Health Assessment for Nursing Practice

8th Edition - January 22, 2025
Imprint: Elsevier
Authors: Susan Fickertt Wilson, Jean Foret Giddens
Language: English
Paperback ISBN:
9 7 8 - 0 - 4 4 3 - 1 2 4 4 3 - 3
Paperback ISBN:
9 7 8 - 0 - 4 4 3 - 1 2 7 4 4 - 1
LooseLeaf ISBN:
9 7 8 - 0 - 4 4 3 - 1 2 7 4 5 - 8
eBook ISBN:
9 7 8 - 0 - 4 4 3 - 1 2 7 4 6 - 5

Learn how to confidently perform a physical exam and prepare for the Next Generation NCLEX® Examination (NGN)! Health Assessment for Nursing Practice, Eighth Edition, focuses… Read more

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Learn how to confidently perform a physical exam and prepare for the Next Generation NCLEX® Examination (NGN)! Health Assessment for Nursing Practice, Eighth Edition, focuses on what you need to know, providing easy-to-understand guidelines and timesaving learning tools that demonstrate how to perform an effective physical examination. This completely updated text has everything you need to succeed on the NGN, confidently conduct and document an accurate assessment, and prepare for clinical practice.

UPDATED! Content reflects the latest research and thinking in health assessment in nursing practice
Health assessment case studies on the Evolve companion website help you prepare for the Next Generation NCLEX^® Exam
Straightforward, easy-to-understand, need-to-know coverage gives you the knowledge and confidence to perform an effective health assessment and physical examination
Clear differentiation between basic skills and advanced skills helps you discern need-to-know skills from skills that would be performed by an advanced practitioner or only in special circumstances
Time-tested two-column format helps link assessment techniques with normal and abnormal findings
Vivid full-color photos and illustrations visually demonstrate key assessment techniques to promote better understanding
UNIQUE! Concept Overviews present core concepts in the context of health assessment, with discussions of pain, oxygenation, perfusion, tissue integrity, motion, sensory perception, nutrition, metabolism, and intracranial regulation
UNIQUE! Clinical Judgment boxes explain the thought process of an experienced nurse making a clinical decision to give you an expert perspective on clinical judgment and the decision-making process in nursing practice
UNIQUE! Situational Variations sections address special circumstances or needs for patients in wheelchairs or other limitations and exam variations
Age-Related Variations sections address special considerations or needs for infants and children, adolescents, and older adults
Summary of Findings sections demonstrate how to chart normal findings, including documentation in the Electronic Heath Record (EHR)
Clinical Application and Clinical Judgment sections at the end of each chapter include review questions to help assess your understanding of need-to-know content, while case studies promote the development of clinical reasoning skills in the context of health assessment and physical examination
UNIQUE! Adapting Health Assessment to the Hospitalized Patient chapter explains special techniques for performing a head-to-toe assessment of a patient in a hospital setting
Ethnic, Cultural, and Spiritual Variations boxes help you anticipate the unique needs of a multicultural patient population
Health Assessment Across the Life Span unit contains four separate chapters that cover all lifespan content, including older adults, pregnant patients, and infants, children, and adolescents
Synthesis and Application of Health Assessment unit details how to conduct, document, and adapt the head-to-toe examination

Title of Book
Cover image
Title page
Table of Contents
Copyright
Dedication
About the Author
Contributors
Preface
Unit I. Foundations for Health Assessment
1. Introduction to Health Assessment
Health Assessment as a Component of Professional Nursing Practice
Components of Health Assessment
Standard 1: Assessment
Standard 2: Diagnosis
Standard 3: Outcome Identification
Standard 4: Planning
Standard 5: Implementation
Standard 6: Evaluation
Health History
Signs and Symptoms
Clinical Manifestation
Physical Examination
Documentation of Data
Types of Health Assessments
Context of Care
Patient Needs
Health Assessment Skills
Skin
Head, Eyes, Ears, Nose, Throat
Chest and Lungs
Cardiovascular
Musculoskeletal
Abdomen
Neurologic
Genitalia
Clinical Reasoning and Judgment
Health Promotion and Health Protection
Clinical Application and Clinical Judgment
Case Study 1
Case Study 2
Interview data
Examination data
2. Obtaining a Health History
The Interview
The Physical Setting
A Patient-Centered Approach
Age
Culture
Gender Identity and Expression
Language
Physical or Emotional Distress
Sensory Impairment
Cognitive Impairment
Establishing Rapport
Professional Behavior
Effective Communication
Phases of the Interview
Introduction Phase
Discussion Phase
Summary Phase
What are the key points to ensure a successful interview with a patient?
The Art of Asking Questions
Types of Interview Questions
Open-Ended Questions
Directive Questions
Techniques That Enhance the Interview
Active Listening
Facilitation
Clarification
Reflection
Addressing Inconsistencies
Interpretation
Summarization
Behaviors that Interfere with the Interview
Using Medical Terminology
Expressing Value Judgments
Interrupting the Patient
Being Authoritarian or Paternalistic
Using “Why” Questions
Challenging Situations
Personal Questions
Silence
Displays of Emotion
Overly Talkative Patient
Others in the Room
Disruptive Individuals
The Health History
Types of Health Histories
Components of the Health History
Biographic Data
Reason for Seeking Health Care
History of Presenting Illness and Symptom Analysis
Present Health Status
Past Health History
Family History
Personal and Psychosocial History
Review of Systems
Onset: When Did the Symptom Begin?
Location: Where is the Symptom?
Duration: How Long Does the Symptom Last?
Characteristics: Describe the Symptom
Aggravating Factors: What Makes the Symptom Worse?
Related Symptoms: Are Other Symptoms Present?
Treatment: What Factors Alleviate the Symptom?
Severity: Describe the Intensity of the Symptom
Recognizing Domestic Violence
Screening Questions for Domestic Violence
Age-Related Variations
Infants, Children, and Adolescents
Pregnancy
Older Adults
Clincial Application and Clinical Judgment
Case Study
Activity
3. Techniques and Equipment for Physical Assessment
Infection Control Practices
Standard Precautions
Hand Hygiene
Personal Protective Equipment
Respiratory Hygiene/Cough Etiquette
Patient Placement
Contaminated Patient Care Equipment and Sharps
Environmental Control
Using Alcohol-Based Hand Sanitizer
Washing With Soap and Water
Gloves
Masks, Eye Protection, Face Shields
Gowns
Transmission-Based Precautions
Techniques of Physical Assessment
Inspection
Palpation
Percussion
Auscultation
Setting and Patient Positioning
Equipment Used During the Examination
Thermometer
Stethoscope
Equipment to Measure Blood Pressure
Pulse Oximeter
Scales to Measure Body Weight and Height
Skinfold Caliper
Ruler and Tape Measure
Wood Lamp
Magnification Device
Penlight
Visual Acuity Charts
Distance Vision Examination
Near-Vision Examination
Ophthalmoscope
Otoscope
Audioscope
Tuning Fork
Nasal Speculum
Doppler
Goniometer
Percussion Hammer and Neurologic Hammer
Monofilament
Vaginal Speculum
Transilluminator
Clinical Application and Clinical Judgment
4. General Inspection and Measurement of Vital Signs
General Inspection
Appearance
Body Structure and Position
Body Movement
Emotional Status, Disposition, and Behavior
Height and Weight
Height
Weight
Vital Signs
Temperature
Oral Temperature
Temporal Artery Temperature
Tympanic Membrane Temperature
Axillary Temperature
Rectal Temperature
Heart Rate
Respiratory Rate
Oxygen Saturation
Blood Pressure
Blood Pressure Measurement: Methods and Sites
Physiologic Factors That Affect Blood Pressure Measurements
Common Errors Associated With Blood Pressure Measurement
Patient Preparation
Blood Pressure Measurement
Pain
Errors Resulting in False-High Blood Pressure Measurement
Errors Resulting in False-Low Blood Pressure Measurement
Age-Related Variations
Infants and Children
Older Adults
Clinical Application and Clinical Judgment
5. Culture Competence
Ethnic, Cultural, and Spiritual Awareness
Changing Demographics
Cultural Diversity
Definitions
Standards of Care and Practice
General Terms
Terms Used to Describe Gender
Terms Used to Describe Sex/Sexual Orientation
Cultural Competence
Develop Cultural Competence
Avoid Stereotyping
Apply Cultural Competence to a Health History
Introductory Questions
Primary Language and Method of Communication
Personal Beliefs About Health and Illness
Beliefs About a Current Health Problem (Sickness)23,24
Religious or Spiritual Influences
Roles in the Family
Special Dietary Practices
Personal and Individual Barriers
Knowledge Barriers
Remember
Clinical Application and Clinical Judgment
6. Pain Assessment
Concept Overview
Anatomy and Physiology
The Pain Process
Types of Pain
Classification by Pain Duration
Classification by Pain Pathology
The Pain Experience
Pain Threshold and Pain Tolerance
Cognitive Factors and Cultural Influences
Coping Strategies
Problem-Focused Coping Strategies
Emotion-Focused Coping Strategies
Health History
Factors That Influence Pain Assessment
Interview Questions
Symptom Analysis
Onset
Location
Duration
Characteristics
Aggravating Factors
Related Symptoms
Treatment by the Patient
Severity
Response to Pain
Pain Assessment Tools
Examination
Age-Related Variations
Infants and Children
Older Adults
Situational Variations
Patients Who Cannot Communicate
Clinical Application and Judgment
Case Study
7. Mental Health Assessment
Concept Overview
Anatomy and Physiology
Culturally Relevant Phenomena in Mental Health Nursing
Health History
General Health History
Present Health Status
Past Health History
Family History
Personal and Psychosocial History
Self-Concept
Interpersonal Relationships
Stressors
Anger
Alcohol Use
Recreational Drug Use
Problem-Based History
Depression
Depression
Anxiety
Anxiety
Alcohol Use
Drug Use
Interpersonal Violence
Substance Abuse, Depression, and Intimate Partner Violence
Recommendations to Reduce Risk (Primary Prevention)
Substance Abuse: National Institute on Drug Abuse
Screening Recommendations (Secondary Prevention)
US Preventive Services Task Force
Examination
ROUTINE TECHNIQUES
General Observation
Pupil Size
Pupil Reaction to Light
Nystagmus
Convergence
Corneal Reflex
Techniques for Special Circumstances
ASSESS mental status.
Orientation
Memory
Calculation ability
Communication skills
Judgment and reasoning
Abstract reasoning
Age-Related Variations
Infants, Children, and Adolescents
Older Adults
Common Problems and Conditions
Mood Disorders
Major Depression
Postpartum Depression
Bipolar Disorder
Suicide
Psychotic Disorders
Schizophrenia
Anxiety Disorders
Generalized Anxiety Disorder
Obsessive-Compulsive Disorder (OCD)
Posttraumatic Stress Disorder
Substance Use Disorders
Alcohol Abuse
Drug Abuse
Neurocognitive Disorders
Delirium
Dementia
Clinical Application and Clinical Judgment
Case Study
Interview Data
Examination Data
Clinical Judgment
8. Nutritional Assessment
Concept Overview
Anatomy and Physiology
Macronutrients
Carbohydrate
Protein
Fat
Micronutrients
Water
Health History
General Health History
Present Health Status
Past Health History
Family History
Personal and Psychosocial History
Problem-Based History
Weight Loss
Weight Gain
Difficulty in Chewing or Swallowing
Loss of Appetite or Nausea
Assessment of Dietary Intake
Clinical Recommendations
US Preventive Services Task Force
Examination
ROUTINE TECHNIQUES
Techniques for Special Circumstances
CALCULATE desirable body weight (DBW).
CALCULATE percentage change in weight.
MEASURE the waist circumference.
CALCULATE waist-to-hip ratio.
ESTIMATE body fat by measuring triceps skinfold.
ASSESS nutritional status by reviewing laboratory tests (if available).
Age-Related Variations
Infants and Children
Adolescents
Older Adults
Common Problems and Conditions
Obesity
Hyperlipidemia
Protein-Calorie Malnutrition
Eating Disorders
Clinical Application and Clinical Judgment
Case Study
Interview Data
Examination Data
Clinical Judgment
Unit II. Health Assessment of the Adult
CHAPTER 9. Skin, Hair, and Nails
Concept Overview
Anatomy and Physiology
Skin
Epidermis
Dermis
Subcutaneous Layer
Appendages
Hair
Nails
Eccrine Sweat Glands
Apocrine Sweat Glands
Sebaceous Glands
Health History
General Health History
Present Health Status
Past Health History
Family History
Personal and Psychosocial History
Problem-Based History
Skin
Hair
Nails
Recommendations to Reduce Risk (Primary Prevention)
American Cancer Society
United States Preventative Services Task Force
Screening Recommendations (Secondary Prevention)
American Cancer Society
Examination
ROUTINE TECHNIQUES
Case Presentation
Noticing/Recognizing Cues
Interpreting/Analyzing Cues and Prioritizing Hypotheses
Responding/Taking Action
Reflecting
Age-Related Variations
Infants and Children
Adolescents
Older Adults
Situational Variations
Patients With Limited Mobility
Expected and Abnormal Findings
Common Problems and Conditions
Skin
Clavus (Corn)
Dermatitis
Psoriasis
Pityriasis Rosea
Lesions Caused by Viruses
Lesions Caused by Fungal Infections
Candidiasis
Lesions From Bacterial Infections
Lesions From Insects
Skin Cancers
Skin Lesions Caused by Abuse
Hair
Pediculosis (Lice)
Alopecia Areata
Hirsutism
Nails
Onychomycosis
Paronychia
Ingrown Toenail
Clinical Application and Clinical Judgment
Case Study
Interview Data
Examination Data
Clinical Judgment
CHAPTER 10. Head and Neck
Anatomy and Physiology
Skull and Face
Neck
Larynx
Thyroid Gland
Cardiovascular Structures
Regional Lymph Nodes
Health History
General Health History
Present Health Status
Past Health History
Family History
Personal and Psychosocial History
Problem-Based History
Headache
Head Injury
Dizziness
Neck Pain
Neck Lump or Mass
Examination
ROUTINE TECHNIQUES: HEAD
Techniques for Special Circumstances: Head
PALPATE the structures of the skull for symmetry, tenderness, and intactness.
PALPATE the structures of the face and jaw, noting jaw movement and tenderness.
PALPATE the temporal arteries for pulsation, texture, and tenderness, and AUSCULTATE the temporal arteries for bruits.
ROUTINE TECHNIQUES: NECK
Techniques for Special Circumstances: Neck
PALPATE the neck for anatomic structures and trachea.
PALPATE the thyroid gland for size, consistency, tenderness, and presence of nodules.
PALPATE regional lymph nodes for size, consistency, mobility, and tenderness.
Age-Related Variations
Infants and Children
Older Adults
Common Problems and Conditions
Head
Headaches
Tension Headache
Migraine Headache
Cluster Headache
Posttraumatic Headache
Hydrocephalus
Neck
Repetitive Neck Strain (Text Neck)
Torticollis
Thyroid Disorders
Hyperthyroidism
Hypothyroidism
Thyroid Cancer
Clinical Application and Clinical Judgment
Case Study
Interview Data
Examination Data
Clinical Judgment
CHAPTER 11. Eyes
Concept Overview
Anatomy and Physiology
External Structures
Eyebrow
Eyelid
Conjunctiva
Lacrimal Gland
Structures of the Eye
Sclera
Uvea
Retina
Chambers and Fluids
Ocular Function
Vision
Eye Movement
Health History
General Health History
Present Health Status
Past Health History
Family History
Personal and Psychosocial History
Problem-Based History
Difficulty With Vision
Eye Pain or Discomfort
Glaucoma
Examination
ROUTINE TECHNIQUES
Eyes
Techniques for Special Circumstances
ASSESS eye movements for the six cardinal fields of gaze (tests cranial nerves III, IV, and VI).
PERFORM the cover–uncover eye test.
PALPATE the eyes and lacrimal puncta.
INSPECT the conjunctiva of the upper eyelid.
TEST corneal reflex.
INSPECT anterior chamber for transparency, iris surface, and chamber depth of each eye.
INSPECT intraocular structures of each eye as part of an ophthalmoscopic examination.
Age-Related Variations
Infants and Children
Older Adults
Common Problems and Conditions
External Eye
Chalazion
Hordeolum (Stye)
Conjunctivitis
Corneal Abrasion or Ulcer
Internal Eye
Cataract
Glaucoma
Clinical Application and Clinical Judgment
Case Study
Interview Data
Examination Data
Clinical Judgment
CHAPTER 12. Ears, Nose, and Throat
Concept Overview
Anatomy and Physiology
Ears
External Ear
Middle Ear
Inner Ear
Nose and Sinuses
Mouth and Oropharynx
Health History
General Health History
Present Health Status
Past Health History
Family History
Personal and Psychosocial History
Problem-Based History
Hearing Loss
Ringing in the Ears (Tinnitus)
Ear Pain
Sinus Pain
Nasal Discharge
Sore Throat
Hoarseness or Excessive Throat Clearing
Mouth Lesions
Toothache
Recommendations to Reduce Risk (Primary Prevention)
Screening Recommendations (Secondary Prevention)
Examination
Techniques for Special Circumstances: Ear
PALPATE the external ears and mastoid areas for characteristics, tenderness, and edema.
INSPECT the ear canal and internal ear structures.
TEST hearing acuity.
Techniques for Special Circumstances: Nose
PALPATE the nose to assess for tenderness and patency.
INSPECT the nasal cavity for color, surface characteristics, lesions, erythema, discharge, and foreign bodies.
PALPATE the frontal and maxillary paranasal sinus areas for tenderness.
Techniques for Special Circumstances: Mouth
PALPATE the teeth, inner lips, and gums for condition, stability, and tenderness.
PALPATE the tongue for texture.
Case Presentation
Noticing/Recognizing Cues
Interpreting/Analyzing Cues and Forming Hypotheses
Responding/Taking Action
Reflecting
Age-Related Variations
infants and Children
Older Adults
Common Problems and Conditions
Ears
Foreign Body
Infection
Hearing Loss
Nose
Epistaxis
Inflammation/Infection
Mouth and Oropharaynx
Inflammation/Infection
Lesions
Clinical Application and Clinical Judgment
Case Study
Interview Data
Examination Data
Clinical Judgment
CHAPTER 13. Respiratory System
Concept Overview
Anatomy and Physiology
Internal Thorax
External Thorax
Topographic Markers
Mechanics of Breathing
Health History
General Health History
Present Health Status
Past Health History
Family History
Personal and Psychosocial History
Home Environment
Occupational Environment
Travel
Problem-Based History
Cough
Shortness of Breath
Chest Pain With Breathing
Recommendations to Reduce Risk (Primary Prevention)
Examination
TECHNIQUES FOR SPECIAL CIRCUMSTANCES
PALPATE the thorax for pain and stability.
PALPATE for thoracic expansion.
PALPATE for vocal (tactile) fremitus.
PALPATE the trachea for position.
PERCUSS the thorax for tone.
PERCUSS for diaphragmatic excursion.
Case Presentation
Noticing/Recognizing Cues
Interpreting/Analyzing Cues and Forming Hypotheses
Responding/Taking Action
Reflecting
Age-Related Variations
Infants, Children, and Adolescents
Older Adults
Common Problems and Conditions
Inflammation/Infection
Acute Bronchitis
COVID-19
Pneumonia
Tuberculosis
Pleural Effusion
Chronic Pulmonary Disease
Asthma
Emphysema
Chronic Bronchitis
Acute or Traumatic Conditions
Pneumothorax
Hemothorax
Other Pulmonary Conditions
Atelectasis
Lung Cancer
Clinical Application and Clinical Judgment
Case Study
Interview Data
Examination Data
Clinical Judgment
CHAPTER 14. Cardiovascular System
Concept Overview
Anatomy and Physiology
Heart and Great Vessels
Pericardium and Cardiac Muscle
Blood Flow Through the Heart
Cardiac Cycle
Peripheral Vascular System
Lymph System
Health History
General Health History
Present Health Status
Past Health History
Family History
Personal and Psychosocial History
Problem-Based History
Chest Pain
Shortness of Breath
Cough
Urinating During the Night
Fatigue
Fainting (Syncope)
Swelling of Extremities
Leg Cramps or Pain
Recommendations to Reduce Risk (Primary Prevention)
Screening Recommendations (Secondary Prevention)
US Preventive Services Task Force
Blood Pressure Screening
Lipid-Level Screening
Examination
Techniques for Special Circumstances
PALPATE the precordium for pulsations, thrills, lifts, and heaves.
AUSCULTATE the temporal and carotid arteries for bruits.
CALCULATE the ankle-brachial indexes (ABIs) to estimate arterial occlusion.
MEASURE each leg circumference to assess for symmetry.
ASSESS for varicose veins.
PALPATE epitrochlear lymph nodes for size, consistency, mobility, tenderness, and warmth.
PALPATE inguinal lymph nodes for size, consistency, mobility, tenderness, and warmth bilaterally.
Case Presentation
Noticing/Recognizing Cues
Interpreting/Analyzing Cues and Forming Hypotheses
Responding/Taking Action
Reflecting
Age-Related Variations
Infants, Children, and Adolescents
Older Adults
Common Problems and Conditions
Cardiac Disorders
Valvular Heart Disease
Angina Pectoris
Acute Coronary Syndrome
Heart Failure
Pericarditis
Peripheral Vascular Diseases
Hypertension
Venous Thromboembolism and Thrombophlebitis
Peripheral Artery Disease and Venous Insufficiencies
Clinical Application and Clinical Judgment
Case Study
Interview Data
Examination Data
Clinical Judgment
CHAPTER 15. Abdomen
Concept Overview
Anatomy and Physiology
Peritoneum, Musculature, and Connective Tissue
Alimentary Tract
Mouth
Esophagus
Stomach
Small Intestine
Large Intestine (Colon) and Rectum
Accessory Organs
Liver
Gallbladder
Pancreas
Spleen
Urinary Tract
Kidneys
Ureters
Bladder
Vasculature of the Abdomen
Health History
General Health History
Present Health Status
Past Health History
Family History
Personal and Psychosocial History
Esophageal Cancer
Stomach Cancer
Colorectal Cancer
Problem-Based History
Abdominal Pain
Nausea and Vomiting
Indigestion or Heartburn
Abdominal Distention
Change in Bowel Habits
Yellow Discoloration of Eyes or Skin (Jaundice)
Problems With Urination
Liver Cancer
Pancreatic Cancer
Recommendations to Reduce Risk of Colorectal Cancer (Primary Prevention)
Screening Recommendations (Secondary Prevention)
Examination
Right Upper Quadrant
Right Lower Quadrant
Left Upper Quadrant
Left Lower Quadrant
Techniques for Special Circumstances
PERCUSS the abdomen for tones.
ASSESS the abdomen for pain caused by inflammation.
PERCUSS the liver to determine span and descent.
PERCUSS the spleen for size.
PALPATE the liver for lower border and pain.
PALPATE the gallbladder for pain.
PALPATE the spleen for border and pain.
PALPATE the kidneys for contour and pain.
PERCUSS the kidneys for costovertebral angle pain.
Case Presentation
Noticing/Recognizing Cues
Interpreting/Analyzing Cues and Forming Hypotheses
Responding/Taking Action
Reflecting
Age-Related Variations
Infants, Children, and Adolescents
Older Adults
Common Problems and Conditions
Alimentary Tract
Gastroesophageal Reflux Disease
Hiatal Hernia
Peptic Ulcer Disease
Inflammatory Bowel Disease
Colorectal Cancer
Hepatobiliary System
Viral Hepatitis
Cirrhosis
Cholecystitis With Cholelithiasis
Pancreas
Pancreatitis
Urinary System
Urinary Tract Infections
Urinary Tract Calculi (Stones)
Clinical Application and Clinical Judgment
Case Study
Interview Data
Examination Data
Clinical Judgment
16. Musculoskeletal Assessment
Concept Overview
Anatomy and Physiology
Bones, Muscles, and Connective Tissue
Bones
Skeletal Muscles
Joints
Ligaments and Tendons
Cartilage and Bursae
Skeleton and Supporting Structures
Skull and Neck
Trunk and Pelvis
Upper Extremities
Lower Extremities
Health History
General Health History
Present Health Status
Past Health History
Family History
Personal and Psychosocial History
Problem-Based History
Pain
Problems With Movement
Problems With Daily Activities
Osteoporosis
Recommendations to Reduce Risk (Primary Prevention)
Screening Recommendations (Secondary Prevention)
Examination
ROUTINE TECHNIQUES
Techniques for Special Circumstances
ASSESS for nerve root compression.
ASSESS for carpal tunnel syndrome.
ASSESS for rotator cuff injury.
ASSESS for knee effusion.
ASSESS knee stability.
ASSESS for meniscal damage or tear.
ASSESS for hip flexion contracture.
Case Presentation
Noticing/Recognizing Cues
Interpreting/Analyzing Cues and Forming Hypotheses
Responding/Taking Action
Reflecting
Age-Related Variations
Infants, Children, and Adolescents
Older Adults
Common Problems and Conditions
Bones
Fracture
Osteoporosis
Joints
Rheumatoid Arthritis
Osteoarthritis
Bursitis
Gout
Spine
Herniated Nucleus Pulposus
Clinical Application and Clinical Judgment
Case Study
Interview Data
Examination Data
Clinical Judgment
17. Neurologic System
Concept Overview
Anatomy and Physiology
Central Nervous System
Protective Structures
Cerebrospinal Fluid and Cerebral Ventricular System
Brain
Cerebrum
Diencephalon
Basal Ganglia
Brainstem
Cerebellum
Peripheral Nervous System
Spinal Cord
Cranial Nerves
Spinal Nerves
Reflex Arc
Autonomic Nervous System
Health History
General Health History
Present Health Status
Past Health History
Biographic Data and Family History
Behaviors
Conditions
Family History
Personal and Psychosocial History
Problem-Based History
Headache
Seizures
Loss of Consciousness
Changes in Movement
Changes in Sensation
Difficulty Swallowing (Dysphagia)
Difficulty Communicating
Recommendations to Reduce Risk (Primary Prevention)
Examination
Techniques for Special Circumstances
ASSESS cranial nerves.
ASSESS cerebellar function.
Balance
Coordination, Upper Extremity
Coordination, Lower Extremity
ASSESS for sensory function.
ASSESS deep tendon reflexes.
DETERMINE the Glasgow Coma Scale (GCS) Score.
Case Presentation
Noticing/Recognizing Cues
Interpreting/Analyzing Cues and Forming Hypotheses
Responding/Taking Action
Reflecting
Age-Related Variations
Infants, Children, and Adolescents
Older Adults
Common Problems and Conditions
Disorders of the Central Nervous System
Multiple Sclerosis
Meningitis
Encephalitis
Spinal Cord Injury
Head Injury
Parkinson Disease (PD)
Cerebrovascular Accident (CVA)
Disorders of Peripheral Nerves
Myasthenia Gravis
Guillain-Barré Syndrome
Clinical Application and Clinical Judgment
Case Study
Interview Data
Examination Data
Clinical Judgment
18. Breasts and Axillae
Anatomy and Physiology
Female Breast
Male Breast
Lymphatic Network
Health History
General Heath History
Present Health Status
Past Health History
Family History
Personal and Psychosocial History
Incidence
Mortality
Problem-Based History
Breast Pain or Tenderness
Breast Lump
Nipple Discharge
Axillary Lumps or Tenderness
Breast Swelling or Enlargement (Men)
Screening Recommendations US Preventive Services Task Force
BRCA-Related Cancer Risk Assessment
Mammography Screening Recommendations
Examination
Female Breast Examination
ROUTINE TECHNIQUES: FEMALE BREAST
Male Breast Examination
Female Breast Examination
Male Breast Examination
Age-Related Variations
Infants and Children
Adolescents
Older Adults
Situational Variations
Patient With Mastectomy
Common Problems and Conditions
Benign Breast Disease
Fibrocystic Changes to the Breast
Fibroadenoma
Ductal Ectasia
Intraductal Papillomas
Breast Cancer
Invasive Breast Cancer
Noninvasive Breast Cancer
Other Breast Conditions
Mastitis
Galactorrhea
Gynecomastia
Clinical Application and Clinical Judgment
Case Study
Interview Data
Examination Data
Clinical Judgment
19. Female Reproductive System
Concept Overview
Anatomy and Physiology
Anatomy
External Genitalia
Mons Pubis
Clitoris
Labia
Vestibule
Perineum
Internal Structures
Vagina
Uterus
Fallopian Tube
Ovaries
Physiology
Menstrual Cycle
Climacteric
Health History
General Health History
Present Health Status
Past Health History
Family History
Personal and Psychosocial History
Sexual History
Menstrual History
Pregnancy History
Problem-Based History
Pain
Genital Lesion
Vaginal Discharge
Problems With Menstruation
Menopausal Symptoms
Problems With Urination
Background
Recommendations to Reduce Risk (Primary Prevention)
Screening Recommendations (Secondary Prevention)
Background
Recommendations to Reduce Risk (Primary Prevention)
Screening Recommendations (Secondary Prevention)
Cervical Cancer
Ovarian Cancer
Examination
Preparing for the Female Examination
ROUTINE TECHNIQUES
Techniques for Special Circumstances
PALPATE the Skene and Bartholin glands for surface characteristics, discharge, and tenderness.
PALPATE the vaginal opening for tone.
INSPECT internal structures (as part of a speculum examination).
PALPATE internal structures as part of a bimanual examination.
Age-Related Variations
Infants and Children
Adolescents
Older Adults
Common Problems and Conditions
Infections
Bacterial Vaginosis
Vulvovaginal Candidiasis (VVC)
Sexually Transmitted Infection
Chlamydia
Gonorrhea
Syphilis
Trichomoniasis
Herpes Genitalis
Human Papillomavirus (Genital Warts, Condyloma Acuminatum)
Pediculosis Pubis (Crabs, Pubic Lice)
Pelvic Inflammatory Disease (PID)
Benign Reproductive Conditions
Premenstrual Syndrome (PMS)
Endometriosis
Uterine Leiomyomas
Ovarian Cysts
Malignant Reproductive Conditions
Cervical Cancer
Endometrial Cancer
Ovarian Cancer
Prolapse or Herniation
Uterine Prolapse
Cystocele
Rectocele
Clinical Application and Clinical Judgment
Case Study
Interview Data
Examination Data
Clinical Judgment
20. Male Reproductive System
Anatomy and Physiology
External Genitalia
Scrotum
Penis
Internal Structures
Testes
Ducts
Glands
Inguinal Area
Health History
General Health History
Present Health Status
Past Health History
Family History
Personal and Psychosocial History
Sexual History
Problem-Based History
Pain
Genital Lesion
Penile Discharge
Andropause Symptoms
Difficulty With Erection
Problems With Urination
Background
Recommendations to Reduce Risk (Primary Prevention)
Screening Recommendations (Secondary Prevention)
Examination
Preparing for the Male Examination
Techniques for Special Circumstances
PALPATE the scrotum for surface characteristics and tenderness.
PALPATE the testes, epididymides, and vas deferens for location, consistency, tenderness, and nodules.
TRANSILLUMINATE the scrotum for evidence of fluid and masses.
PALPATE the inguinal canal for evidence of indirect hernia or direct hernia.
Age-Related Variations
Infants and Children
Adolescents
Older Adults
Common Problems and Conditions
Infections
Tinea cruris (Jock Itch)
Sexually Transmitted Infection (STI)
Chlamydia
Gonorrhea
Syphilis
Trichomoniasis
Herpes Genitalis
Human Papillomavirus (Genital Warts, Condylomata Acuminatum)
Pediculosis Pubis (Crabs, Pubic Lice)
Epididymitis
Reproductive Conditions
Testicular Torsion
Hydrocele
Spermatocele
Varicocele
Peyronie Disease
Testicular Cancer
Clinical Application and Clinical Judgment
Case Study
Interview Data
Examination Data
Clinical Judgment
21. Anus, Rectum, and Prostate
Anatomy and Physiology
Rectum
Anal Canal and Anus
Prostate
Health History
General Health History
Present Health Status
Past Health History
Family History
Problem-Based History
Rectal Bleeding
Rectal Pain
Anal Lesion
Fecal Incontinence
Prostate-Related Problems With Urination (Male Patients)
Background
Recommendations to Reduce Risk (Primary Prevention)
Screening Recommendations (Secondary Prevention)
Examination
ROUTINE TECHNIQUES
Age-Related Variations
Infants and Children
Adolescents
Older Adult
Common Problems and Conditions
Conditions of the Anus and Rectum
Hemorrhoids
Anorectal Fissure
Anorectal Abscess and Fistula
Rectal Polyp
Carcinoma of the Rectum and Anus
Rectal Prolapse
Conditions of the Prostate
Benign Prostatic Hyperplasia
Prostatitis
Prostate Cancer
Clinical Application and Clinical Judgment
Case Study
Interview Data
Examination Data
Clinical Judgment
Unit III. Health Assessment Across the Life Span
22. Assessment of the Infant, Child, Adolescent
ANATOMY AND PHYSIOLOGY
Anatomical Differences
Developmental Milestones and Assessment
Skin
Head
Ears, Nose, Throat, Mouth
Lungs
Heart
Musculoskeletal
Lymph System
Neurologic
Breasts
Reproductive System
Health History
Components of the Pediatric Health History
Biographic Data
Reason for Seeking Health Care
History of Present Illness
Present Health Status
Past Health History
Prenatal Care
Maternal Health During Pregnancy
Labor and Delivery Process
Newborn Course
Family History
Home Environment
Personal and Psychosocial History
Personal Status
Family and Social Relationships
Diet and Nutrition
Sleep
Mental Health
Sexuality
Development
Health Promotion Activities
Review of Systems
General Symptoms
Skin, Hair, Nails
Head, Eyes, Ears, Nose, and Throat
Congenital or Perinatal Hearing Loss
Neonatal Risk Factors (birth to 1 month)
Infant Risk Factors (1–24 months)
Breasts
Respiratory System
Cardiovascular System
Gastrointestinal System
Urinary System
Reproductive System
Musculoskeletal System
Neurologic System
Otitis Media
EXAMINATION
Vital Signs and Baseline Measurements
Temperature
Heart and Respiratory Rates
Blood Pressure
Height/Length
Weight
Head Circumference
Examination of Newborns and Infants
Baseline Measurements
Developmental Assessment
Skin, Hair, and Nails
Skin
Hair and Nails
Head and Neck
Head
Neck
Infant Care
Eyes
Ears, Nose, and Throat
Ears
Nose and Mouth
Respiratory System
Cardiovascular System
Abdomen
Musculoskeletal System
Hip Dislocation
Neurologic System
Breasts
Reproductive System and Perineum
Female Examination
Male Examination
Perianal Examination
Examination of Toddlers, Preschool, and School-Aged Children
Physical Appearance and Baseline Measurement
Toddlers
Preschool Age
School Age
Development Assessment
Toddlers
Preschool Age
School Age
Skin, Hair, and Nails
Skin
Hair and Nails
Head and Neck
Head
Neck
Eyes
Ears, Nose, and Throat
Ears
Nose and Mouth
Respiratory System
Cardiovascular System
Abdomen
Musculoskeletal System
Neurologic System
Breasts
Reproductive System and Perineum
Female Examination
Male Examination
Perianal Examination
Examination of Adolescents
Baseline Measurements
Development Assessment
Skin, Hair, and Nails
Skin
Hair and Nails
Head, Neck, Eyes, Ears, Nose, and Throat
Respiratory System
Cardiovascular System
Abdomen
Musculoskeletal System
Neurologic System
Breasts
Reproductive System
Female
Male Examination
Perianal Examination
Situational Variations
The Preparticipation Physical Examination (PPE)
PPE History
PPE Physical Examination Components
Review of Vital Signs
1. Inspection
2. Range of Motion of Cervical Spine
3. Resisted Shoulder Shrug
4. Resisted Shoulder Abduction
5. Internal and External Shoulder Rotation
6. Extension and Flexion of the Elbows
7. Pronation and Supination of the Elbows
8. Fist Clench and Finger Spread
9. Inspection
10. Back Extension
11. Back Flexion
12. Inspection of Lower Extremities
13. Quadricep Contraction
14. Duck Walk
General
Acute Illness
Cardiovascular
Neurologic
Musculoskeletal
Pulmonary
Genitourinary
Dermatology
Females
Clearing an Athlete for Sports Participation
Common Problems and Conditions
Skin Conditions
Atopic Dermatitis
Diaper Dermatitis
Impetigo
Herpes Varicella (Chickenpox)
Ear and Eye Conditions
Acute Otitis Media
Conjunctivitis
Mouth and Throat Conditions
Dental Caries
Tonsillitis
Cleft Lip and Cleft Palate
Respiratory Conditions
Cystic Fibrosis
Childhood Asthma
Croup Syndromes
Cardiovascular Conditions
Congenital Heart Defects
Musculoskeletal Conditions
Muscular Dystrophies
Myelomeningocele
Scoliosis
Neurologic Conditions
Hydrocephalus
Cerebral Palsy
Attention Deficit Hyperactivity Disorder
Clinical Application and Clinical Judgment
Case Study
Interview Data
Examination Data
Clinical Judgment
CHAPTER 23. Assessment of the Pregnant Patient
Anatomy and Physiology
Health History
Components of Prenatal Health History
Integumentary System
Respiratory System
Cardiovascular System
Gastrointestinal System
Urinary System
Musculoskeletal System
Reproductive System
Breasts
Reason for Seeking Care
Present Health Status
Past Health History
Gynecologic and Obstetric History
Nägele’s Rule
Family History
Personal and Psychosocial History
Attitude Toward the Pregnancy
Diet/Nutritional History
Tobacco, Alcohol, and Illicit Drug Use
Environment
Maternal Characteristics
Maternal Habits
Obstetric History
Current Medical Problems
Problems With Current Pregnancy
Problem-Based History
Skin, Hair, Nails
Nose and Mouth
Ears
Eyes
Respiratory System
Cardiovascular System
Breasts
Gastrointestinal System
Genitourinary System
Musculoskeletal System
Neurologic System
Recommendations to Reduce Risk (Primary Prevention)
Screening Recommendations (Secondary Prevention)
Examination
Common Problems and Conditions
Abruptio Placentae
Placenta Previa
Hydramnios (Polyhydramnios)
Pregnancy-Induced Hypertension
Premature Rupture of Membranes
Clinical Application and Clinical Judgment
Case Study
Interview Data
Examination Data
Clinical Judgment
CHAPTER 24. Assessment of the Older Adult
Anatomy and Physiology
Skin, Hair, and Nails
Head and Neck
Eyes
Ears
Mouth
Respiratory System
Cardiovascular System
Gastrointestinal and Urinary System
Musculoskeletal System
Neurologic System
Breasts
Reproductive System
Female
Male
Health History
Components of the Health History for Older Adults
Present Health Status
Past Health History
Family History
Personal and Psychosocial History
Personal Status
Family and Social Relationships
Diet/Nutrition
Malnutrition in Older Adults
Physical Changes
Economic and Social Issues
Mental Health
Sleep
Alcohol Use
Environment
Review of Systems
Pain
Skin, Hair, and Nails
Eyes, Ears, Nose, and Throat
Respiratory System
Cardiovascular System
Abdomen
Urinary System
Musculoskeletal System
Neurologic System
Reproductive System
Falls in Older Adults
Examination
Vital Signs and Baseline Measurements
Temperature
Heart and Respiratory Rates
Blood Pressure
Height and Weight
Examination of Body Systems
Skin
Hair and Nails
Head and Neck
Eyes
Ears and Hearing
Mouth
Respiratory System
Cardiovascular System
Abdomen
Musculoskeletal System
Neurologic System
Breasts and Axilla
Reproductive System
Female
Male
Rectum, Anus, Prostate
Situational Variations
Functional Assessment
Activities of Daily Living (ADLs)
Instrumental Activities of Daily Living (IADLs)
Functional Mobility
Cognitive Function
Global Cognitive Performance
Executive Functioning
Motor Speed
Episodic Memory
Cognitive Impairment
Common Problems and Conditions
Macular Degeneration
Alzheimer Disease
Urinary Incontinence
Clinical Application and Clinical Judgment
Case Study
Interview Data
Examination Data
Clinical Judgment
Unit IV. Synthesis and Application of Health Assessment
CHAPTER 25. Conducting a Comprehensive Health Assessment
Guidelines for Adult Head-to-Toe Examination
Getting Started
Obtain a History
Assess Vital Signs and Other Baseline Measurements
Examine Hands
Examine Head and Face
Examine Eyes
Examine Ears
Examine Nose
Examine Mouth
Examine Neck
Examine Upper Extremities
Examine Posterior and Lateral Thorax
Examine Anterior Thorax
Examine Breasts
Male
Female
Examine Abdomen
Examine Lower Extremities
Examine Genitalia, Perianal Area, and Rectum
Male Patient
Female
Documentation of the History and Physical Examination
Health History
Biographic Data
Reason for Seeking Care
History of Present Illness
Present Health Status
Past Health History
Family History
Personal and Psychosocial History
Personal Status
Family and Social Relationships
Diet/Nutrition
Functional Ability
Mental Health
Tobacco, Alcohol, and Illicit Drug Use
Health Promotion Activities
Environment
Review of Systems
General Symptoms
Skin, Hair, and Nails
Head and Neck
Eyes
Ears, Nose, and Throat
Breasts and Axilla
Cardiovascular System
Respiratory System
Abdomen
Musculoskeletal System
Neurologic System
Reproductive System
Physical Examination
General Survey
Skin, Hair, and Nails
Head
Neck
Eyes
Ears
Nose
Mouth
Respiratory System
Breasts and Axilla
Cardiovascular System
Heart
Peripheral Vascular
Abdomen
Musculoskeletal System
Neurologic System
Reproductive System
Problem List
Chapter Outline
CHAPTER 26. Adapting Health Assessment
Skin
Intravenous Infusion Site
Surgical Incision
Open Wound
Infected Incision
Respiratory System
Nasal Cannula
Oxygen Mask
Tracheostomy Tube
Chest Tube
Abdomen
Nasogastric Tube
Gastrostomy Tube
Ostomy
Musculoskeletal System
Cast
Summary
Chapter Outline
Appendix A. Abbreviations
Symbols
Appendix B. Answer Key
Chapter 1 Introduction to Health Assessment
Review Questions
Case Study 1
Case Study 2
Chapter 2 Obtaining a Health History
Genogram
Review Questions
Chapter 3 Techniques and Equipment for Physical Assessment
Chapter 4 General Inspection and Measurement of Vital Signs
Chapter 5 Culture Competence
Review Questions
Chapter 6 Pain Assessment
Case Study
Review Questions
Chapter 7 Mental Health Assessment
Case Study
Review Questions
Chapter 8 Nutritional Assessment
Case Study
Review Questions
Chapter 9 Skin, Hair, and Nails
Case Study
Review Questions
Chapter 10 Head and Neck
Case Study
Review Questions
Chapter 11 Eyes
Case Study
Review Questions
Chapter 12 Ear, Nose, and Throat
Case Study
Review Questions
Chapter 13 Respiratory System
Case Study
Review Questions
Chapter 14 Cardiovascular System
Case Study
Review Questions
Chapter 15 Abdomen
Case Study
Review Questions
Chapter 16 Musculoskeletal Assessment
Case Study
Review Questions
Chapter 17 Neurological System
Case Study
Review Questions
Chapter 18 Breasts and Axillae
Case Study
Review Questions
Chapter 19 Female Reproductive System
Case Study
Review Questions
Chapter 20 Male Reproductive System
Case Study
Review Questions
Chapter 21 Anus, Rectum, and Prostate
Case Study
Review Questions
Chapter 22 Assessment of the Infant, Child, and Adolescent
Case Study
Review Questions
Chapter 23 Assessment of the Pregnant Patient
Case Study
Review Questions
Chapter 24 Assessment of the Older Adult
Case Study
Review Questions
Glossary
Illustration Credits
Index
Special Features
Case Study
Clinical Judgment
Concept Overview
Summary of Expected Findings
Ethnic, Cultural, and Spiritual Variations
Frequently Asked Questions
Health Promotion for Evidence-Based Practice
Risk Factors

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Health Assessment for Nursing Practice

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Susan Fickertt Wilson

Jean Foret Giddens

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