲狀腺功能亢進症可能會導致眼球突出，伴隨上眼瞼抬高，造成驚訝或凝視的表情。甲狀腺功能低下症或黏液水腫可能會導致面部乾燥、腫脹，皮膚乾燥、特徵粗糙，並伴隨頭髮和眉毛變薄。腎上腺激素產量增加或類固醇的使用可能會導致圓臉和紅潤的臉頰，稱為月亮臉，並在上唇、下巴和鬢角區域出現過度的毛髮生長。長期疾病、飢餓和脫水可能導致眼窩、臉頰和太陽穴凹陷。技能 29.5 描述了如何評估顱骨和面部。
Figure 29.11 ◻\square Bones of the head. 圖 29.11 ◻\square 頭部的骨骼。
Assessing the Skull and Face 評估頭骨和面部
PLANNING
Assignment 規劃
作業
Due to the substantial knowledge and skill required, assessment of the skull and face is not assigned to AP. However, many aspects are observed during usual care and may be recorded by individuals other than the nurse. Abnormal findings must be validated and interpreted by the nurse. 由於需要大量的知識和技能，頭顱和面部的評估不會分配給助理護理人員。然而，在日常護理中會觀察到許多方面，並且可以由除護理人員以外的個體記錄。異常發現必須由護理人員進行驗證和解釋。
IMPLEMENTATION 實施
Performance 表現
Prior to performing the assessment, introduce self and verify the client’s identity using agency protocol. Explain to the client what you are going to do, why it is necessary, and how to participate. Discuss how the results will be used in planning further care or treatments. 在進行評估之前，介紹自己並根據機構的程序確認客戶的身份。向客戶解釋您將要做什麼、為什麼這是必要的以及如何參與。討論結果將如何用於規劃進一步的護理或治療。
Perform hand hygiene and observe other appropriate infection prevention procedures. 執行手部衛生並遵守其他適當的感染預防程序。
Equipment 設備
None 抱歉，您沒有提供任何文本進行翻譯。請提供要翻譯的內容
3. Provide for client privacy. 3. 保障客戶隱私。
4. Inquire if the client has any history of the following: past problems with lumps or bumps, itching, scaling, or dandruff; history of loss of consciousness, dizziness, seizures, headache, facial pain, or injury; when and how any lumps occurred; length of time any other problem existed; any known cause of problem; associated symptoms, treatment, and recurrences. 4. 詢問客戶是否有以下歷史：過去是否有腫塊或隆起、癢、脫屑或頭皮屑的問題；是否有失去意識、頭暈、癲癇、頭痛、面部疼痛或受傷的歷史；腫塊何時及如何出現；其他問題存在的時間長度；問題的已知原因；相關症狀、治療和復發情況。
Created from polyu-ebooks on 2022-09-10 00:25:54
