Table Of ContentCopyright © 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
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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
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Copyright © 2001 by F. A. Davis Company
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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
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Copyright © 2001 F.A. Davis Company
To Our Families
and Students
Copyright © 2001 F.A. Davis Company
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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
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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
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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
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