Pocket Guide for Nursing Health Assessment: A Best Practice Approach

554 Pages·2010·7.935 MB·English

by  Sharon Jensen

Pocket Guide for
Nursing
Health
Assessment
A BEST PRACTICE
APPROACH
Sha ron Je nsen, MN, RN
Instructor
School of Nursing
Seattle University
Seattle, Washington
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Acquisitions Editor: Elizabeth Nieginski
Product Director: Renee A. Gagliardi
Design Coordinator: Joan Wendt
Illustration Coordinator: Brett Macnaughton
Manufacturing Coordinator: Karin Duffi eld
Prepress Vendor: SPi Technologies
Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins.
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 elec-
tronic copies, or utilized by any information storage and retrieval system without written permis-
sion from the copyright owner, except for brief quotations embodied in critical articles and reviews.
Materials appearing in this book prepared by individuals as part of their offi cial duties as U.S. gov-
ernment employees are not c overed by the above-mentioned copyright. To request permission,
please contact Wolters Kluwer Health / Lippincott Williams & Wilkins at Two Commerce Square,
2001 Market Street, Philadelphia, PA 19103, via email at [email protected], or via our website
at lww.com (products and services).
Printed in China
Library of Congress Cataloging-in-Publication Data
Jensen, Sharon, 1955-
Pocket guide for nursing health assessment : a best practice approach / Sharon Jensen.
p. ; cm.
Includes bibliographical references and index.
Summary: “This full-color spiral-bound pocket guide provides quick access to all aspects of the
nursing health history and physical examination. It includes a quick guide to assessing the hospitalized
patient and key topics and questions for health promotion, common symptoms, and sentinel sy mptoms
requiring immediate medical intervention. This clinical guide is a perfect companion to Jensen’s
Nursing Health Assessment: A Best Practice Approach”—Provided by publisher.
ISBN 978-1-58255-846-2 (spiral bound : alk. paper)
1. Nursing assessment—Handbooks, manuals, etc. I. Jensen, Sharon, 1955– Nursing health
assessment. II. Title.
[DNLM: 1. Nursing Assessment—Handbooks. WY 49]
RT48.J463 2011
616.07'5—dc22
2010026388
Care has been taken to confi rm the accuracy of the information presented and to describe generally
accepted practices. However, the author(s), 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 recommended may not be
considered absolute and universal recommendations.
The author(s), 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 fl ow 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 Administra-
tion (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 clinical
practice.
LWW.com
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Clinical Consultant
Jo Anne Kirk, MSN, RN
Clinical Instructor
University of Texas at Tyler
Tyler, Texas
iii
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Preface
The Pocket Guide for Nursing Health Assessment: A Best Practice
Approach was designed to work as a clinical handbook and up-to-date
reference for nurses when interviewing patients of all age groups and
cultural backgrounds, taking health histories, promoting health, and
performing physical assessments. The content derives from and has
been developed in conjunction with Nursing Health Assessment:
A Best Practice Approach and serves to both review the core content
provided in the textbook as well as help students apply their founda-
tional learning through reinforcement and streamlined presentation.
The content focuses on key questions in the area of health promo-
tion, reviewing important risk factors and outlining essential teach-
ing points for risk assessment and intervention. It includes essential
questions to review common and concerning signs and symptoms for
each health assessment topic. The chapters review the key techniques
of examination, outlining normal and unexpected fi ndings. Finally,
tables of fi ndings provide a quick reference by which students can
compare and contrast results to assist with eventual nursing and
medical diagnoses.
Key Features
Key features include the following:
• Abundant full-color illustrations and photos throughout highlight-
ing essential anatomy and physiology, techniques of physical
assessment, and normal and abnormal physiologic fi ndings
• Inclusion of health promotion content throughout, which focuses
on the nurse’s key role in patient education and advocacy and
disease prevention
• Safety alerts, which call attention to areas of concern that require
special techniques or adaptations to protect or preserve the health
of patients or caregivers
• Samples of documentation that assist students to remember how to
record their fi ndings
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• Lifespan and Cultural Considerations that remind students of
variations according to age or background that may infl uence
fi ndings
• Spiral binding that allows the pocket guide to remain open on any
fl at surface, which is especially useful in clinical settings
Organization
This book is organized into four units. The fi rst two chapters (Unit I)
focus on the basic foundations of nursing health assessment, review-
ing essential concepts of interviewing/history taking and physi-
cal assessment. Unit II contains chapters that review assessments
pertinent to all patients in all circumstances: general survey, vital
signs, pain, nutrition, and mental health. Unit III reviews the health
assessment of each body system, from skin through the genital/rectal
examinations. Finally, Unit IV contains assessments for patients at
every stage of the lifespan.
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Contents
1
UNIT Basic Assessment Concepts 1
1 Interview and Health History 3
2 Overview of Physical Examination 18
2
UNIT General Health Assessments 31
3 General Survey, Vital Signs, and Pain Assessment 33
4 Nutrition Assessment 58
5 Mental Health Assessment 73
3
UNIT Regional Examinations 97
6 Skin, Hair, and Nails Assessment 99
7 Head and Neck Assessment 124
8 Eyes Assessment 140
9 Ears Assessment 167
10 Nose, Sinuses, Mouth, and Throat Assessment 182
11 Thorax and Lung Assessment 202
12 Heart and Neck Vessels Assessment 223
13 Peripheral Vascular with Lymphatics Assessment 243
14 Breasts with Lymphatics Assessment 263
15 Abdominal Assessment 281
16 Musculoskeletal Assessment 306
17 Neurological Assessment 346
18 Male Genitalia and Rectal Assessment 381
19 Female Genitalia and Rectal Assessment 408
4
UNIT Health Assessment Across the Lifespan 433
20 Adult Head-to-Toe Examination 435
21 Pregnant Women 451
22 Children: Newborns Through Adolescents 464
23 Older Adults 496
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