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Copyright © 2022 Elsevier, Inc. All Rights Reserved. 15
Student Laboratory Manual for
WILSON & GIDDENS

Health Assessment for
Nursing Practice
Seventh Edition
Student Laboratory Manual prepared by

Susan Fickertt Wilson, PhD, RN
Emeritus Associate Professor
Harris College of Nursing and Health Sciences
Texas Christian University
Fort Worth, Texas
ELSEVIER
3251 Riverport Lane
St. Louis, Missouri 63043
STUDENT LABORATORY MANUAL FOR HEALTH ASSESSMENT FOR

NURSING PRACTICE, SEVENTH EDITION ISBN: 978-0-323-76323-3
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Preface
The purpose of this Laboratory Manual is to provide structure for students as they practice with classmates acting as
patients to obtain health histories and perform physical examinations.
• The History contains questions about the patient’s Present health state, Past health history, Family history, Personal
and psychosocial history, and Review of Systems with space to document findings. 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 of Chapter 2 to help students learn this terminology. Also, the Review of Systems in
chapters containing a health history uses lay terminology followed by medical terminology in parentheses to help
students learn these terms.
• The Examination section in Chapters 6–17, and 19–22 provides techniques performed in the left column with
space for documenting findings in the right column. Techniques for Special Circumstances have been integrated
within the Routine Techniques. Each examination technique is numbered to facilitate discussion of 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) PERFORM hand hygiene.
• The Clinical Judgment that follows the history and examination sections uses the first two layers of the Clinical
Judgment Measurement Model to help students analyze data. These include: 1) Recognize cues for this patient.
Identify relevant findings from the history and examination and 2) Analyze cues. Organize and link the recognized
cues to the patient’s clinical presentation.
• A Performance Check List for examination skills has been added following each examination section in Chapters
7–17 and 22 as a structure to evaluate students. There are four descriptors of performance: Correct (C), Incomplete
(Inc), Incorrect (I), and Not performed (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) PERFORMS hand hygiene.
• Following the Skills Performance Check List is an Implementation checklist that allows an appraisal of the student’s
implementation of the examination including assembly and use of equipment, the organization of the examination,
the confidence demonstrated by the student, and the student’s interaction with the “patient.” These skills are written
to direct the evaluator who assesses the implementation of 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 of the Check List there is space to tally the number from each category of descriptors in each of the
categories in Examination and Implementation.
• There are no laboratory activities for Chapters 1, 18, 23, and 24.
iii
Contents
Chapter 2 Obtaining a Health History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Chapter 3 Techniques and Equipment for Physical Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Chapter 4 General Inspection and Measurement of 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 of the Infant, Child, and Adolescent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149
Chapter 20 Assessment of the Pregnant Patient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169
Chapter 21 Assessment of the Older Adult . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 193

Chapter 22 Conducting a Head-to-Toe Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217
v
Student Name ____________________________________________________________ Date _________________________
CHAPTER 2 Obtaining a Health History
With your lab partner assuming the role of a patient, conduct a comprehensive history. Your “student patient” may role-play
a person with particular related symptoms and history.
HISTORY
BIOGRAPHIC DATA
Date Name Preferred name Sex Gender Identity

Male Male
Female Female
Both
Neither
Date of Age Race/Ethnicity Religion Language(s)

birth
Marital status Occupation

S M D W
REASON FOR SEEKING CARE (Presenting problem)
HISTORY OF PRESENT ILLNESS

Symptom Analysis of Presenting Problem (Onset, Location, Duration, Characteristics, Aggravating factors, Related
symptoms, Treatment, Severity)
PRESENT HEALTH STATUS

• Describe your current health conditions.
ο How long have you had these conditions?
ο How have these health conditions affected your daily activities?

2 Chapter 2 Obtaining a Health History
• What medications or supplements do you take? (Include prescription, over-the-counter, herbs, and vitamins)
(Document if no medications or supplements are taken)
Name of Drug/Supplement Dosage/Frequency Last Dose Taken Reason for Taking
• Describe any medical treatments you are receiving (e.g., breathing treatments, dialysis, wound dressing):
(Document if no medical treatments are received)
• Describe any allergies to medications, foods, medical products (e.g., latex, contrast, tape), or things in the environment.
Describe your symptoms and their frequency. (Document if there are no allergies)
Allergic To Reaction and frequency
PAST HEALTH HISTORY

Childhood Illnesses (Check all that apply):
Measles ❏ Mumps ❏ Rubella ❏ Chickenpox ❏

Pertussis ❏ Influenza ❏ Ear infections ❏ Throat infections ❏
Other (describe) ❏
Copyright © 2022 Elsevier, Inc. All Rights Reserved.

Chapter 2 Obtaining a Health History 3
List previous medical conditions, surgeries, hospitalizations, or injuries. (Document if none apply)
Name and Type Date Residual Problems
Immunization Date/s Immunization Date/s

Diphtheria, tetanus, acellular pertussis (DTaP) Haemophilus influenzae type b (Hib)
Hepatitis A (HepA) Hepatitis B (HepB)
Human papillomavirus (HPV) Influenza (IIV)
Inactivated poliomyelitis (IPV) Influenza live attenuate vaccine (LAIV)
Meningococcal serogroups A, C, W, Y Meningococcal serogroup B (MenB)
(MenACWY)
Measles, mumps, rubella (MMR) Pneumococcal conjugate vaccine (PCV13)
Pneumococcal polysaccharide vaccine (PPS23) Zoster recombinant (RZV)
Rotavirus (RV) Tetanus toxoid (Td)
Tetanus, diphtheria, acellular pertussis (Tdap) Varicella (VAR)
Zoster live (ZVL) Other
www.cdc.gov/vaccines/schedules. Accessed 1/27/20.
Last Examination Date Outcome

Last Physical
Last Vision
Last Dental
Other (describe)
Women Only
Last Pap Test
Last Mammogram
Men Only
Prostate Exam

Obstetric history
Last menstrual period (LMP) Date Outcome

Pregnancies Dates Gravida (number of pregnancies) ________
Para (number of births) ________
Abortion/miscarriage ________
FAMILY HISTORY
(Document age and current health of family members. If deceased, indicate age and cause of death.)
Person Age Current Health Person Age Current Health

Mother Father
Sister Brother
Sister Brother
Daughter Son
Daughter Son
Draw a genogram for your lab partner’s family history.

PERSONAL AND PSYCHOSOCIAL HISTORY

Personal Status
• How would you describe yourself? or How do you feel about yourself?
• Describe your cultural/religious affiliations and practices.
• Describe your education, occupational history, and work satisfaction.
• Describe your perception of adequate time for leisure and rest, hobbies and interests.
Family and Social Relationships

• Describe your satisfaction with interpersonal relationships including significant others, individuals in home, and
your role within family.
• Describe the state of health of these individuals. Describe social interactions with friends, social organizations, or
religious groups.

Diet/Nutrition
• Describe your appetite, typical food and fluid intake, and caffeine intake.
• Do you have any dietary restrictions or food intolerances?
• Have you had any changes in appetite or weight; changes in taste of food; problems while eating, e.g., indigestion,
pain, difficulty chewing or swallowing? If yes, describe.
• Have you had experiences with overeating, sporadic eating, or intentional fasting? If yes, describe.
Functional Ability
Do you need any assistance performing any of the following activities?†
Dressing ❏ Toileting ❏ Bathing ❏ Eating ❏ Ambulating ❏
Shopping ❏ Cooking ❏ Housekeeping ❏ Managing finances ❏
If unable to perform independently, describe.

†
Mental Health
• Describe your sources of stress. How do you cope with these stresses?
• Have you had feelings of anxiety, depression, irritability, or anger? If yes, describe.
Tobacco, Alcohol, and Illicit Drug Use
Tobacco use: Y ❏ N ❏ Type: Daily use:

Alcohol intake: Y ❏ N ❏ Type: Drinks per day:
Illicit drug use: Y ❏ N ❏ Describe: Frequency:

Health Promotion Practices

• What activities do you perform regularly to maintain your health?
Exercise (type/frequency):
Stress management:
Sleep habits:
Use of seat belts:
Other:
Environment (Include living and work environments)

• Describe actions do you take to main your environmental safety? (Circle hazards below and add others as warranted.)
Potential hazards within home e.g., lack of fire or smoke detectors, poor lighting, steep stairs, inadequate
heat, open gas heaters, inadequate pest control, violent behaviors, firearms
Potential hazards within e.g., noise, water or air pollution, heavy traffic, overcrowding, violence,
neighborhood firearms, sale/use of street drugs
Potential hazards within work e.g., inhalants, noise, heaving lifting, machinery, psychological stress
environment
Any travel outside the United Describe locations and dates
States
REVIEW OF SYSTEMS
• Remember to ask questions using lay terms the patient understands, but document using medical terminology. For
example, ask the patient if he has shortness of breath; if he says “yes,” perform and document a symptom analysis
and document that the patient “reports dyspnea.” (See the Learning Activity at the end of this chapter for a listing
of lay and medical terms.)
• Check all boxes that apply and add additional data below each section.
• Document if no symptoms are reported.
General Symptoms
Pain ❏ Fatigue ❏ Weakness ❏ Fever ❏
Unexplained changes in
Problems sleeping ❏
weight ❏
Additional data:

Integumentary System
Skin lesions (wounds, Excessive dryness ❏ Excessive sweating or Changes in skin
sores, growths) ❏ odors ❏ temperature, texture,
color ❏
Change in a mole ❏ Sore that does not heal ❏ Rashes ❏ Itching (pruritus) ❏
Frequent bruising ❏ Changes in amount, texture, Hair loss (alopecia) ❏ Itching scalp ❏
distribution of hair ❏
Changes in texture, color, Use of sunscreen ❏ Skin self-examination ❏ Types and frequency of
or shape of nails ❏ nail care ❏
Additional data:
Head
Headaches ❏ Significant trauma ❏ Dizziness ❏ Fainting (syncope) ❏
Use of protective head gear ❏
Additional data:
Eyes
Discharge ❏ Redness ❏ Itching (Pruritis) ❏ Excessive tearing ❏
Eye pain (Ophthalmalgia) ❏ Change in vision ❏ Difficulty reading ❏ Blurred vision ❏
Sensitivity to bright lights Blind spots ❏ Floaters ❏ Halo around lights ❏

(Photophobia) ❏
Double vision (Diplopia) ❏ Do you wear Do you wear contact Use protective
eyeglasses? ❏ lenses? ❏ eyewear? ❏
Additional data:
Ears
Ear pain (otalgia) ❏ Excessive earwax ❏ Discharge ❏ Recurrent infections ❏
Decreased hearing ❏ Sensitivity to noises ❏ Ringing in the ears (tinnitus) ❏ Use of hearing device ❏
Protect ears from excessively loud noises ❏
Additional data:

Nose, Nasopharynx, Sinuses

Nasal discharge ❏ Nose bleeds (epistaxis) ❏ Sneezing ❏ Nasal obstruction ❏
Sinus pain ❏ Postnasal drip ❏ Change in ability to smell ❏ Snoring ❏
Additional data:
Mouth/Oropharynx
Sore throat ❏ Tongue or mouth lesions Bleeding gums ❏ Dental prosthesis
(abscess, sore, ulcer) ❏ (dentures, bridges) ❏
Altered taste ❏ Difficulty swallowing Trouble chewing ❏ Change in voice ❏
(dysphagia) ❏
Oral hygiene practice (frequency of brushing/flossing) ❏
Additional data:
Neck
Lymph node Edema or mass in Neck pain ❏ Neck stiffness/limitation in
enlargement ❏ neck ❏ movement ❏
Additional data:
Breasts
Pain ❏ Swelling (edema) ❏ Lumps or masses ❏ Breast dimpling ❏
Nipple discharge ❏ Change in nipples ❏
Additional data:

Respiratory System
Cough, nonproductive Coughing up blood Frequent colds ❏ Shortness of breaths
or productive ❏ (hemoptysis) ❏ (dyspnea) ❏
Night sweats ❏ Wheezing ❏ High pitched, musical sound Pain with breathing (inspiration/
when breathing (stridor) ❏ expiration) ❏
Handwashing Tuberculosis Smoking cessation ❏ Reducing secondhand smoke ❏
frequency ❏ screening ❏
Additional data:
Cardiovascular System
Sensation of heart fluttering Chest pain ❏ Shortness of breath Difficulty breathing unless
or racing (palpitations) ❏ (dyspnea) ❏ sitting up (orthopnea) ❏
Periodic shortness of breath Coldness in extremities ❏ Numbness ❏ Swelling (edema) of hands
during sleep (paroxysmal or feet ❏
nocturnal dyspnea) ❏
Varicose veins ❏ Leg pain with activity Leg pain with activity Abnormal sensation
relieved by rest (intermittent not relieved by rest in extremities
claudication) ❏ (rest pain) ❏ (paresthesia) ❏
Changes in color of Limit salt and fat intake ❏ Blood pressure
extremities ❏ screening ❏
Additional data:
Gastrointestinal System
Pain ❏ Heartburn ❏ Nausea/vomiting ❏ Vomiting blood
(hematemesis) ❏
Yellowing of sclera/skin Increased abdominal size due to Changes in usual bowel Painful defecation ❏
(jaundice) ❏ fluid accumulation (ascites) ❏ habits ❏
Passing gas (flatus) Change in color or consistency of Constipation ❏ Diarrhea ❏
excessively ❏ stools ❏
Blood in stools Hemorrhoids ❏ Dietary analysis ❏ Colon cancer
(hematochezia) ❏ screening ❏
Additional data:

Urinary System
Changes in color, Difficulty initiating urine Repeated need to urinate Sudden, almost
contents, or odor of flow (hesitancy) ❏ (frequency) ❏ uncontrollable need to
urine ❏ urinate (urgency) ❏
Change in urine Excessive urination during Pain with urination Pain in back between ribs
stream ❏ the night (nocturia) ❏ (dysuria) ❏ and ilium (flank pain) ❏
Blood in urine Inability to control urination Excretion of abnormally large Decreased urine output
(hematuria) ❏ (incontinence) ❏ volumes of urine (polyuria) ❏ (oliguria) ❏
Plan to prevent urinary Performing Kegel
tract infections ❏ exercises ❏
Additional data:
Reproductive System
Male: Lesions ❏ Pain in penis or Masses in penis or Penile discharge ❏
testicles ❏ testicles ❏
Hernia ❏
Female: Lesions ❏ Pain ❏ Vaginal discharge/ Absent menstruation
odor ❏ (amenorrhea) ❏
Excessive Painful menstruation Irregular Pelvic pain ❏
menstruation (dysmenorrhea) ❏ menstruation
(menorrhagia) ❏ (metrorrhagia) ❏
Sexual Activity
Are you currently ❏ No
involved in a sexual ❏ Yes Is the nature of the relationship heterosexual, homosexual, or bisexual?
relationship(s)?
What is the type and Type: ❏Vaginal ❏Anal ❏Oral ❏Oher _____________________________
frequency of sexual Frequency:
activity?
Number of sexual
partners in last 3
months?
Do you protect ❏ No
yourself from sexually ❏ Yes, what method is used?
transmitted infections
(STIs)?
Do you use birth ❏ No
control? ❏ Yes, what method is used?
Problems with sexual activity
Change in sex Infertility ❏ Exposure to Females: Pain Females: Bleeding after
drive ❏ sexually transmitted intercourse intercourse (postcoital
infections ❏ (dyspareunia) ❏ bleeding) ❏
Males: Inability to Males: Premature
achieve erection ejaculation ❏
(impotence) ❏
Additional data:

Musculoskeletal System
Muscle twitching ❏ Muscle cramping/pain ❏ Muscle weakness ❏ Joint swelling (edema) or
redness (erythema) ❏
Joint pain ❏ Joint stiffness/ Noise with joint movement Limitations in range of
deformity ❏ (crepitus) ❏ motion ❏
Back pain ❏ Amount and kind of Osteoporosis screening ❏
weekly exercise ❏
Additional data:
Neurologic System
Headache ❏ Seizures ❏ Fainting/loss of consciousness Changes in movement ❏
(syncope) ❏
Inability to coordinate muscle Change in Difficulty swallowing Difficulty communicating
movement (ataxia) ❏ sensation ❏ (dysphagia) ❏ (dysphasia) ❏
Use seat belts in a vehicle ❏ Wear helmet ❏
Additional data:
CLINICAL JUDGMENT
1. Recognize cues for this patient. Identify relevant and important data from the history. (Which information is
relevant/irrelevant? Which information is most important? What is of immediate concern?)
2. Analyze cues. Organize and link the recognized cues to the patient’s clinical presentation. (Why is a particular cue or
subset of cues of concern? What other information would help establish the significance of a cue or subset of cues?)
3. Using the analysis above, develop a problem list for this patient.

LEARNING ACTIVITY: With your lab partner, quiz each other on the lay terms and medical terms used to document a
health history. For example, ask your partner (from the left side of the table), “What is the medical term for swelling?” or
work from the other side by asking, “If you want to know if the patient has had syncope, what term do you use with the
patient?”
When the patient reports these symptoms: → You document symptoms using these terms:
Skin, Hair, and Nails

Itching Pruritus
Tiny red or purple spots on the skin surface formed by Petechiae
minute hemorrhages
Swelling Edema
Hair loss Alopecia
Head, Eyes, Ears, Nose, Throat

Brief loss of consciousness, fainting Syncope
Eye pain Ophthalmalgia
Double vision Diplopia
Increased sensitivity to light Photophobia
Ear pain Otalgia
Ear wax Cerumen
Ringing in the ears Tinnitus
Nose bleed Epistaxis
Difficulty swallowing Dysphagia
Respiratory system
Coughing up blood Hemoptysis
Short of breath Dyspnea
High-pitched, musical sound when breathing Stridor
Cardiovascular system
Sensation that the heart is racing or fluttering Palpitations
Difficulty breathing unless sitting up Orthopnea
Periodic shortness of breath during sleep Paroxysmal nocturnal dyspnea
Leg pain during activity relieved with rest Intermittent claudication
Leg pain during activity not relieved with rest Rest pain
Abnormal sensations in extremities Paresthesia
Gastrointestinal system
Vomiting blood Hematemesis
Yellowish color of skin or sclera Jaundice
Increased abdominal size due to fluid accumulation Ascites

When the patient reports these symptoms: → You document symptoms using these terms:
Passing gas Flatus
Blood in the feces/stool Hematochezia
Urinary system
Difficulty initiating urine flow Urinary hesitancy
Repeated need to urinate Urinary frequency
Sudden, almost uncontrollable need to urinate Urinary urgency
Painful urination Dysuria
Pain in the back between ribs and ilium Flank pain
Blood in the urine Hematuria
Inability to control urination Incontinence
Excretion of abnormally large volumes of urine Polyuria
Excessive urination during the night Nocturia
Decreased urine output Oliguria
Reproductive system – Female

Absent menstruation Amenorrhea
Excessive menstruation Menorrhagia
Painful menstruation Dysmenorrhea
Irregular menstruation Metrorrhagia
Painful intercourse Dyspareunia
Bleeding after intercourse Postcoital bleeding
Reproductive system – Male

Inability to achieve an erection Impotence
Musculoskeletal system
Noise with joint movement Crepitus
Redness (e.g., of joints) Erythema
Neurologic system
Inability to coordinate muscle movement Ataxia
Difficulty communicating Dysphasia

CHAPTER 3 Techniques and Equipment for

Physical Assessment
Equipment Provided by Student Equipment Provided by School Lab

• Penlight • Empty cardboard box and fluid-filled bag for percussion
• Stethoscope • Sphygmomanometer
• Ruler • Thermometer(s)
• Pulse oximeter
• Scale to measure weight and height
• Skin-fold calipers
• Ruler or tape measure
• Visual acuity charts
• Ophthalmoscope
• Otoscope with specula
• Audioscope with specula
• Tuning fork
• Nasal speculum
• Doppler
• Goniometer
• Percussion hammer or neurologic hammer
• Monofilament
• Vaginal speculum
After performing hand hygiene, perform these examination techniques with a lab partner.
Examination Techniques Document Findings

Inspection
Inspect the skin on the forearm of your lab partner.
What is the overall color? Do you see any variations in color? Color:
Notice the hair on the arm—amount, color, patterns. Hair color/distribution:
Do you see a lesion (scar, mole) on the forearm? If so,
where is it located, what color is it, and what size is it? Lesions:
Does using a pen light to create tangential lighting
improve the inspection?
Using a penlight, inspect our lab partner’s pupillary Pupil reactivity and equality
constriction and equality.

16 Chapter 3 Techniques and Equipment for Physical Assessment
Examination Techniques Document Findings

Palpation Palpate a radial pulse.
With your lab partner, practice light palpation with deep light
your fingertips and deep palpation with your hands. In
the column to the right, indicate the type of palpation
appropriate for the example given.
Palpate the texture of skin.
deep light
Palpate the abdomen.
deep light
Palpate tenderness over a muscle.
deep light
Touch the skin of your lab partner. Notice the
temperature, moisture, and skin texture. Skin Palpation
Temperature:
Moisture:
Texture:
Percussion Empty cardboard box:
Practice indirect finger percussion using the surface of
the following three objects: an empty cardboard box, a
Table surface:
table surface, and a liquid-filled plastic container.
Can you hear percussion tones?
Can you hear differences in the tones of the various Liquid-filled plastic container:
objects?
Practice indirect finger percussion with your lab partner.
Percuss over the following places: abdomen over the Abdomen-stomach:
stomach; abdomen over the liver; chest over the lung
field; and chest over the sternum. Abdomen-liver:
Can you hear percussion tones?
Chest-lung:
an you hear differences in tones as you percuss the
C
different areas? Chest-sternum:
Auscultation
Identify the following parts of your stethoscope: earpiece,
tubing, head (bell and diaphragm) (See Fig. 3.8A.) If your
stethoscope has a two-sided head, turn it to the bell and then
to the diaphragm. How can you tell which side is engaged?
Place the earpieces in your ears, pointing forward. Gently
rub or tap the head of the stethoscope to sound.
With your lab partner, listen with your stethoscope for
sounds at the following locations: Yes No
abdomen Abdomen ❏ ❏
carotid artery Carotid artery ❏ ❏
lungs Lungs ❏ ❏
heart Heart ❏ ❏
brachial artery Brachial artery ❏ ❏
Indicate “Y” or “N” whether you can hear sounds.
Chapter 3 Techniques and Equipment for Physical Assessment 17
USING EQUIPMENT
With a lab partner, complete the following activities using the equipment available in your lab.
Thermometers
Electronic thermometer:
• Put a disposable sheath over the probe. See Fig. 3.7A for an example. What is the temperature? _______________
• What temperature unit is the electronic thermometer calibrated in?
Fahrenheit ❏ Celsius ❏ Both ❏
Tympanic thermometer:
• Put a disposable sheath over the probe. See Fig. 3.7B for an example. What is the temperature? _______________
Temporal artery thermometer:

• Depress the scan button on the thermometer and slide across one side of the lab partner’s forehead to behind the
ear. See Fig. 3.7C for an example. What is the temperature? _______________________
Sphygmomanometer/Cuffs
• Practice placing and removing a cuff on your lab partner’s arm. See Fig. 3.9A for an example.
• Compare various sizes of cuffs. See Fig. 3.10 for an example. Practice steps involved in determining a correct fit on
your lab partner.
• Holding the cuff tightly wrapped in your hand, practice inflating the cuff with the inflation bulb, then slowly deflate
the cuff using the control knob next to the inflation bulb.
• If your lab has one, examine an automated blood pressure device. (See Fig 3.9B for an example.) How does the
procedure for placing a cuff differ compared with the manual BP cuffs?
• Determine how to turn the device on and off. Identify the display for blood pressure measurement. What other
information is displayed?
Pulse Oximeter
• Turn on the device, place the probe on the finger of your lab partner, and record the oxygen saturation of arterial
blood (SaO2). See Fig. 3.11 for an example.
Level = ______%
• What does this mean?
Scale to measure body weight and height

• Calibrate the weight on a standing platform scale to 0 (zero) before weighing your lab partner. See Fig. 3.12A for an
example.
• Determine the weight of your lab partner by balancing the weights. ______________lb.
• Determine the height of your lab partner ________ft, ______In.

Skin-Fold Calipers
• What are the calibrations of the calipers? See Fig. 3.13 for an example.
• Manipulate the calipers. Measure the thickness of your lab partners triceps skin fold. See Fig. 8.11 for an
example of the technique.
• Use Table 8.6 to determine the percentile. Document your findings,
Average of measurements:_______________________________mm.
Percentile: _______________________________
Ruler and Tape Measure

• Notice the units of measurement on your ruler: Tape measure:
• Measure the following spots with your ruler. Write your measurements in the space provided.
a. in./cm.
b. in./cm.
c. in./cm.
• Measure the circumference of your lab partner’s left wrist and his or her left forearm, 4 inches below the elbow.
Record your measurements. Left wrist __________ Left forearm __________

Visual Acuity Charts

• Distance vision. Using a Snellen visual acuity chart at a distance of 20 feet from your lab partner, test distance vision
and screen for color and field perceptions of each eye with glasses off and on. (See Figs. 3.15A-D for examples.)
Document your findings.
Eye glasses off glasses on

Left eye /20 /20
Right eye /20 /20
_________ Correctly Identified red and green lines.
_________ Identified green line as longer.
• Near vision. While your lab partner holds a Rosenbaum or similar tool 14 Inches from the face, test near vision of
each eye. See Fig. 3.16 for an example. Document your findings.
Eye glasses off glasses on

Left eye /20 /20
Right eye /20 /20
Ophthalmoscope
• Practice attaching and removing the head of the ophthalmoscope. See Fig. 3.17A for an example.
• Turn on the power switch to your instrument. Shine the light from the instrument against your hand. Turn the
aperture dial and observe the various settings: large light, small light, red-free filter, slit light, and grid light. As you
shine these on your hand, identify each setting.
• Locate the lens selector dial. Turn the lens and observe the red and black numbers.
• Look through the eyepiece at your hand (or another object) and slowly turn the lens selector dial. Become familiar
with adjusting the magnification while looking through the eyepiece.
Otoscope
• Practice attaching and removing the head of the otoscope. See Fig. 3.18A for an example.
• Compare adult and pediatric speculums (black, cone-shaped pieces).
• Place a speculum on the head of the otoscope.
• Turn on the power switch to your instrument. Shine the light from the instrument against your hand.
• Look through the lens at your hand or another small object.
Audioscope
• Select a speculum that snuggly fits the ear canal of your lab partner and attach the speculum to the audioscope.
See Fig. 3.19 for an example.
• Instruct your lab partner: After the speculum is placed in the external auditory canal, he or she should raise an
index when a tone is heard.

• Turn on the audioscope by sliding the switch to the desired screening level. A light appears when the audioscope is
ready for use.
• As tones are delivered at each frequency or Hertz, the patient indicates the tone can be heard, providing objective
measurement of hearing.
Tuning Fork
• Identify the type or types of tuning forks available in your lab. See Fig. 3.20 for an example.
• Strike the tuning fork against the palm of your hand. Place the vibrating tuning fork on your sternum, clavicle,
styloid process of your radius (wrist), and/or lateral or medial malleolus (ankle).
• Are you able to hear and feel vibrations?
Nasal Speculum
• Use the simple nasal speculum with a penlight to visualize the lower and middle turbinates of both sides of the nose
of your lab partner. See Fig. 3.21 for an example of a nasal speculum.
• Describe your findings.
Doppler
• Turn the Doppler on and listen to the vascular tones over the radial or brachial artery of your lab partner. See Fig. 3.22
for an example. What sounds do you hear over the vessel?
Goniometer
• See Fig. 3.23 for an example of a goniometer. Refer to Box 14.1 for How to Use a goniometer and Fig. 14.21 for an
example of its use.
• What is the calibration for measurement?
• Set the goniometer at the following angles: 90°, 60°, 110°, 45°
• Practice using the goniometer by measuring your lab partner’s flexed elbow. Document your findings.
• Right elbow ________0 Left elbow _________0
Percussion hammer and neurologic hammer
• Notice the different designs of each hammer. The percussion hammer as a triangular shape, while the neurologic
hammer is rounded on both sides. See Fig. 3.24 for an example of a percussion hammer.
• With your lab partner sitting on a table with legs hanging free, use the pointed surface of the percussion hammer to
strike the patella tendon to test the deep tendon reflex. See Fig. 15.22D for an example.
• Document your results using Box 15.3 for Scoring Deep Tendon Reflexes (DTRs)
• Patellar reflex score ____________________
• With your lab partner in the same position, passively flex the foot and strike the Achilles tendon with the flat surface
of the percussion hammer. See Fig. 15.22E for an example. Document your findings using Box 15.3.

• Achilles reflex score ____________________
Monofilament
• Out of your lab partner’s line of vision, place the monofilament on the ball of your lab partner’s bare foot and apply
slight pressure so that the wire bends.
• Ask your lab partner to indicate when and where the wire is felt. Repeat the procedure on the other foot.
• Repeat the procedure at other sites: plantar aspect of the foot, great toe, and heel of each foot.
• Document the findings:
Ball of foot Plantar aspect Great toe Heel

Right foot
Left foot
Vaginal Speculum
• All specula are composed of two blades and a handle and are available as either reusable metal or disposable plastic
models (Fig. 3.26). Plastic and metal specula differ slightly in the ease of use and positioning.
• Examine the blades and handle of the speculum and practice opening and closing the blades.
• Practice is necessary in order to use these confidently and ensure patient comfort.
• There are three types of vaginal specula: Graves, Pederson, and pediatric or virginal.
 The Graves speculum is available in a variety of sizes. The bottom blade is slightly longer than the top blade to
conform to the longer posterior vaginal wall and aid in visualization.
 The Pederson speculum has blades that are as long as those of the Graves speculum, but are narrow and flatter.
 The pediatric or virginal speculum is smallest in all dimensions of width and length.
• The metal speculum has two positioning devices. The top blade is hinged and has a thumb lever attached. When
the thumb level is pressed down, the distal end of the top blade rises and opens the speculum. The blade can be
locked open at that point by tightening the screw on the thumb lever. The proximal end of the speculum can also be
opened wider if necessary by loosening and then tightening another thumb screw on the handle.
• The bottom blade of a disposable plastic speculum is fixed to a posterior handle, and the upper blade is fixed to the
anterior lever handle. When the lever is pressed, the distal end of the top blade opens; at the same time the base
of the speculum widens. As the speculum opens, it goes through a series of clicking sounds until it snaps into the
desired position. The patient should be forewarned about the clicking and snapping sounds. In addition, some of
the plastic models have a port through which a light source can be inserted directly into the speculum.

CHAPTER 4 General Inspection and

Measurement of Vital Signs
GENERAL INSPECTION
With your lab partner assuming the role as a patient, document a general inspection using the guide in the left column. Document
your findings in the right column or use a marker to highlight data in the left column that accurately describes the patient.
Examination Techniques Findings (document findings below)
Physical Appearance Physical Appearance

Is the appearance consistent with stated age?
Are there signs of physical distress, shortness of breath,
anxiety or pain? If yes, describe.
Describe the patient’s general color and condition of skin
and general hygiene.
Body Structure and Position Body Structure and Position

What is the patient’s stature (height, body size)?
Describe the patient’s body symmetry.
What is the patient’s posture? Is it straight, comfortable, and
relaxed or uncomfortable, e.g., in a tripod or fetal position?
Body Movement Body Movement

Observe the patient’s movement. Does the patient move
and walk with ease?
Describe the gait and movement of extremities.
Describe any assistive devices used.
Does the patient move easily from standing to sitting or
from sitting to lying? If no, describe.
Does the patient move all extremities? If no, describe.
Describe any limitations to range of motion?
Is there any indication of pain with movement? If, yes,
describe.
Describe any involuntary movements.
Emotional/Mental Status and Behavior Emotional/Mental Status and Behavior

Describe patient’s level of consciousness. Is he/she alert?
Describe the patient’s eye contact.
Does the patient converse appropriately? If no, describe.
Are facial expressions and body language appropriate for
the conversation? If no, describe.
Is the dress appropriate for the weather? If no, describe.
Is the behavior appropriate? If no, describe.

24 Chapter 4 General Inspection and Measurement of Vital Signs
With a lab partner, complete the following activities using the equipment available in your lab.
Equipment: • Platform scale • Thermometer • Watch/clock with a second hand • Stethoscope • Sphygmomanometer •
Pulse oximeter
PERFORM hand hygiene.
HEIGHT AND WEIGHT

Measure and record your lab partner’s height in both inches and centimeters: __________ in. __________ cm
Measure and record your lab partner’s weight in both pounds and kilograms: __________ lb __________ kg
Use the BMI calculator online to determine your lab partner’s body mass index (BMI): __________
VITAL SIGNS
Temperature
Measure and record your lab partner’s temperature using different routes. Use a variety of thermometers if your lab has
different ones available. Compare the results.
Temperature Reading (circle scale)
Oral F C
Axillary F C
Tympanic F C
Temporal artery F C
Heart Rate
Measure and record your lab partner’s heart rate by taking a pulse in the three locations indicated below. Count the pulse
for 15 seconds and multiply by 4, or count the pulse for 30 seconds and multiply by 2. Do you get the same pulse rate in each
location? Document the rate and circle the rhythm.
Brachial Radial Carotid
15 sec × 4 30 sec × 2 15 sec × 4 30 sec × 2 15 sec × 4 30 sec × 2
Heart Rate Rate Rate

Rate Rhythm Rhythm Rhythm
Regular Regular Regular
Regularly Regularly Regularly
irregular irregular irregular
Irregularly Irregularly Irregularly
irregular irregular irregular

Chapter 4 General Inspection and Measurement of Vital Signs 25
Respiratory Rate
Count and record the respiratory rate of your lab partner in both a sitting and supine position. Count the breaths for
15 seconds and multiply by 4, or count for 30 seconds and multiply by 2.
Sitting Supine
15 sec × 4 30 sec × 2 15 sec × 4 30 sec × 2
Respirations Rate Rate

Quality Quality
Depth Depth
Are respirations easier to count with the patient in a sitting or supine position?
Blood Pressure
While your lab partner is in both a supine and sitting position, measure and record a blood pressure reading in both arms
using a manual blood pressure device. Record your findings below.
Sitting Supine
Right arm Left arm Right arm Left arm
Blood pressure
If your lab has one, take your lab partner’s blood pressure using an electronic blood pressure device.
Are the readings using the electronic device different from your manual readings? Are the blood pressures different with
position changes or between the two arms? If a difference is noted, what might account for this difference?
Oxygen Saturation
Clip a pulse oximeter to your lab partner’s index finger to measure the oxygen saturation. Record your findings.
Oxygen (O2) saturation ________________________% on room air.
With the pulse oximeter still in place, ask your lab partner to hold his or her breath, notice the change in the O2 percentage,
and record your findings.
Pain Assessment
Ask your lab partner to rate his or her pain or comfort level on a scale of 0 to 10. If any pain is reported, complete a symptom
analysis (Onset, Location, Duration, Characteristics, Aggravating factors, Related symptoms, Treatment, Severity). (More
detail is found in Chapter 6 Pain Assessment.)
Pain rating __________________
Symptom Analysis ________________________________________________________________________________

CHAPTER 5 Cultural Competence
With your lab partner assuming the role of a patient, conduct a cultural assessment. Your “student patient” may role-play a
person with selected symptoms and cultural beliefs. As an alternative, perform the assessment outside of class with a person
of a culture/race different from your own.
HEALTH HISTORY
BIOGRAPHIC DATA

Male Male
Female Female
Both
Neither

birth

S M D W
PERSONAL AND PSYCHOSOCIAL HISTORY

Introductory Questions
• Where were you born?
• Which cultural practices are important to you?
Primary Language and Method of Communication

• What is your primary language?

28 Chapter 5 Cultural Competence
• Which language is usually spoken in your home?
• How well do you speak, read, and write English?
• Will you need the services of a translator during the time you are in this health care facility?
• Tell me about your preferred styles of communication, such as use of eye contact, touch, silence, personal space, or
communicating with specific family members.
• How do you show respect for others?
Personal Beliefs About Health and Illness

• Do you believe that you have control over your health? If not, what or whom do you believe controls it?
• What are some practices or rituals that you believe will improve your health?
• Do you use or have you used any alternative healing methods such as acupuncture, acupressure, ayurvedic medicine,
healing touch, or herbal products? If yes, describe the methods used and their effectiveness.
• Whom do you consult when you are ill?
• Which specific practices or rituals do you believe should be used to treat your health problem?
• Who makes the health decisions in your family?
• Which health topics do you feel uncomfortable discussing?
• Which examination procedures do you find embarrassing?

Chapter 5 Cultural Competence 29
Beliefs About a Current Health Problem (Sickness)

• What do you call this sickness?
• What do you think caused the sickness?
• Why do you think it started when it did?
• What do you think the sickness does? How does it work?
• How bad is your sickness?
• What kind of treatment do you think you should receive?
• What are the most important results you hope to achieve from this treatment?
• What do you fear most about this sickness?
• What problems has your sickness caused for you?
Religious or Spiritual Influences

• If time or the situation only permits asking one question, ask, “What spiritual needs or concerns related your health
do you have at this time?”
• How would you describe your current spiritual or religious beliefs?
• In what ways is your spirituality/religion meaningful to you?

30 Chapter 5 Cultural Competence
• What practices do you perform as a part of your daily religious and spiritual life (e.g., meditation, prayer, Bible
reading)?
• How do your beliefs affect your health practices?
• How does your faith help you cope with illness?
• Are there any specific aspects of medical care that your religion discourages or forbids?
• Are there any religious or spiritual practices or rituals you would like to have available while you are receiving care?
• What part of your religion or spirituality would you like the nurses to consider as they care for you?
• What knowledge or understanding would strengthen your relationship with the nurses?
Roles in the Family

• Who makes the decisions in your family?
• What is the composition of your family? How many generations or family members live in your household?
Special Dietary Practices

• What is the main type of food eaten in your home?
• Are there any foods that are forbidden by your culture or foods that are a cultural requirement? If yes, what are they?

Chapter 5 Cultural Competence 31
• Who in your family is responsible for food preparation?
• Are there any specific beliefs or preferences about food, such as those believed to cause or cure illness? If so,
what are they?
CLINICAL JUDGMENT
1. Recognize cues for this patient. Identify relevant findings from this interview. (Which information is relevant/irrelevant?
Which information is most important? What is of immediate concern?)
2. Analyze Cues. Organize and link the recognized cues to the person’s interview. (Why is a particular cue or subset of
cues of concern? What other information would help establish the significance of a cue or subset of cues?)
3. What needs does this person have at this time based on this cultural assessment?

CHAPTER 6 Pain Assessment
With your lab partner assuming the role of a patient, conduct a focused history and examination. Your “student patient” may
role-play a person with acute or chronic pain.
HEALTH HISTORY
BIOGRAPHIC DATA

Male Male
Female Female
Both
Neither

birth

S M D W
REASON FOR SEEKING HEALTH CARE (Presenting Problem)
HISTORY OF PRESENT ILLNESS
Symptom Analysis
• Onset (When does pain occur, is the onset sudden or gradual, what is the cause of the pain?)
• Location (Where do you feel the pain?)

34 Chapter 6 Pain Assessment
• Duration (How long does the pain last?)
• Characteristics (What does the pain feel like?)
• Aggravating factors (What makes the pain worse?)
• Related symptoms (What other symptoms do you experience with the pain?)
• Treatment (What have you done to relieve the pain? How effective was the treatment?)
• Severity (How would you describe the intensity, strength, or severity of the pain? How severe do you allow your
pain to become before you take medication to relieve it?). Fig. 6.2A and B provides two scales for rating pain.
*The Clinically Aligned Pain Assessment (CAPA) tool in Table 6.1 shows five questions asked regarding comfort, change
in pain, pain control, functioning, and sleep with possible responses.

Chapter 6 Pain Assessment 35
Response to Pain
• How do you react to or express your pain? What do you fear most about your pain? What problems does your pain
cause?
• Does the pain have a particular meaning for you? If yes, what is it?
• What has been your past experience with pain and pain relief?
• How has pain affected your quality of life? How has it altered your life (e.g., does it interfere with your sleep, appetite,
mood, walking ability, work, relationships with others)?

36 Chapter 6 Pain Assessment
EXAMINATION
Equipment: • Stethoscope • Sphygmomanometer
Techniques Findings (document findings below)
➤ 1. PERFORM hand hygiene.
The nurse stands in front of the patient who is seated.
➤ 2. IDENTIFY the patient using two identifiers (name,

date of birth).
➤ 3. OBSERVE the patient for facial expressions and any

behaviors to relieve pain.
➤ 4. LISTEN for sounds the patient makes (indicating pain).
➤ 5. MEASURE the blood pressure.
➤ 6. PALPATE a pulse for rate.
➤ 7. ASSESS the respiratory rate and pattern.
➤ 8. INSPECT the site of pain for appearance.
➤ 9. PALPATE the site for pain.
➤ Routine techniques

Chapter 6 Pain Assessment 37
CLINICAL JUDGMENT
1. Recognize Cues for this patient. Identify relevant findings from the history and examination. (Which information is
relevant/irrelevant? Which information is most important? What is of immediate concern?)
2. Analyze Cues. Organize and link the recognized cues to the patient’s clinical presentation. (Why is a particular cue
or subset of cues of concern? What other information would help establish the significance of a cue or subset of
cues?)
3. Using the analysis above, develop a problem list for this patient.

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countersigned
countervailing
counties
counting
countless
Countries
COUNTRY
countrymen
Counts
County
Coup
coupable
couple
coupled
Cour
courage
courageously
Courant
Courcol
courier
couriers
course
courses
COURT
courteous
courteously
courtesies
courtesy
Courts
courtyard
courtyards
cousin
Cousteau
Coutts
couvert
Covadonga
covenant
covenants
Coventry
cover
covered
covering
covers
covert
covertly
covet
coveted
covetous
cow
Coward
cowardice
cowardly
cowboys
Cowden
cowe
cowed
Cowes
cows
Cox
coöperation
crack
cracks
cradle
craft
crafty
Cragin
cramped
cranage
Cranborne
Crane
Crash
crashed
crashing
craved
crawl
crawled
creameries
create
created
creates
Creating
creation
Creator
creature
creatures
credence
credentials
credible
credibly
Credit
creditable
credited
creditor
creditors
credulity
creed
creeds
Creek
Creeks
creeps
Creighton
Creole
Creoles
crept
Crescent
Crespo
crest
crests
Cretan
Cretans
Crete
Creusot
crevices
crew
crews
Cridler
cried
cries
crime
Crimean
crimeless
crimes
criminal
criminally
criminals
cripple
crippled
cripples
crippling
crises
crisis
CRISPI
Cristobal
Critic
critical
critically
criticise
criticised
criticises
criticising
criticism
criticisms
criticized
critics
Croatia
Croatian
Croatians
crocketed
Croix
Croker
Crokerism
Crombet
Cromer
Cromwell
CRONJE
Crookes
crop
crops
crore
crores
Crosby
CROSS
crossed
crosses
crossing
crossings
Crossley
Crossmon
crowd
crowded
crowding
crowds
Crowell
Crown
crowned
crowning
Crowns
Crozier
crucial
crude
crudeness
crudest
cruel
cruelly
cruelties
cruelty
Cruikshank
Cruise
cruiser
cruisers
crumbles
crumbling
crusade
crusaders
crush
crushed
crushing
Cruz
cry
crying
crystal
crystallise
crystallized
crystallizes
Crystallography
Cuba
Cuban
Cubans
cubic
cubical
cuerda
Cuestas
CUGNONI
Cugo
cul
Culebra
Culex
culinary
cullender
Culling
Cullom
culminated
culminating
culmination
culpability
culpabilité
culpable
culprits
cult
cultivable
cultivate
cultivated
cultivating
cultivation
cultivator
cultivators
cults

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Student Laboratory Manual for Health

Assessment for Nursing Practice Susan

WILSON & GIDDENS

Student Laboratory Manual prepared by

STUDENT LABORATORY MANUAL FOR HEALTH ASSESSMENT FOR

Copyright © 2022 by Elsevier, Inc. All rights reserved.

Previous editions copyrighted 2017, 2012, and 2008

Library of Congress Control Number: 9780323763233

Executive Content Strategist: Lee Henderson

Printed in the United States of America

Last digit is the print number: 9 8 7 6 5 4 3 2 1

Chapter 2 Obtaining a Health History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Chapter 3 Techniques and Equipment for Physical Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Chapter 4 General Inspection and Measurement of 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 of the Infant, Child, and Adolescent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149

Chapter 20 Assessment of the Pregnant Patient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169

Chapter 21 Assessment of the Older Adult . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 193

CHAPTER 2 Obtaining a Health History

Date Name Preferred name Sex Gender Identity

Date of Age Race/Ethnicity Religion Language(s)

Marital status Occupation

REASON FOR SEEKING CARE (Presenting problem)

HISTORY OF PRESENT ILLNESS

PRESENT HEALTH STATUS

ο How long have you had these conditions?

ο How have these health conditions affected your daily activities?

Copyright © 2022 Elsevier, Inc. All Rights Reserved. 1

Name of Drug/Supplement Dosage/Frequency Last Dose Taken Reason for Taking

Allergic To Reaction and frequency

PAST HEALTH HISTORY

Measles ❏ Mumps ❏ Rubella ❏ Chickenpox ❏

Copyright © 2022 Elsevier, Inc. All Rights Reserved.

Name and Type Date Residual Problems

Immunization Date/s Immunization Date/s

Last Examination Date Outcome

Copyright © 2022 Elsevier, Inc. All Rights Reserved.

Last menstrual period (LMP) Date Outcome

Para (number of births) ________

Person Age Current Health Person Age Current Health

Draw a genogram for your lab partner’s family history.

Copyright © 2022 Elsevier, Inc. All Rights Reserved.

PERSONAL AND PSYCHOSOCIAL HISTORY

• Describe your cultural/religious affiliations and practices.

• Describe your education, occupational history, and work satisfaction.

Family and Social Relationships

Copyright © 2022 Elsevier, Inc. All Rights Reserved.

• Do you have any dietary restrictions or food intolerances?

Shopping ❏ Cooking ❏ Housekeeping ❏ Managing finances ❏

If unable to perform independently, describe.

Tobacco, Alcohol, and Illicit Drug Use

CHAPTER 3 Techniques and Equipment for

• Determine the height of your lab partner __ft, In.

Record your measurements. Left wrist Left forearm

• Right elbow 0 Left elbow _0

CHAPTER 4 General Inspection and