Health Assessment in Nursing PDF
Preview Health Assessment in Nursing
81602_fm.qxd 7/23/09 8:27 AM Page i Health Assessment in Nursing FOURTH EDITION Janet Weber, RN, EdD Professor Department of Nursing Southeast Missouri State University Cape Girardeau, Missouri Jane H. Kelley,RN, PhD Adjunct Professor School of Nursing University of Mississippi Medical Center Jackson, Mississippi 81602_fm.qxd 8/3/09 6:39 PM Page ii Acquisitions Editor: Elizabeth Nieginski Project Manager: Katherine Burland Editorial Assistant:Laura Scott Director of Nursing Production:Helen Ewan Art Director, Design:Joan Wendt Art Director, Illustration: Brett MacNaughton Manufacturing Coordinator:Karin Duffield Vendor Manager: Beth Martz Production Services:Macmillan Publishing Solutions Fourth Edition Copyright ©2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Copyright © 2007, 2003 by Lippincott Williams & Wilkins. Copyright © 1998 by Lippincott- Raven Publishers. All rights reserved. This book is protected by copyright. No part of this book may be reproduced or transmitted in any form or by any means, including as photocopies or scanned-in or other electronic copies, or utilized by any information storage and retrieval system without written permission from the copyright owner, except for brief quotations embodied in crit- ical articles and reviews. Materials appearing in this book prepared by individuals as part of their official duties as U.S. government employees are not covered by the above-mentioned copyright. To request permission, please contact Lippincott Williams & Wilkins at 530 Walnut Street, Philadelphia PA 19106, via email at [email protected] or via website at lww.com (products and services). Not authorized for sale in North America and the Caribbean. 9 8 7 6 5 4 3 2 1 Library of Congress Cataloging-in-Publication Data Weber, Janet. Health assessment in nursing / Janet Weber, Jane H. Kelley. — 4th ed. p. ; cm. Includes bibliographical references and index. ISBN 978-1-60831-608-3 (alk. paper) 1. Nursing assessment. I. Kelley, Jane, 1944– II. Title. [DNLM: 1. Nursing Assessment—methods. WY 100.4 W374h 2010] RT48.W43 2010 610.73—dc22 2009028726 Care has been taken to confirm the accuracy of the information presented and to describe gen- erally accepted practices. However, the authors, editors, and publisher are not responsible for errors or omissions or for any consequences from application of the information in this book and make no warranty, expressed or implied, with respect to the currency, completeness, or accuracy of the contents of the publication. Application of this information in a particular situation remains the professional responsibility of the practitioner; the clinical treatments described and recom- mended may not be considered absolute and universal recommendations. The authors, editors, and publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accordance with the current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any change in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new or infrequently employed drug. Some drugs and medical devices presented in this publication have Food and Drug Administration (FDA) clearance for limited use in restricted research settings. It is the responsibility of the health care provider to ascertain the FDA status of each drug or device planned for use in his or her clin- ical practice. LWW.COM 81602_fm.qxd 7/23/09 8:27 AM Page iii My husband, children, mother, father, and grandmothers who shared their wisdom in special ways Janet My husband, mother, father, and grandmother, each of whom has helped me to see the world through new eyes Jane But there’s no vocabulary For love within a family, love that’s lived in But not looked at, love within the light of which All else is seen, the love within which All other love finds speech. This love is silent. From The Elder Statesman, T. S. Eliot (1888–1964) 81602_fm.qxd 8/7/09 3:59 PM Page iv Contributors Linda W. Bugle, PhD, RN Brenda Johnson, RN, PhD Professor of Nursing Professor Southeast Missouri State University Southeast Missouri State University Anna, Illinois Cape Girardeau, MO CHAPTER 34:ASSESSING COMMUNITIES CHAPTER 32: ASSESSING FRAIL ELDERLY CLIENTS Christina Byrd, MSN, ACNP-BC, ANP-BC, CNRN Fleetwood Loustalot, PhD, FNP-BC, CDE Neurosciences Nurse Practitioner Adjunct Faculty Southeast Missouri Hospital University of Mississippi Medical Center 1701 Lacey Street School of Nursing Cape Girardeau, Missouri Jackson, Mississippi CHAPTER 27:NERVOUS SYSTEM CHAPTER 11: ASSESSING SPIRITUALITY AND RELIGIOUS PRACTICES Jill C. Cash, MSN, APRN, CNP Nurse Practitioner Bobbi Morris, APRN, FNP-BC Logan Primary Care Instructor Marion, Illinois Southeast Missouri State University CHAPTER 29:ASSESSING CHILDBEARING WOMEN CHAPTER 28: PULLING IT ALL TOGETHER CHAPTER 30:ASSESSING NEWBORNS AND INFANTS Ann Sprengel, EdD, MSN, RN CHAPTER 31:ASSESSING CHILDREN AND ADOLESCENTS Professor Southeast Missouri State University Kathy Casteel, APRN, BC, FNP Cape Girardeau, Missouri Family Nurse Practitioner Cape Girardeau Physician Associates CHAPTER 12:ASSESSING NUTRITION Cape Girardeau, Missouri CHAPTER 21: PERIPHERAL VASCULAR SYSTEM CHAPTER 26:MUSCULOSKELETAL SYSTEM Cathy Young, DNSc, RN, FNP, BC Nancy Collins, RN, MSN Associate Professor Cardiology Nurse Texas Tech University Health Science Center DuPage Medical Group—Cardiology Lubbock, Texas Winfield, Illinois CHAPTER 9:ASSESSING VICTIMS OF VIOLENCE CHAPTER 22:ABDOMEN CHAPTER 23:FEMALE GENITALIA CHAPTER 24:MALE GENITALIA Rosie Danker, BSN, RN, CDE Certified Diabetes Educator—Diabetes Rehab Nurse St. Francis Medical Center Cape Girardeau, Missouri CHAPTER 28:PULLING IT ALL TOGETHER iv 81602_fm.qxd 8/7/09 3:59 PM Page v Reviewers Maureen Anthony, PhD, RN, CDE Julie Duff Cloutier, RN, BScN McAuley School of Nursing Laurentian University University of Detroit Sudbury, Ontario Detroit, Michigan Dana Edge, PhD, RN Maureen Belden, MS, RN University of Calgary University of Michigan Calgary, Alberta Ann Arbor, Michigan Brenda Eraut, RN, BSN David Bennett, PhD Douglas College Kennesaw State University New Westminster, British Columbia Kennesaw, Georgia Sarah Evans, RN, MN Elizabeth Blunt, PhD, RN, CRNP George Brown College Drexel University Toronto, Ontario Philadelphia, Pennsylvania Helen Ewing Kathleen Bobay, PhD, RN, NEA-BC Centre for Nursing College of Nursing Athabasca University Marquette University Athabasca, Alberta Milwaukee, Wisconsin Elizabeth Farren, PhD, MSN, BSN Cindy Bork, EdD, RN Baylor University Winona State University Dallas, Texas Winona, Minnesota Cindy Fenske, MS, RN Judy Ann Karpecki Bornais, RN, BA, BScN, University of Michigan MSc, CDE Ann Arbor, Michigan The University of Windsor Windsor, Ontario Elizabeth Fornasier, RN, BScN, Med George Brown College Linda A. Browne, MSN, BSN Toronto, Ontario Southwest Georgia Technical College Thomasville, Georgia Candace Ginsberg, MSN, RN, C-NP College of St. Scholastica Lorraine Cramp, RN, BA, BScN, MEd, PhD Duluth, Minnesota Centennial College Toronto, Ontario Lynne Harwood-Lunn, RN, BScN, MN School of Nursing Kathleen Curtis, BSN, RN York University Mt. Carmel College of Nursing Toronto, Ontario Columbus, Ohio Anna Helewka, RPN, RN, BSN, MSN Donna Davis, RN, NP-C, CNS, MSN Douglas College Imperial Valley College New Westminster, British Columbia Imperial, California v 81602_fm.qxd 8/7/09 3:59 PM Page vi vi REVIEWERS Judy Hileman, ARNP, PhD John McNulty, MS, RN University of Missouri, Kansas City School of Nursing Kansas City, Missouri University of Connecticut Storrs, Connecticut Karen Hoffman, ADAA Indiana Wesleyan University Wendy Mortimer, MSN, CRNP Marion, Indiana Reading Hospital School of Allied Health West Reading, Pennsylvania Jane Kassens, MSN, CS, FNP Georgia State University Yvonne Nathan, EdD, RN Atlanta, Georgia SUNY-Downstate Medical Center Brooklyn, New York Kate Kniest, MSN Harper College Lynn Nichols, PhD, RN Palatine, Illinois St. John Fisher College Rochester, New York Robin Eades Koch, RN, MSN, NNP Laura Nicholson, RN, MN, ENC Piedmont Virginia Community College Centennial College Charlottesville, Virginia Toronto, Ontario Rhonda Lansdell, AND Linda Nykolyn, RN, BScN Northeast Mississippi Community College NorQuest College Booneville, Mississippi Edmonton, Alberta Sandra Longman, BScN, MA Pat O’Leary, DSN, RN, COI Seneca College Middle Tennessee State University Toronto, Ontario Murfreesboro, Tennessee Noelle Lottes, RN, MS, CPNP, CFNP Pat Olsen, MN, RN Purdue University Shoreline Community College West Lafayette, Indiana Shoreline, Washington Joanne Louis, BScN, RN, MSc Catherine Pagel, RN, MSN University of Toronto Mercy College of Health Sciences Toronto, Ontario Des Moines, Iowa Diana Mager, CRN, MSN Marilyn Pestano-Harte, RN, MSN Fairfield University Florida International University Fairfield, Connecticut Miami, Florida Monique Mallet-Boucher, BScN, BEd, Med, MN Karen Piotrowski, MSN, RNC University of New Brunswick D’Youville College Fredericton, New Brunswick Buffalo, New York Shantia McCoy, MSN, CRNP Nancy Prince, MSN, RN, FNP LaSalle University Eastern Michigan University Philadelphia, Pennsylvania Ypsilanti, Michigan Sheila McKay, RN, MN Jennifer Prinz Red Deer College Spencerian College Red Deer, Alberta Louisville, Kentucky 81602_fm.qxd 8/7/09 3:59 PM Page vii REVIEWERS vii Mary Radford, RN, MSN Barbara Thompson, RN, BScN, MScN The University of Tennessee at Martin Sault College Martin, Tennessee Sault Ste. Marie, Ontario Carol Reid Valerie Trousdale, MSN, BSN Century College Baylor University White Bear Lake, Minnesota Dallas, Texas Lois Ripley, BSN, MS Creina Twomey, C, BN, MN West Virginia University, Parkersburg Memorial University Parkersburg, West Virginia St. John’s, Newfoundland Margot Rykhoff, RN, BScN, MA(Ed) Marsha Wamsley, RN, MS Humber College Institute of Technology Sinclair Community College and Advanced Learning Dayton, Ohio Toronto, Ontario Ming Wang-Letzkus Mary Scott, RN, MSN, PhD California State University, Los Angeles University of California, San Francisco Los Angeles, California School of Nursing San Francisco, California Paige D. Wimberley, MSN, RN, CNS, CNE Arkansas State University Joyce Shanty, MS, RN Jonesboro, Arkansas Indiana University of Pennsylvania Indiana, Pennsylvania Sandra Wynn, MSN, BS, APRN, BC Bluefield State College Karen Smith, BN, PN Bluefield, West Virginia Centre for Nursing Studies St. John’s, Newfoundland Joanne Yastik, MSN, RN University of Detroit Mercy Judy Stauder, MSN, RN Detroit, Michigan Stark State College of Technology Canton, Ohio Patti Zuzelo, EdD, RN, CS La Salle University Audrey Steenbeek, PhD, MSN, BSN Philadelphia, Pennsylvania Dalhousie University Halifax, Nova Scotia Lynne Thibeault, RN, BScN, NP-PHC, MEd Confederation College Thunder Bay, Ontario 81602_fm.qxd 7/23/09 8:27 AM Page viii Preface With the fourth edition of Health Assessment in Nursing, our analyses, and formulation of nursing diagnoses, collaborative goal remains to help students acquire the skills they need to problems, or referrals. perform nursing assessments in today’s ever changing health Unit IV reinforces the need to adapt assessment to the care environment. As nurses provide more care in a variety of context of the client. Chapters provide specific information settings—acute care agencies, clinics, family homes, rehabili- about ways to assess childbearing women, newborns and tation centers, and long-term care facilities—they need to be infants, children and adolescents, elderly clients, families, and more prepared than ever before to perform accurate, timely communities. Separate chapters for each of these groups allow health assessments. No matter where a nurse practices, two students easy access to the information they need when taking components are essential for accurate collection of client data: another course (i.e., pediatric nursing or community health a comprehensive knowledge base and expert nursing assess- nursing). For example, rather than look for toddler considera- ment skills. With that in mind, we have filled these pages with tions in each body system chapter, the student can look to in-depth, accurate information; illustrations; and learning tools Chapter 31 to find head-to-toe information for the toddler. The that help the student develop skills to collect both subjective chapter on assessing elderly clients provides an in-depth assess- and objective data. In addition to nursing assessment skills, ment of functional health of the frail elderly population. today’s nurses also need expert critical thinking skills to ana- lyze the data they collect and to detect client problems— ORGANIZATION OF THE ASSESSMENT whether they are nursing problems that can be treated inde- CHAPTERS pendently by nurses, collaborative problems that can be treated in conjunction with other health care practitioners, or medical Assessment chapters walk students through the entire assess- problems that require referral to appropriate professionals. This ment process from an anatomy and physiology review to data textbook teaches students to use critical thinking skills to ana- collection to analysis. Each assessment chapter includes the lyze the data they collect. following organization: • Structure and Function ORGANIZATION OF THE TEXT • Health Assessment • Collecting Subjective Data: The Nursing Health History This fourth edition of Health Assessment in Nursing has four • Collecting Objective Data: Physical Examination units: • Validating and Documenting Findings I. Nursing Data Collection, Documentation, and Analysis • Analysis of Data II. Integrative Holistic Nursing Assessment • Diagnostic Reasoning: Possible Conclusions III. Nursing Assessment of Physical Systems • Case Study IV. Nursing Assessment of Special Groups Structure and Function sections review key anatomy and Unit I describes the nurse’s role in health assessment. It physiology, which provide the knowledge base the nurse draws introduces the student to data collection and analysis as part of on to complete assessment. Health Assessment sections give in- the nursing process. Separate chapters provide in-depth infor- depth assessment parameters, including nursing health history, mation about each step of the assessment process: collecting physical assessment, and validation and documentation of the subjective data, collecting objective data, validating and docu- data. Nursing Health History information is presented in two menting data, and analyzing the data. The process of using crit- columns; column one gives examples of questions to ask the ical thinking skills to assess clients is discussed. client, and column two gives the rationale for asking the ques- Unit II introduces the student to the unique perspective tion. This approach helps students understand the “Whys” that the client should never be viewed as an isolated individual. behind the “Whats,” promoting critical thinking. Next, physical Concepts covered in this unit are applicable throughout the examination procedures are illustrated in a step-by-step fashion entire client assessment. The unit begins by explaining how to across three columns. Column one tells the student exactly how obtain an overall view or general impression of the client. to perform specific aspects of the examination. Column two Assessment techniques to determine the client’s mental status presents normal findings and normal variations, while column and comfort level are described; as are ways to determine if the three presents a variety of abnormal findings. In addition, client is a victim of violence; and ways that culture, spirituality, Abnormal Findings displays depict common abnormal find- religion, and nutrition affect the client’s holistic health. ings, helping students to identify their findings. Sample docu- Unit III immerses the student in actual assessment tech- mentation demonstrates proper documentation technique, a niques for all body systems. Separate chapters cover techniques must for all students. for each body system; and techniques to adapt for the older Analysis of the Data sections provide common nursing client are highlighted in each chapter. The unit concludes with diagnoses (well, risk, and actual) and possible collaborative a chapter on “Pulling It All Together,” which shows the student problems related to the specific body system. The case study how to integrate assessment of all body systems. Students can uses a sample client to walk students through the diagnostic use the examples provided to model their own data collections, reasoning process. viii
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