Health Assessment & Physical Examination

888 Pages·1997·154.39 MB·English

by  Mary Ellen Zator Estes

HEALTH
ASSESSMENT
(^Physical Examination
«r
Mary
Ellen Zator Este
Contents
UNIT I: LAYING THE FOUNDATION 1 15 Heart and Peripheral Vasculature 407
Catherine Wilson Cox, RN, MSN, CCRN, CEN
1 The Nursing Process 3
Mary Ellen Zator Estes, RN, MSN, CCRN 16 Abdomen 455
2 The Patient Interview 17 Eileen V. Caulfield, MA, RN-C
Theresa Perfetta Cappello, PhD, RN, Ct Hy 17 Musculoskeletal System 491
Jean Urban Coleman, EdD, RN, CS Patricia A. Connor, RN, CS, OCN, MSN
3 The Complete Health History 39 18 Mental Status and Neurological
Mary Ellen Zator Estes, RN, MSN, CCRN Techniques 551
Mary Jordheim Gokey, RN, MSN
Bonnie R. Sakallaris, RN, MSN, CCRN
UNITH: SPECIAL ASSESSMENTS 69
19 Female Genitalia 605
4 Developmental Assessment 71
Tamera Cauthorne-Burnette, RN, MSN, FNP, CS
Jane L. Echols, PhD, RN
20 Male Genitalia 641
Marjorie A. Maddox, EdD, ARNP, ANP-C
Randie R. McLaughlin, MS, CRNP
5 Cultural Assessment 101 Evelyn B. Blaemire, MS, CRNP
Jane L. Echols, PhD, RN
21 Anus, Rectum, and Prostate 667
6 Spiritual Assessment 129 Randie R. McLaughlin, MS, CRNP
Barbara Springer Edwards, RN, CCRN, MTS
7 Nutritional Assessment 153
Susan P. Gardella, MSN, RN, CPNP UNIT IV: SPECIAL POPULATIONS 687
22 Pregnant Patient 689
UNITIH: PHYSICAL ASSESSMENT 187 Mitzi Boilanger, RN-C, MS
Susan Abbott Rogge, RN, OB/GYN NP
8 Physical Assessment
23 Pediatric Patient 715
Techniques 189
Mary Ellen Zator Estes, RN, MSN, CCRN Kathy A. Murphy, MSN, RN-C, CS
9 General Assessment and
Vital Signs 203 UNITV: PUTTING IT ALL
Barbara Brown Bonheur, MS, RN TOGETHER
771
10 Skin, Hair, and Nails 221
24 The Complete Health and
Tamera Cauthorne-Burnette, RN, MSN, FNP, CS
Physical Assessment 773
11 Head and Neck 265 Mary Ellen Zator Estes, RN, MSN, CCRN
Jo Anne H. Peach, RN, MSN, FNP-C
12 Eyes, Ears, Nose, Mouth, REFERENCES AND BIBLIOGRAPHY 795
and Throat 285
Jo Anne H. Peach, RN, MSN, FNP-C GLOSSARY 809
13 Breasts and Regional Nodes 341
Tamera Cauthorne-Burnette, RN, MSN, FNP, CS INDEX 825
14 Thorax and Lungs 365
Mary Ellen Zator Estes, RN, MSN, CCRN ABBREVIATIONS Inside Back
*The coverphotograph illustrates the assessmentfor Tinel's sign, a testfor carpal tunnel syndrome.

ASSESSMENT
(^Physical Examination
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ASSESSMENT
(^Physical Examination
Mary Ellen Zator Estes, RN, MSN, CCRN
Assistant Professor
School ofNursing
Marymount University
Arlington, Virginia
and
Former Critical Care Nursing Education Coordinator
The GeorgeWashington University Medical Center
Washington, D.C.
Consulting Editors
Holly SkodolWilson, RN, PhD, FAAN Lynn Keegan, RN, PhD
San Francisco, California SanAntonio,Texas
Bf
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Cover Design: Brucie Rosch
The coverphotograph illustrates the assessmentfor Tinel's sign, a testforcarpal tunnelsyndrome.
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1 2 3 -t S ~ 8 9 1 XXX 03 02 01 00 99 98 97
Library ofCongress Cataloging-in-Publication Data
Health assessment & physical examination Man,' Ellen
Zator Estes; consulting editors. Holly Skodol Wilson. Lynn Keegan.
p. cm.
Includes bibliographical references and index.
ISBN 0-8273-7U7-0
1. Nursing assessment. 2. Physical diagnosis. I. Estes. Man-
Ellen Zator. II. Wilson. Holly Skodol. III. Keegan. Lynn.—
[DNLM: 1. Nursing Assessment. 2. Physical Examination nursing.
WY
100.4 H433 1997]
RT48.H425 1997
6l6.07'5—dc21
DNLM DLC
for Library of Congress 97-13500
CIP
To Matthew, Katie, and Andrew
I love you more today than yesterday
but not as much as tomorrow.
. . .
Spiral Staircase
£*£*£**
CONTRIBUTORS
xvi Stages of the Interview Process 21
Stage I 21
REVIEWERS
xviii Stage n 21
m
PREFACE XX Stage 21
Factors Affecting Communication 21
ACKNOWLEDGMENTS Listening 21
xxiii
Nonverbal Cues 21
ABOUT THE AUTHOR
xxiv Distance 22
Territory 22
BOXED FEATURES xxv
Effective Interviewing Techniques 12
HOW TO USE THIS TEXT \\\ in Open-Ended Questions 23
Closed Questions 23
Encouraging Talking 24
Silence 24
UNIT LAYING THE FOUNDATION
I: 1 Grouping Communication Techniques 24
CHAPTER THE NURSING PROCESS Listening Responses 24
1 : 3 Action Responses 27
Assessment 4
Nontherapeutic interviewing Techniques 29
Health History 4
Problematic Questioning Techniques 32
Physical Assessment Findings 4
Interviewing the Patient with Special Needs 33
Diagnostic and Laboratory Data
5 The Hearing-Impaired Patient 33
Nursing Diagnosis
5 The Visually Impaired Patient 34
Nursing Diagnosis Formulation
5 The Speech-Impaired and Aphasic Patient 34
Types ofNursing Diagnoses 6
The Non-English-Speaking Patient 34
Writing the Nursing Diagnosis 8
The Patient with Low IQ 35
Planning 9
The Emotional Patient 35
Prioritization 9
The Very 111 Patient 35
Patient Goals 10
The Sexually Aggressive Patient 35
Patient Outcome Formulation 10
The Older Adult 36
Intervention Selection 10
Implementation 11 CHAPTER THE COMPLETE
3:
Evaluation 11 HEALTH HISTORY
39
Critical Pathways 11
Types of Health History 40
Documenting the Nursing Process 12
Preparing for the Health History 40
Computerized Health History 41
CHAPTER 2: THE PATIENT INTERVIEW 17 Identifying Information 41
The Patient Interview 18 Today's Date 41
The Role ofthe Nurse 18 Biographical Data 41
The Role ofthe Patient 18 The Complete Health History
Factors Influencing the Interview 19 Assessment Tool 42
Approach 19 Source and Reliability ofInformation 42
Environment 19 Patient Profile 42
Confidentiality 20 Age, Sex, Race 42
Note Taking 20 Marital Status 42
Time, Length, Duration 20 Reason for Seeking Health Care and
Biases and Preconceptions 20 ChiefComplaint 42