Nursing Health Assessment: An Interactive Case-Study Approach + Hogstel: Practical Guide to Health Assessment Through the Life Span, 3rd Edition PDF
Preview Nursing Health Assessment: An Interactive Case-Study Approach + Hogstel: Practical Guide to Health Assessment Through the Life Span, 3rd Edition
Copyright © 2001 F.A. Davis Company P R A C T I C A L G U I D E T O P A R T H E A LT H A S S E S S M E N T T H RO U G H T H E L I F E S PA N 1 Copyright © 2001 F.A. Davis Company This page intentionally left blank Copyright © 2001 F.A. Davis Company P R A C T I C A L G U I D E T O H E A LT H A S S E S S M E N T T H R O U G H T H E L I F E S PA N Third Edition Mildred O. Hogstel, PhD, RN, C Professor Emeritus Harris School of Nursing Texas Christian University Fort Worth, Texas Linda Cox Curry, PhD, RN Professor Harris School of Nursing Texas Christian University Fort Worth, Texas F. A. Davis Company • Philadelphia Copyright © 2001 F.A. Davis Company F. A. Davis Company 1915 Arch Street Philadelphia, PA 19103 www.fadavis.com Copyright © 2001 by F. A. Davis Company Copyright © 1993, 1996 by F. A. Davis Company. All rights reserved. This book is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without written permission from the publisher. Printed in Canada Last digit indicates print number: 10 9 8 7 6 5 4 3 2 1 Acquisitions Editor: Lisa A. Biello Developmental Editor: Diane Blodgett Production Editor: Jessica Howie Martin Cover Designer: Louis J. Forgione As new scientific information becomes available through basic and clinical research, recommended treatments and drug therapies undergo changes. The authors and publisher have done everything possible to make this book accurate, up to date, and in accord with accepted standards at the time of publication. The authors, editors, and publisher are not responsi- ble for errors or omissions or for consequences from application of the book, and make no warranty, expressed or implied, in regard to the con- tents of the book. Any practice described in this book should be applied by the reader in accordance with professional standards of care used in re- gard to the unique circumstances that may apply in each situation. The reader is advised always to check product information (package inserts) for changes and new information regarding dose and contraindications before administering any drug. Caution is especially urged when using new or infrequently ordered drugs. Library of Congress Cataloging-in-Publication Data Hogstel, Mildred O. Practical guide to health assessment through the life span / Mildred O. Hogstel, Linda Cox Curry.—3rd ed. p. cm. Includes bibliographical references and index. ISBN 0-8036-0871-3 1. Nursing assessment—Handbooks, manuals, etc. I. Curry, Linda Cox. II. Title. RT48.H643 2001 616.07⬘5—dc21 2001017246 Authorization to photocopy items for internal or personal use, or the internal or personal use of specific clients, is granted by F. A. Davis Company for users registered with the Copyright Clearance Center (CCC) Transactional Reporting Service, provided that the fee of $.10 per copy is paid directly to CCC, 222 Rosewood Drive, Danvers, MA 01923. For those organizations that have been granted a photocopy license by CCC, a separate system of payment has been arranged. The fee code for users of the Transactional Reporting Service is: 8036-0803/01 + $.10. Copyright © 2001 F.A. Davis Company To Our Families and Students Copyright © 2001 F.A. Davis Company This page intentionally left blank Copyright © 2001 F.A. Davis Company P r e face Health assessment is an essential component of the nursing process and includes the health history; psychosocial history; physical, functional, and mental status examinations; and cul- tural, ethnic, family, and environmental assessments. The es- sential components of the assessment process may be com- pleted in a few minutes in an emergency; at the other extreme, assessment may take place over several weeks in the client’s home. The nurse has to use judgment in deciding which parts of the assessment are needed for a specific client in a certain setting depending on priorities. The purpose of this book is to provide nursing students and practicing nurses in all areas including community settings with a practical and easy-to-use reference to the major com- ponents, sequence, and methodology of health assessment. It is assumed that the user of this book will have completed courses in anatomy and physiology and will have completed or currently be enrolled in a course in health assessment. This book can easily be kept in a pocket until needed. When the nurse is ready to perform any part of the assessment, the book may be placed on a table near the client’s bed or chair. The book has been designed for easy reference. The third edi- tion has been expanded to include more content that will be helpful in better understanding the assessment process. New areas include assessment of the use of alternative and comple- mentary therapies; antepartum and intrapartum assessment; expanded coverage of communication skills, especially when communicating with clients of different ages, with different needs, and from different cultural and ethnic backgrounds; family communication and assessment; variations in physical assessment based on various racial and ethnic differences; and a basic orientation to and expansion of physical assessment techniques. The equipment needed, sequence, and techniques for each system have also been expanded. The steps of what to assess in carrying out a physical examination of each body vii Copyright © 2001 F.A. Davis Company Preface continued system are listed. It should be noted that some of the assess- ment techniques (for example, an internal gynecologic exami- nation and a prostate examination) are included as essential components of a total assessment, but they will not be per- formed by the novice practitioner. Normal and/or common findings and significant deviations from normal are included for each system. Common findings are those that are not considered normal because they do not occur in everyone but that rarely need referral (e.g., lentigo senilis in older adults or cradle cap in infants). Common and significant findings that should be referred for follow-up are shown in color. A special section, clinical alert, is also in color. This section notes special instructions the nurse needs to be aware of during the assessment and/or concerns related to the findings such as immediate referral. A few sample diagnostic tests are listed for each system. The nurse will refer the client to a physician, advance practice nurse (where appropriate), or other healthcare provider who may order and evaluate the diagnostic tests. Sample North American Nursing Diagnosis Association (NANDA) nursing diagnoses are also included for each system. These are not meant to be inclusive because nursing diagnoses are very indi- vidualized. However, the samples should guide the reader to- ward other possible diagnoses. These diagnoses should be helpful in preparing individual care plans after the assessment phase. Essential client and family education, home health notes, and a list of associated community agencies for each system also have been expanded or added. Perinatal, pediatric, and geriatric adaptations have been re- vised for each section of the health history, physical examina- tion, and client-family education. Racial and ethnic adapta- tions and additions have been made where appropriate. For each body system, a brief sample of how to document the physical findings is presented. Samples of primarily normal and some common abnormal findings are documented. Signif- icant deviations from normal will need more detailed docu- mentation. These samples are only a general guide because viii Copyright © 2001 F.A. Davis Company Preface continued methods of documentation vary with the institution or agency format, the setting, and the client’s needs or status. The appendices contain selected sample history, mental sta- tus, functional assessment, and physical assessment forms as well as other reference material that will be helpful in per- forming and documenting a complete health assessment. A glossary of the most commonly used abbreviations and terms in health assessment appears at the back of the book so that other references will not be needed for this information. Fol- lowing this is a list of specific references used in each of the three sections of the book and other health assessment re- sources that may be consulted for further reading. The authors believe that nurses will find this assessment book a helpful, time-saving clinical guide while they are learn- ing or becoming more skilled in health assessment techniques in the classroom or any clinical setting in which they assess clients. Mildred O. Hogstel Linda Cox Curry ix
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