81619_fm.qxd 7/24/09 2:21 PM Page viii 81619_fm.qxd 7/24/09 2:21 PM Page i LabLab ManualManual toto AccompanyAccompany HealthHealth AssessmentAssessment inin NursingNursing FOURTH EDITION JANET WEBER, RN, MSN, EdD Professor Department of Nursing Southeast Missouri State University Cape Girardeau, Missouri JANE KELLEY, RN, PhD Adjunct Professor University of Mississippi Medical Center Jackson, MS Retired from School of Nursing American University of Beirut Beirut, Lebanon ANN SPRENGEL, RN, MSN, EdD Professor Department of Nursing Southeast Missouri State University Cape Girardeau, Missouri 81619_fm.qxd 7/24/09 2:21 PM Page ii Compositor: TechBooks Printer/Binder: Victor Graphics Copyright © 2010 by Lippincott Williams & Wilkins Publishers. All rights reserved. No part of this book may be used or reproduced in any manner whatsoever without written permission with the following exception: testing materials may be copied for classroom use, provided the instructor has adopted its accompanying text, Health Assessment in Nursing, fourth edition, by Janet Weber and Jane Kelley. Printed in the United States of America. For information write Lippincott Williams & Wilkins Publishers, 530 Walnut Street, Philadelphia, Pennsylvania 19106-3780. ISBN: 978-0-7817-8161-9 Any procedure or practice described in this book should be applied by the health care practi- tioner under appropriate supervision in accordance with professional standards of care used with regard to the unique circumstances that apply in each practice situation. Care has been taken to confirm the accuracy of information presented and to describe generally accepted practices. However, the authors, editors, and publisher cannot accept any responsibility for errors or omissions or for any consequences from application of the information in this book and make no warranty, express or implied, with respect to the contents of the book. 10 9 8 7 6 5 4 3 81619_fm.qxd 7/24/09 2:21 PM Page iii ContentsContents Contributors v CHAPTER 8 Preface vii Assessing Pain: The Fifth Vital Sign 40 UNIT I CHAPTER 9 Nursing Data Collection, Documentation, Assessing Victims of Violence 46 and Analysis 1 CHAPTER 10 CHAPTER 1 Assessing Culture 51 Nurse’s Role in Health Assessment: Collecting and Analyzing Data 3 CHAPTER 11 CHAPTER 2 Assessing Spirituality and Religious Practices 56 Collecting Subjective Data 7 CHAPTER 12 CHAPTER 3 Assessing Nutrition 60 Collecting Objective Data 13 UNIT III CHAPTER 4 Nursing Assessment of Validating and Documenting Data 17 Physical Systems 65 CHAPTER 5 CHAPTER 13 Analyzing Data Using Critical Skin, Hair, and Nails 67 Thinking Skills 21 CHAPTER 14 UNIT II Head and Neck 79 Integrative Holistic Nursing Assessment 25 CHAPTER 15 CHAPTER 6 Eyes 89 Assessing Mental Status and Psychosocial CHAPTER 16 Developmental Level 27 Ears 100 CHAPTER 7 CHAPTER 17 Assessing General Status and Vital Signs 34 Mouth, Throat, Nose, and Sinuses 108 iii 81619_fm.qxd 7/24/09 2:21 PM Page iv iv CONTENTS CHAPTER 18 UNIT IV Thorax and Lungs 120 Nursing Assessment of Special Groups 245 CHAPTER 19 CHAPTER 29 Breasts and Lymphatic System 132 Assessing Childbearing Women 247 CHAPTER 20 CHAPTER 30 Heart and Neck Vessels 143 Assessing Newborns and Infants 258 CHAPTER 21 CHAPTER 31 Peripheral Vascular System 154 Assessing Children and Adolescents 267 CHAPTER 22 CHAPTER 32 Abdomen 165 Assessing Frail Elderly Clients 283 CHAPTER 23 CHAPTER 33 Female Genitalia 176 Assessing Families 289 CHAPTER 24 CHAPTER 34 Male Genitalia 187 Assessing Communities 295 CHAPTER 25 Answer Key 305 Anus, Rectum, and Prostate 197 Appendix: Diagnostic Reasoning Guides 324 CHAPTER 26 Musculoskeletal System 207 CHAPTER 27 Neurological System 222 CHAPTER 28 Pulling It All Together 233 Copyright © 2010. Lippincott Williams and Wilkins. 81619_fm.qxd 7/24/09 2:21 PM Page v ContributorsContributors Suha Ballout, RN, BSN Masters Candidate American University of Beirut Medical Center Beirut, Lebanon Chapter 8, Assessing Pain: The Fifth Vital Sign Linda Bugle, RN, PhD Associate Professor Southeast Missouri State University Department of Nursing Cape Girardeau, Missouri Chapter 34, Assessing Communities Cathy Young, DNSc, APRN, BC Associate Professor Texas Tech University Health Sciences Center Lubbock, Texas Jill C. Cash, MSN, APRN, BC Family Nurse Practitioner Southern Illinois OB-GYN Associates Carbondale, Illinois Chapter 30, Assessing Newborns and Infants Chapter 31, Assessing Children and Adolescents Crystal Denise Tripp, RN, CPN Missouri Delta Medical Center Sikeston, Missouri Case Study, Chapter 31: Assessing Children and Adolescents Brenda Johnson, RN, PhD Associate Professor Southeast Missouri State University Department of Nursing Cape Girardeau, Missouri Chapter 32, Assessing Frail Elderly Clients v 81619_fm.qxd 7/24/09 2:21 PM Page vi 81619_fm.qxd 7/24/09 2:21 PM Page vii PrefacePreface The Lab Manual to Accompany Health Assessment in Nursing,4th edition, can be used as a laboratory manual and study guide for the third edition of Health Assessment in Nursing. Each chapter corre- sponds to a chapter in the textbook, and contains a chapter pretest, interactive learner activities, a nursing history checklist, a physical assessment checklist, a chapter posttest, critical thinking questions, case studies, and a self-reflection and evaluation tool. The lab manual can assist you with comprehending theoretical content, applying this content to acquiring history and physical assessment skills, and preparing for tests. Prior to beginning study in each textbook chapter, take the Chapter Pretest. This test is designed to assess the information you may already know from a prior course. It tests basic information related to the content framework or the anatomy and physiology basic to each chapter. (Answers are located in the back of the book.) If you answer most of the questions correctly, proceed to the next section. Otherwise, review the basic framework content or anatomy and physiology found at the very begin- ning of the appropriate chapter. Next read the chapter and then participate in the Learner Activities. These activities are designed to assist you with learning the assessment skills covered in each chapter. These activities actively involve you as a learner to promote understanding and retention of chapter content. Then you can interview your lab partner using the Nursing History Checklist tool provided to document findings. After practicing the physical examination on your lab partner, you can document your findings on the Physical Assessment Checklist tool provided. Both of these tools serve as a reminder of the steps involved in performing a thorough nursing history and physical examination. The completed checklists can also be handed in to your nursing instructor to be evaluated for accu- racy and completeness of client data. To test your comprehension of the content provided, take the Chapter Posttest. Again, the test answers are provided in the back of the lab manual. To test your critical thinking abilities, answer the Critical Thinking Questions found after the posttest. One or two case studies follow this section to test your ability to apply new knowledge in analyzing the client data you documented from a health history interview and physical examination. Finally, use the Self-Reflection and Evaluation tool to identify the degree to which you have met each of the chapter learning objectives. This self-evaluation will help you identify those parts of the chapter you need to review to fully comprehend the knowledge needed to effectively perform a client nursing history and physical examination. We hope and believe this lab manual will assist you to actively learn the content and skills needed to effectively perform a Client Nursing History and Physical Examination. Best wishes and happy learning. Janet Weber Jane Kelley Ann Sprengel vii 81619_fm.qxd 7/24/09 2:21 PM Page viii 81619_ch01-08.qxd 7/24/09 2:33 PM Page 1 UNIT I Nursing Data Collection, Documentation, and Analysis 81619_ch01-08.qxd 7/24/09 2:33 PM Page 2 81619_ch01-08.qxd 7/24/09 2:33 PM Page 3 CHAPTER 1 Nurse’s Role in Health Assessment: Collecting and Analyzing Data Chapter Overview The activities and quizzes that follow are designed to enhance learning about the initial step of the nurs- ing process. Assessment involves the collection of data on which to make a nursing judgment. In prac- tice, nurses collect data continually, beginning with initial comprehensive assessments and continuing with ongoing partial assessments, focused or problem-oriented assessments, and emergency assessments. CHAPTER PRETEST Activity A MATCHING Match the terms in the left column with the correct descriptions in the right column. Term Description 1. Assessment a. Developing a plan of nursing care and outcome criteria 2. Diagnoses b. Carrying out the plan of care c. Sensations or symptoms that can be verified only by the client 3. Planning (e.g., pain) 4. Implementation d. Problem that requires the attention or assistance of other 5. Evaluation health care professionals e. Assessing whether outcome criteria have been met and revising 6. Nursing diagnosis the plan of care if necessary 7. Subjective data f. Collection of subjective and objective data 8. Objective data g. Clinical judgment about individual, family, or community responses to actual or potential health problems and life processes 9. Collaborative problem h. Physiologic complications that nurses monitor to detect their 10. Referral problem onset or changes in status i. Analysis of subjective and objective data to make a profes- sional nursing judgment j. Findings directly observed or indirectly observed through measurements (e.g., body temperature) 3 81619_ch01-08.qxd 7/24/09 2:33 PM Page 4 4 CHAPTER 1 NURSE’S ROLE IN HEALTH ASSESSMENT: COLLECTING AND ANALYZING DATA Activity B LEARNER ACTIVITIES Working with peers in the learning lab After reading Chapter 1 in the textbook, participate in the following activities with your lab partner as assigned. 1. Assess your lab partner’s dietary intake for yesterday and his or her satisfaction with the intake. 2. Share with your lab partner the last time you went to a physician.