Table Of Content403X-FM.qxd 1/5/05 5:27 AM Page i
PROFESSIONAL GUIDE TO
Assessment
403X-FM.qxd 1/5/05 5:27 AM Page ii
403X-FM.qxd 1/5/05 5:27 AM Page iii
PROFESSIONAL GUIDE TO
Assessment
403X-FM.qxd 1/5/05 5:27 AM Page iv
STAFF The clinical treatments described and recommend-
ed in this publication are based on research and
Executive Publisher consultation with nursing,medical,and legal au-
Judith A.Schilling McCann,RN,MSN thorities.To the best ofour knowledge,these proce-
dures reflect currently accepted practice.Neverthe-
Editorial Director less,they can’t be considered absolute and universal
H.Nancy Holmes recommendations.For individual applications,all
recommendations must be considered in light of
Clinical Director
the patient’s clinical condition and,before adminis-
Joan M.Robinson,RN,MSN tration ofnew or infrequently used drugs,in light
ofthe latest package insert information.The au-
Senior Art Director
thors and publisher disclaim any responsibility for
Arlene Putterman any adverse effects resulting from the suggested
procedures,from any undetected errors,or from the
Editorial Project Manager
reader’s misunderstanding ofthe text.
Jennifer P.Kowalak
© 2006 by Lippincott Williams & Wilkins.All rights
Clinical Project Manager reserved.This book is protected by copyright.No
Beverly Ann Tscheschlog,RN,BS part ofit may be reproduced,stored in a retrieval
system,or transmitted,in any form or by any
Editor means— electronic,mechanical,photocopy,
Julie Munden recording,or otherwise — without prior written
permission ofthe publisher,except for briefquota-
Clinical Editor tions embodied in critical articles and reviews and
Maryann Foley,RN,BSN testing and evaluation materials provided by the
publisher to instructors whose schools have adopt-
Copy Editors
ed its accompanying textbook.Printed in the Unit-
Kimberly Bilotta (supervisor),Scotti Cohn, ed States ofAmerica.For information,write Lip-
Heather Ditch,Judith Orioli, pincott Williams & Wilkins,323 Norristown Road,
Carolyn Petersen,Irene Pontarelli, Suite 200,Ambler,PA 19002-2756.
Kelly Taylor,Dorothy P.Terry,
PGASS – D N O S A J J M A M
PamelaWingrod
07 06 05 10 9 8 7 6 5 4 3 2 1
Designer
Linda Jovinelly Franklin (project manager) Library ofCongress
Cataloging-in-Publication Data
Digital Composition Services
Diane Paluba (manager),Joyce Rossi Biletz, Professional guide to assessment.
p.;cm.
Donna S.Morris
Includes bibliographical references and index.
Manufacturing 1. Diagnosis—Handbooks,manuals,etc.2. Nurs-
Patricia K.Dorshaw (director),BethJ.Welsh ing assessment—Handbooks,manuals,etc.3.
Physical diagnosis—Handbooks,manuals,etc. I.
Editorial Assistants Lippincott Williams & Wilkins.
Megan L.Aldinger,Karen J.Kirk, [DNLM:1. Physical Examination—Handbooks.
2. Laboratory Techniques and Procedures—Hand-
LindaK.Ruhf
books.3. Medical History Taking—Handbooks.
Indexer WB 39 P9625 2006]
Barbara Hodgson RC71.P758 2006
616.07'5—dc22
ISBN 1-58255-403-X (alk.paper) 2004028714
403X-FM.qxd 1/5/05 5:27 AM Page v
Contents
Contributors and consultants vii
Foreword ix
1 Health history 1
2 Fundamental physical assessment
techniques 18
3 Mental health assessment 36
4 Nutrition 58
5 Integumentary system 85
6 Eyes 118
7 Ears,nose,and throat 143
Assessment in color after 150
8 Respiratory system 171
9 Cardiovascular system 208
10 Breasts and axillae 254
11 Gastrointestinal system 272
12 Endocrine system 315
13 Hematologic and immune systems 343
14 Female genitourinary system 379
15 Male genitourinary system 412
v
403X-FM.qxd 1/19/05 1:03 PM Page vi
vi CONTENTS
16 Musculoskeletal system 433
17 Neurologic system 465
18 Assessing the pregnant patient 520
19 Assessing the neonate 563
Appendices
Quick-reference guide to laboratory test results 596
Quick guide to head-to-toe assessment 608
Normal laboratory value changes
in elderlypatients 622
Resources for professionals,patients,
and caregivers 626
Selected references 630
Color photo credits 632
Index 633
403X-FM.qxd 1/5/05 5:27 AM Page vii
Contributors and
consultants
Deborah A.Andris,RN-CS,MSN,APNP Michelle L.Foley,RN,C,MA
Nurse Practitioner,Bariatric Surgery Director,Nursing Education
Program Charles E.Gregory School ofNursing
Medical College ofWisconsin Raritan Bay Medical Center
Milwaukee Perth Amboy,N.J.
Jemma Bailey-Kunte,APRN-BC,MS,FNP Catherine B.Holland,RN,PhD,ANP,
Clinical Lecturer BC-APRN,CNS
Binghamton (N.Y.) University Associate Professor
Nurse Practitioner Southeastern Louisiana University
Lourdes Hospital Baton Rouge
Binghamton,N.Y.
Julia Anne Isen,RN,MS,FNP-C
Cheryl A.Bean,APRN,BC,DSN,ANP, Nurse Practitioner – Internal Medicine
AOCN Veterans Administration Medical Center
Associate Professor San Francisco
Indiana University School ofNursing Assistant Clinical Professor
Indianapolis University ofCalifornia at San Francisco
School ofNursing
Natalie Burkhalter,RN,MSN,ACNP,
CS,FNP Nancy Banfield Johnson,RN,MSN,
Associate Professor ANP(inactive)
Texas A&M International University Nurse Manager
Laredo Kendal at Ithaca (N.Y.)
Shelba Durston,RN,MSN,CCRN Gary R.Jones,RN,MSN,CNS,FNP
Nursing Instructor ARNP,Disease Management Program
San Joaquin Delta College Mercy Health Center
Stockton,Calif. Fort Scott,Kans.
StaffNurse
San Joaquin General Hospital Vanessa C.Kramasz,RN,MSN,FNP-C
French Camp,Calif. Nursing Faculty & Family Nurse
Practitioner
Tamara D.Espejo,RN,MS Gateway Technical College
RN/Clinical Educator Kenosha,Wis.
Aurora Behavioral Healthcare-Charter Oak
Covina,Calif.
vii
403X-FM.qxd 1/19/05 1:02 PM Page viii
viii CONTRIBUTORS AND CONSULTANTS
Priscilla A.Lee,MN,FNP Monica Narvaez Ramirez,RN,MSN
Instructor in Nursing Faculty
Moorpark (Calif.) College University ofthe Incarnate Word
San Antonio,Tex.
Susan Luck,RN,MS,CCN
Director ofNutrition Regina Reed,RN,MSN,FNP
Biodoron Immunology Center Associate Professor
Hollywood,Fla. Washington State Community College
Marrietta,Ohio
Ann S.McQueen,RNC,MSN,CRNP
Family Nurse Practitioner
Healthlink Medical Center
Southampton,Pa.
Dale O’Donnell,RN,BSN
Administrator Community Surgery Center
Community Hospital
Munster,Ind.
William J.Pawlyshyn,RN,MS,MN,
APRN,BC
Nurse Practitioner Consultant
New England Geriatrics
West Springfield,Mass.
Catherine Pence,RN,MSN,CCRN
Assistant Professor
Good Samaritan College ofNursing
Cincinnati
Abby Plambeck,RN,BSN
Freelance Writer
Milwaukee
Theresa Pulvano,RN,BSN
Nursing Educator
Ocean County Vocational Technical School
Lakehurst,N.J.
403X-FM.qxd 1/5/05 5:27 AM Page ix
Foreword
Physical assessment skills and accurate The first four chapters are devoted to a
interpretation ofassessment findings detailed collection ofsubjective and objec-
are the foundation for the implemen- tive data,including health history,assess-
tation ofsafe,competent care to individuals ment techniques,mental health status,and
across all levels ofcare delivery.As the cor- nutritional assessment.Thereafter,each
nerstone ofthe health care process,assess- chapter focuses on assessment for an indi-
ment assists in identifying health status, vidual body system.Each body system chap-
health needs,and problems in order to pro- ter covers anatomy and physiology;health
vide timely,evidence-based,effective care. history,which includes chiefcomplaing,
Today,more than ever,health care profes- current and past health,and family and psy-
sionals face multiple challenges in their dai- chosocial history;physical assessment,and
ly practice including performing the assess- normal and abnormal findings in an easy-
ments,recording the findings,and making to-follow format.Further,chapters include a
the decisions — always under constant cog- quick-scan chart that helps interpret abnor-
nizance oftime.The ultimate challenge is mal findings and differentiate among possi-
balancing these tasks with total competence ble causes.Appendices provide valuable in-
and accuracy,while keeping patient care in formation about head-to-toe assessment,
the forefront. laboratory test results,and resources for the
Professional Guide to Assessmentaims to health care professional,for the patients you
enhance and refine your knowledge base care for,and for their caregivers.
and skill proficiency level,permitting an ac- In these times ofincreasing multiprob-
curate,reliable,and thorough health assess- lem patients in a complex health care envi-
ment.Indeed,it’s imperative that as a health ronment,Professional Guide to Assessment
care professional,you have this streamlined provides you with the right questions and
resource available to meet the needs ofa the best techniques to perform a complete
growing,ever-changing,multiproblem pa- patient history and expert physical exami-
tient population. nation in any clinical setting.
Professional Guide to Assessmentprovides
the latest on taking a thorough patient his- Mario R.Ortiz,RN,PhD
tory and performing the right physical as- Assistant Professor
sessment techniques.Eye-catching icons Family & Community Nursing
highlight racial and age-related differences School ofNursing
in assessments and findings as well as spe- University ofPortland (Ore.)
cial assessment points or emergency situa-
tions that may be revealed during an assess-
ment.Additionally,abundant tables and
illustrations help to highlight key topics and
illustrate expert techniques.
ix
403X-FM.qxd 1/5/05 5:27 AM Page x
