STUDENT LABORATORY MANUAL FOR
Health Assessment for Nursing Practice, 7th Edition
by Susan F. Wilson & Jean F. Giddens
Laboratory Manual
,Preƒace
The purpose oƒ this Laboratory Manual is to provide structure ƒor students as they practice with classmates acting as
patients to obtain health histories and perƒorm physical examinations.
• The History contains questions about the patient’s Present health state, Past health history, Ƒamily history, Personal
and psychosocial history, and Review oƒ Systems with space to document ƒindings. In addition to learning how to
obtain a health history, students learn medical terminology, such as documenting “edema” when patients report
“swelling.”
A table is provided at the end oƒ Chapter 2 to help students learn this terminology. Also, the Review oƒ Systems in
chapters containing a health history uses lay terminology ƒollowed by medical terminology in parentheses to help
students learn these terms.
• The Examination section in Chapters 6–17, and 19–22 provides techniques perƒormed in the leƒt column with
space ƒor documenting ƒindings in the right column. Techniques ƒor Special Circumstances have been integrated
within the Routine Techniques. Each examination technique is numbered to ƒacilitate discussion oƒ the skills by
number rather than naming the entire skill. These skills are written to direct the student; thus, the verbs are second
person with an implied “you,” e.g., (You) PERƑORM hand hygiene.
• The Clinical Judgment that ƒollows the history and examination sections uses the ƒirst two layers oƒ the Clinical
Judgment Measurement Model to help students analyze data. These include: 1) Recognize cues ƒor this patient.
Identiƒy relevant ƒindings ƒrom the history and examination and 2) Analyze cues. Organize and link the recognized
cues to the patient’s clinical presentation.
• A Perƒormance Check List ƒor examination skills has been added ƒollowing each examination section in Chapters
7–17 and 22 as a structure to evaluate students. There are ƒour descriptors oƒ perƒormance: Correct (C), Incomplete
(Inc), Incorrect (I), and Not perƒormed (NP). Skills in the Check List are numbered the same as those in the exam-
ination section. These skills are written to direct the evaluator; thus, the verbs are present tense, third person with
an implied “he or she”, e.g., (He/She) PERƑORMS hand hygiene.
• Ƒollowing the Skills Perƒormance Check List is an Implementation checklist that allows an appraisal oƒ the student’s
implementation oƒ the examination including assembly and use oƒ equipment, the organization oƒ the examination,
the conƒidence demonstrated by the student, and the student’s interaction with the “patient.” These skills are written
to direct the evaluator who assesses the implementation oƒ the examination; thus, the verbs are past tense, third
person with an implied “he or she”, e.g., (He/She) Assembled needed equipment.
• At the end oƒ the Check List there is space to tally the number ƒrom each category oƒ descriptors in each oƒ the
categories in Examination and Implementation.
• There are no laboratory activities ƒor Chapters 1, 18, 23, and 24.
iii
,
, Contents
Chapter 2 Obtaining a Health History ................................................................................................................................ 1
Chapter 3 Techniques and Equipment ƒor Physical Assessment .....................................................................................15
Chapter 4 General Inspection and Measurement oƒ Vital Signs.......................................................................................23
Chapter 5 Cultural Competence ...................................................................................................................................... 27
Chapter 6 Pain Assessment .............................................................................................................................................. 33
Chapter 7 Mental Health Assessment ............................................................................................................................. 41
Chapter 8 Nutritional Assessment....................................................................................................................................49
Chapter 9 Skin, Hair, and Nails .........................................................................................................................................57
Chapter 10 Head, Eyes, Ears, Nose, and Throat .................................................................................................................65
Chapter 11 Lungs and Respiratory System ........................................................................................................................ 79
Chapter 12 Heart and Peripheral Vascular System ................................................................................................................87
Chapter 13 Abdomen and Gastrointestinal System...............................................................................................................95
Chapter 14 Musculoskeletal System ................................................................................................................................... 103
Chapter 15 Neurologic System.............................................................................................................................................115
Chapter 16 Breasts and Axillae ............................................................................................................................................ 127
Chapter 17 Reproductive System and the Perineum ...........................................................................................................135
Chapter 19 Assessment oƒ the Inƒant, Child, and Adolescent .............................................................................................149
Chapter 20 Assessment oƒ the Pregnant Patient ................................................................................................................. 169
Chapter 21 Assessment oƒ the Older Adult ..........................................................................................................................193
Chapter 22 Conducting a Head-to-Toe Examination ..........................................................................................................217
v
Health Assessment for Nursing Practice, 7th Edition
by Susan F. Wilson & Jean F. Giddens
Laboratory Manual
,Preƒace
The purpose oƒ this Laboratory Manual is to provide structure ƒor students as they practice with classmates acting as
patients to obtain health histories and perƒorm physical examinations.
• The History contains questions about the patient’s Present health state, Past health history, Ƒamily history, Personal
and psychosocial history, and Review oƒ Systems with space to document ƒindings. In addition to learning how to
obtain a health history, students learn medical terminology, such as documenting “edema” when patients report
“swelling.”
A table is provided at the end oƒ Chapter 2 to help students learn this terminology. Also, the Review oƒ Systems in
chapters containing a health history uses lay terminology ƒollowed by medical terminology in parentheses to help
students learn these terms.
• The Examination section in Chapters 6–17, and 19–22 provides techniques perƒormed in the leƒt column with
space ƒor documenting ƒindings in the right column. Techniques ƒor Special Circumstances have been integrated
within the Routine Techniques. Each examination technique is numbered to ƒacilitate discussion oƒ the skills by
number rather than naming the entire skill. These skills are written to direct the student; thus, the verbs are second
person with an implied “you,” e.g., (You) PERƑORM hand hygiene.
• The Clinical Judgment that ƒollows the history and examination sections uses the ƒirst two layers oƒ the Clinical
Judgment Measurement Model to help students analyze data. These include: 1) Recognize cues ƒor this patient.
Identiƒy relevant ƒindings ƒrom the history and examination and 2) Analyze cues. Organize and link the recognized
cues to the patient’s clinical presentation.
• A Perƒormance Check List ƒor examination skills has been added ƒollowing each examination section in Chapters
7–17 and 22 as a structure to evaluate students. There are ƒour descriptors oƒ perƒormance: Correct (C), Incomplete
(Inc), Incorrect (I), and Not perƒormed (NP). Skills in the Check List are numbered the same as those in the exam-
ination section. These skills are written to direct the evaluator; thus, the verbs are present tense, third person with
an implied “he or she”, e.g., (He/She) PERƑORMS hand hygiene.
• Ƒollowing the Skills Perƒormance Check List is an Implementation checklist that allows an appraisal oƒ the student’s
implementation oƒ the examination including assembly and use oƒ equipment, the organization oƒ the examination,
the conƒidence demonstrated by the student, and the student’s interaction with the “patient.” These skills are written
to direct the evaluator who assesses the implementation oƒ the examination; thus, the verbs are past tense, third
person with an implied “he or she”, e.g., (He/She) Assembled needed equipment.
• At the end oƒ the Check List there is space to tally the number ƒrom each category oƒ descriptors in each oƒ the
categories in Examination and Implementation.
• There are no laboratory activities ƒor Chapters 1, 18, 23, and 24.
iii
,
, Contents
Chapter 2 Obtaining a Health History ................................................................................................................................ 1
Chapter 3 Techniques and Equipment ƒor Physical Assessment .....................................................................................15
Chapter 4 General Inspection and Measurement oƒ Vital Signs.......................................................................................23
Chapter 5 Cultural Competence ...................................................................................................................................... 27
Chapter 6 Pain Assessment .............................................................................................................................................. 33
Chapter 7 Mental Health Assessment ............................................................................................................................. 41
Chapter 8 Nutritional Assessment....................................................................................................................................49
Chapter 9 Skin, Hair, and Nails .........................................................................................................................................57
Chapter 10 Head, Eyes, Ears, Nose, and Throat .................................................................................................................65
Chapter 11 Lungs and Respiratory System ........................................................................................................................ 79
Chapter 12 Heart and Peripheral Vascular System ................................................................................................................87
Chapter 13 Abdomen and Gastrointestinal System...............................................................................................................95
Chapter 14 Musculoskeletal System ................................................................................................................................... 103
Chapter 15 Neurologic System.............................................................................................................................................115
Chapter 16 Breasts and Axillae ............................................................................................................................................ 127
Chapter 17 Reproductive System and the Perineum ...........................................................................................................135
Chapter 19 Assessment oƒ the Inƒant, Child, and Adolescent .............................................................................................149
Chapter 20 Assessment oƒ the Pregnant Patient ................................................................................................................. 169
Chapter 21 Assessment oƒ the Older Adult ..........................................................................................................................193
Chapter 22 Conducting a Head-to-Toe Examination ..........................................................................................................217
v
