Health & Physical Assessment in Nursing by Damico -- Read -- Imperial Library of Trantor

Index

Cover Page Begin Thinking LIKE A NURSE using your PEARSON RESOURCES Health & Physical Assessment in Nursing Health & Physical Assessment in Nursing Thank You

Contributors

Third Edition Contributors Previous Edition Contributors

Advisory Board Reviewers

Preface CHAPTER 1 Health Assessment

Learning Outcomes Key Terms Healthy People 2020 Evidence-Based Practice Health

Definitions of Health Models of Health

Health Assessment

The Interview The Health History The Focused Interview Physical Assessment Documentation

Narrative Notes Problem-Oriented Charting Flow Sheets Focus Documentation Charting by Exception Electronic Health Records (EHRs)

Interpretation of Findings

Knowledge Communication Holistic Approach Developmental Factors Psychologic and Emotional Factors Family Factors Cultural Factors Environmental Factors

Internal Environmental Factors External Environmental Factors

Nursing Process

Assessment Diagnosis Planning Implementation Evaluation

Critical Thinking

Collection of Information Analysis of the Situation Generation of Alternatives Selection of Alternatives Evaluation

Role of the Professional Nurse

Teacher

Informal Teaching Formal Teaching

Learning Needs Goals Objectives Content Teaching Methods Rationales Evaluation

Caregiver Advanced Practice Roles

Nurse Researcher Nurse Practitioner Nurse Anesthetist Clinical Nurse Specialist Nurse Administrator Nurse Educator

Application Through Critical Thinking Case Study

Critical Thinking Questions

References

CHAPTER 2 Human Development Across the Life Span

Learning Outcomes Key Terms Principles of Growth and Development Theories of Development

Cognitive Theory Psychoanalytic Theory Psychosocial Theory

Stages of Development

Infants

Physiologic Growth and Development Motor Development Language Development Cognitive Development Psychosocial Development Assessment of Infants

Toddlers

Physiologic Growth and Development Motor Development Language Development Cognitive Development Psychosocial Development Assessment of Toddlers

Preschool Children

Physiologic Growth and Development Motor Development Language Development Cognitive Development Psychosocial Development Assessment of Preschool Children

School-age Children

Physiologic Growth and Development Motor Development Language Development Cognitive Development Psychosocial Development Assessment of School-age Children

Adolescents

Physiologic Growth and Development Cognitive Development Psychosocial Development Assessment of Adolescents

Young Adults

Physiologic Development Cognitive Development Psychosocial Development Assessment of Young Adults

Middle-aged Adults

Physiologic Development Cognitive Development Psychosocial Development Assessment of Middle-aged Adults

Older Adults

Physiologic Development Cognitive Development Psychosocial Development Assessment of Older Adults

Growth and Development in Health Assessment Factors That Influence Growth and Development

Nutrition Family Culture Socioeconomic Status

Application Through Critical Thinking Case Study

Critical Thinking Questions

References

CHAPTER 3 Wellness and Health Promotion

Learning Outcomes Key Terms Wellness

Wellness Theories

Dunn Leavell and Clark Hattie, Myers, and Sweeney

Health Promotion

Definition Perspectives on Health Promotion

Health Belief Model Theory of Reasoned Action/Planned Behavior Health Promotion Model

Individual Characteristics and Behaviors Behavior-Specific Cognition and Affect Perceived Benefits of Action Perceived Barriers to Action Perceived Self-Efficacy Activity-Related Affect Interpersonal Influences Situational Influences Commitment to a Plan of Action Immediate Competing Demands and Preferences Behavioral Outcomes

Healthy People 2020

Topic Areas

Access to Health Services Education and Community-based Programs Immunization and Infectious Diseases Injury and Violence Prevention Nutrition and Weight Status Physical Activity Sexually Transmitted Diseases and HIV Environmental Health Sleep Health

Infants/Babies Toddlers/Children Adolescents Teens Adults

Substance Abuse Tobacco Use

Health Promotion and the Nursing Process

Assessment Plan Development Roles of the Professional Nurse

Application Through Critical Thinking Case Study

Critical Thinking Questions

References

CHAPTER 4 Cultural Considerations

Learning Outcomes Key Terms Culture

Terms Related to Culture

Race Heritage Ethnicity Diversity

Acculturation

Assimilation

Cultural Competence Cultural Phenomena That Impact Health Care

Communication

Verbal Communication Nonverbal Communication Body Language

Communicating with Language Differences Temporal Relationships Family Patterns Dietary Patterns Health Beliefs and Health Practices

Culture and Obesity Culture in Comprehensive Health Assessment

Ethnic Identity and Culture

Application Through Critical Thinking Case Study

Critical Thinking Questions

References

CHAPTER 5 Psychosocial Assessment

Learning Outcomes Key Terms Psychosocial Health Factors That Influence Psychosocial Health

Internal Factors

Genetics Physical Health Developmental Stage Physical Fitness

External Factors

Family Culture Geography Economic Status

Additional Factors in Psychosocial Health

Self-concept

Feeding and Eating Disorders

Role Development Sexuality Interdependent Relationships Stress and Coping Spiritual and Belief Patterns

The Nursing Process in Psychosocial Assessment

Assessment

Part I. Narrative Framework—Spiritual History

Sample Interview

Part II. Interpretive Framework—Evokes Spiritual Strengths Psychosocial Well-being History of Psychosocial Concerns History of Physiologic Alterations or Diseases Self-concept Family History Other Roles and Relationships Stress and Coping Sensory Perception and Cognition Spiritual and Belief Systems Physical Observation

Organizing the Data

Application Through Critical Thinking Case Study

Critical Thinking Questions

References

CHAPTER 6 Assessment of Vulnerable Populations

Learning Outcomes Key Terms Factors That Influence Vulnerable Populations Race and Ethnicity

Asian American Black or African American Hispanic or Latino Native Hawaiian and Other Pacific Islander American Indian and Alaska Native White or Caucasian Multiracial Racial and Ethnic Approaches to Community Health (REACH)

Age

Abuse

Childhood Maltreatment Elder Abuse Intimate Partner Violence

Infant, Child, and Adolescent Health Adults and Older Adults

Nursing Assessment: Age

Gender

Women's Health Men's Health Sexual Orientation

Nursing Assessment: Gender, Sexual Orientation

Geography Disabilities

Physical Determinants of Health

Nursing Assessment: Disabilities

Socioeconomic Status

Health Insurance Immigrants and Refugees

Nursing Assessment: Immigrants

Incarcerated Men and Women

Nursing Assessment for a Person Who Is Incarcerated

Veterans

Nursing Assessment: Veterans

Homelessness

Nursing Assessment for Homeless Individuals and Families

Application Through Critical Thinking Case Study

Critical Thinking Questions

References

CHAPTER 7 Interviewing and Communication Techniques

Learning Outcomes Key Terms Communication Skills

Interactional Skills

Listening Attending Paraphrasing Leading Questioning Reflecting Summarizing

Barriers to Effective Patient Interaction

False Reassurance Interrupting or Changing the Subject Passing Judgment Cross-Examination Unwanted Advice Technical Terms Sensitive Issues

The Influence of Culture on Nurse-Patient Interactions Professional Characteristics to Enhance the Nurse-Patient Interaction

Positive Regard Empathy Genuineness Concreteness

The Health History Interview

Sources of Information

The Primary Source Secondary Sources

Phases of the Health Assessment Interview

Phase I: Preinteraction Environment Phase II: The Initial Interview Phase III: The Focused Interview

Lifespan Considerations

Focused Interview for Pediatric Patients Focused Interview for Older Adult Patients Nursing Considerations Application Through Critical Thinking Case Study

Critical Thinking Questions

References

CHAPTER 8 The Health History

Learning Outcomes Key Terms The Health History

Components of the Health History

Biographic Data

Name and Address Age and Date of Birth Birthplace Gender Marital Status Sexual Orientation Race Religion Occupation Health Insurance Source of Information Reliability of the Source

Present Health or Illness

Reason for Seeking Care Health Beliefs and Practices Health Patterns Medications

Past History Family History Psychosocial History Review of Body Systems

Documentation Nursing Considerations

Biographic Data Present Health Status: Reason for Seeking Health Care Health Beliefs and Practices Medications Past History, Surgeries, and Illnesses Emotional History Family History Psychosocial History-Occupation Roles and Relationships Ethnicity and Culture Spirituality Self-Concept Review of Systems

Skin, Hair, and Nails Head and Neck Eyes Ears, Nose, Mouth, and Throat Respiratory Breasts and Axillae Cardiac Peripheral Vascular Gastrointestinal Urinary Reproductive Sexuality Musculoskeletal Neurologic

Health History

Date: June 30th

Present Health/Illness

Reason for seeking care Height/Weight Vital signs Health beliefs and practices Health patterns Medications Health goals

Past History

Childhood illnesses Immunizations Medical illnesses Hospitalization Surgery Injury Blood transfusion Emotional/psychiatric problems Allergies Use of tobacco? Use of alcohol Use of illicit drugs

Family History

Father Mother Siblings Grandparents

Psychosocial History

Occupational history Educational level Financial background Roles and relationships Ethnicity and culture Family Spirituality Self-concept

Review of Systems

Skin, hair, nails Head, neck, related lymphatics Eyes Ears, nose, mouth, and throat Respiratory Breasts and axillae Cardiovascular

Peripheral vascular

Abdomen Urinary Reproductive Sexual Musculoskeletal Neurologic

Application Through Critical Thinking Case Study

Critical Thinking Questions

References

CHAPTER 9 Techniques and Equipment

Learning Outcomes Key Terms Basic Techniques of Physical Assessment

Inspection Palpation

Light Palpation Moderate Palpation Deep Palpation

Percussion

Direct Percussion Blunt Percussion Indirect Percussion Sounds

Auscultation

Equipment

Stethoscope Doppler Ultrasonic Stethoscope Ophthalmoscope Otoscope

Professional Responsibilities

Cues Critical Thinking Providing a Safe and Comfortable Environment

Setting Preparation Privacy Examination Considerations Special Considerations

Techniques and Equipment in Assessment of the Obese Patient Standard Precautions

Hand Hygiene Use and Care of Medical Equipment Patient Hazards

Application Through Critical Thinking Case Study

Critical Thinking Questions

References

CHAPTER 10 General Survey

Learning Outcomes Key Terms Components of the General Survey

Physical Appearance Mental Status Mobility Patient Behavior Lifespan Considerations

Measuring Height and Weight

Height Weight Lifespan Considerations

Measuring Vital Signs

Measuring Body Temperature

Factors That Influence Body Temperature Routes for Measuring Body Temperature

Oral Rectal Axillary Tympanic Temporal Artery

Measuring the Pulse Rate

Location of Pulse Points Factors That Influence Pulse Rate Palpation of the Radial Pulse

Measuring Respiratory Rate

Assessment of Respiratory Rate Factors That Influence Respiratory Rate Oxygen Saturation Lifespan Considerations

Measuring Blood Pressure

Circulatory Factors That Influence Blood Pressure Additional Factors Affecting Blood Pressure Assessment of Blood Pressure

Patient Preparation Equipment The Procedure

Lifespan Considerations

Temperature Pulse Respirations Blood Pressure

Pain—The Fifth Vital Sign The Functional Assessment as Part of the General Survey

Functional Assessment Defined Functional Assessment During the General Survey Critical Thinking

Application Through Critical Thinking Case Study

Critical Thinking Questions

References

CHAPTER 11 Pain Assessment

Learning Outcomes Key Terms Definition of Pain Physiology of Pain

Theories of Pain Nervous System

Nociception

Mechanical Thermal Chemical Transduction Transmission Perception Modulation

Responses to Pain

Nature of Pain

Types of Pain Concepts Associated with Pain

Factors Influencing Pain

Lifespan Considerations Cultural Influences Environmental Considerations

Assessment

Pain History

Onset Location Duration Characteristics Aggravating Factors Relieving Factors Treatment Impact on Activities of Daily Living Coping Strategies Emotional Responses

Behavior and Physiologic Reponses to Pain

Behavior Physiologic Responses

Focused Interview

Questions Regarding Onset Questions Regarding Location Questions Regarding Duration Questions Regarding Characteristics of the Pain Questions Regarding Aggravating Factors Questions Regarding Relieving Factors Questions Regarding Treatment Questions Regarding Impact on Activities of Daily Living Questions Related to Coping Strategies Questions Related to Emotional Responses

Physiologic Responses

Assessment Tools

Unidimensional Tools Multidimensional Tools

Application Through Critical Thinking Case Study

Critical Thinking Questions

References

CHAPTER 12 Nutritional Assessment

Learning Outcomes Key Terms Defining Nutritional Health

Health Promotion

Undernutrition Overnutrition Overweight and Obesity Undernutrition Poverty and Food Insecurity

Nutritional Assessment

Nutritional History

Diet Recall Food Frequency Questionnaire Food Record Focused Nutritional History Interview

Physical Assessment

Height Weight

Food Beliefs and Practices Supplement and Medication Use Socioeconomic and Educational Influences

Body Mass Index Height–Weight Tables Waist Circumference Body Composition Measurement

Skinfold Measurements Midarm Muscle Circumference and Calf Circumference Bioelectrical Impedance Analysis Near-Infrared Interactance Laboratory Body Composition

Body Fat References or Standards Physical Assessment

Biochemical Assessment—Laboratory Measurements Cultural Considerations for the Nutritional Assessment Nutritional Assessment Across the Life Span

The Pregnant Female The Lactating Female Infants, Children, and Adolescents Adults The Older Adult

Nutritional Screening and Assessment Tools

ChooseMyPlate Other Assessment Tools

The DETERMINE Checklist The Minimum Data Set Mini Nutritional Assessment and Subjective Global Assessment Malnutrition Universal Screening Tool

Patient Education

Application Through Critical Thinking Case Study

Complete Documentation

SUBJECTIVE DATA: OBJECTIVE DATA:

Critical Thinking Questions

References

CHAPTER 13 Skin, Hair, and Nails

Learning Outcomes Key Terms Anatomy and Physiology Review

Skin and Glands

Epidermis Dermis Subcutaneous Tissue Cutaneous Glands Oil Glands

Hair Nails

Special Considerations

Health Promotion Considerations Lifespan Considerations

Infants and Children The Pregnant Female The Older Adult

Psychosocial Considerations Cultural and Environmental Considerations

Pallor Absence of Color Cyanosis Reddish Blue Tone Erythema Jaundice Carotenemia Uremia Brown Gathering the Data

Laboratory Tests—Skin Diagnostic Tests—Skin Diagnostic Tests—Hair Diagnostic Tests—Nails Focused Interview

Skin Questions Related to Illness or Infection Questions Related to Symptoms, Pain, and Behaviors Questions Related to Age Questions Related to the Environment Hair Nails

Patient-Centered Interaction

Interview Analysis

Patient Education

Risk Factors Patient Education Risk Factors Patient Education Risk Factors Patient Education

Risk Factors Patient Education Physical Assessment

Assessment Techniques and Findings

EQUIPMENT Survey Inspection of the Skin Palpation of the Skin ADDITIONAL ASSESSMENT Assessment for Cancerous Lesions Inspection of the Scalp and Hair Assessment of the Nails

Abnormal Findings

Macule and Patch Papule and Plaque Nodule and Tumor Vesicle and Bulla Pustule Wheal Cyst Atrophy Crust Erosion Fissure Keloid Lichenification Scales Scar Ulcer Ecchymosis Hemangioma Hematoma Petechiae Port-Wine Stain Purpura Spider Angioma Venous Lake Annular

Examples:

Confluent

Example:

Discrete

Example:

Grouped

Example:

Target

Example:

Linear

Example:

Polycyclic

Example:

Zosteriform

Example:

Overview of Skin Lesions

Infectious Skin Lesions Allergic or Inflammatory Skin Lesions Malignant Skin Lesions

Overview of Hair and Scalp Abnormalities Overview of Nail Abnormalities

Application Through Critical Thinking Case Study

Complete Documentation

Subjective Data: Objective Data:

Critical Thinking Questions

Prepare Teaching Plan

References

CHAPTER 14 Head, Neck, and Related Lymphatics

Learning Outcomes Key Terms Anatomy and Physiology Review

Head Neck Lymphatics

Special Considerations

Health Promotion Considerations Lifespan Considerations

Infants and Children The Pregnant Female The Older Adult

Psychosocial Considerations Cultural and Environmental Considerations

Gathering the Data

Thyroid Lymph Nodes Diagnostic Tests

Lymph Nodes Thyroid

Focused Interview

General Questions Questions Related to Illness, Infection, or Injury Questions Related to Symptoms, Pain, and Behaviors Questions Related to Age Questions Related to the Environment

Patient-Centered Interaction

Interview Analysis

Patient Education

Risk Factors Patient Education Risk Factors Patient Education Risk Factor Patient Education Risk Factors Patient Education

Physical Assessment

Assessment Techniques and Findings

EQUIPMENT

The Head The Neck

Abnormal Findings

Headaches

Acromegaly Bell's Palsy Cerebrovascular Accident (CVA, stroke, brain attack) Craniosynostosis Cushing's Syndrome Down Syndrome Fetal Alcohol Syndrome (FAS) Hydrocephalus Parkinson's Disease Torticollis Classic Migraine Cluster Headache Tension Headache

Thyroid Abnormalities

Hyperthyroidism Hypothyroidism Thyroid-Related Disorders

Application Through Critical Thinking Case Study

Complete Documentation

Subjective Data: Objective Data:

Critical Thinking Questions

Prepare Teaching Plan

References

CHAPTER 15 Eye

Learning Outcomes Key Terms Anatomy and Physiology Review

Eye Refraction of the Eye Visual Pathways Accessory Structures of the Eye

Special Considerations

Health Promotion Considerations Lifespan Considerations

Infants and Children The Pregnant Female The Older Adult

Psychosocial Considerations Cultural and Environmental Considerations

Gathering the Data

Focused Interview

General Questions Questions Related to Illness or Infection Questions Related to Symptoms, Pain, and Behaviors Questions Related to Age Questions Related to the Environment

Patient-Centered Interaction

Interview Analysis

Patient Education Physical Assessment

Assessment Techniques and Findings

EQUIPMENT Vision Extraocular Movements (EOM) Inspection of the Eyes ADVANCED SKILL

Abnormal Findings

Disorders of Visual Acuity

Myopia Hyperopia Astigmatism Presbyopia Visual Fields Cardinal Fields of Gaze

Application Through Critical Thinking Case Study

Complete Documentation

Subjective Data: Objective Data:

Critical Thinking Questions

Prepare Teaching Plan

References

CHAPTER 16 Ears, Nose, Mouth, and Throat

Learning Outcomes Key Terms Anatomy and Physiology Review

Ear

External Ear Middle Ear Inner Ear

Nose and Sinuses Mouth Throat

Special Considerations

Health Promotion Considerations Lifespan Considerations

Infants and Children The Pregnant Female The Older Adult

Psychosocial Considerations Cultural and Environmental Considerations

Gathering the Data

Focused Interview

Laboratory Tests for the Ear, Nose, Mouth, and Throat

Cultures and Sensitivity

Diagnostic Tests

Ear Nose and Sinuses Teeth Throat

General Questions Questions Related to Illness or Infection Questions Related to Symptoms, Pain, and Behaviors Questions Related to the Environment Questions Related to Age Nose and Sinuses Mouth and Throat

Patient-Centered Interaction

Interview Analysis

Patient Education Physical Assessment

Assessment Techniques and Findings

EQUIPMENT Ear Nose and Sinuses Mouth and Throat

Abnormal Findings

Keloid Otitis Externa Tophi Otitis Media Perforation of the Tympanic Membrane Scarred Tympanic Membrane Deviated Septum Epistaxis Nasal Polyp Perforated Septum Rhinitis Sinusitis Ankyloglossia Aphthous Ulcers Black Hairy Tongue Oral Carcinoma Cleft Lip Cleft Palate Gingival Hyperplasia Gingivitis Herpes Simplex Leukoplakia Atrophic glossitis Tonsillitis

Application Through Critical Thinking Case Study

Complete Documentation

Subjective Data: Objective Data:

Critical Thinking Questions

Prepare Teaching Plan

References

CHAPTER 17 Respiratory System

Learning Outcomes Key Terms Anatomy and Physiology Review

Lower Respiratory Tract

Trachea Bronchi Lungs Pleural Membranes Mediastinum

Respiratory Process

Muscles of Respiration Thoracic Cage Respiratory Cycle

Landmarks Special Considerations

Health Promotion Considerations Lifespan Considerations

Infants and Children The Pregnant Female The Older Adult

Psychosocial Considerations Cultural and Environmental Considerations

Gathering the Data

Focused Interview

General Questions Questions Related to Illness or Infection Questions Related to Symptoms, Pain, and Behaviors Questions Related to Age Questions Related to the Environment

Patient-Centered Interaction

Interview

Patient Education Physical Assessment

Assessment Techniques and Findings

EQUIPMENT Survey Inspection of the Anterior and Lateral Thorax Inspection of the Posterior Thorax Palpation of the Posterior Thorax Percussion of the Posterior Thorax Auscultation of the Posterior Thorax Assessment of Voice Sounds Palpation of the Anterior and Lateral Thorax Percussion of the Anterior and Lateral Thorax Auscultation of the Anterior and Lateral Thorax Rales/ Crackles Fine Rhonchi Wheezes (sibilant) Normal Findings

Eupnea Eupnea With Sigh

Abnormal Findings

Tachypnea Bradypnea Hyperventilation Hypoventilation Cheyne-Stokes Biot's (Ataxic) Respirations Sighing Obstructive Breathing

Adult Child Infant Barrel Chest Funnel Chest (Pectus Excavatum) Scoliosis Pigeon Chest (Pectus Carinatum) Kyphosis Abnormal Findings

Respiratory Disorders

Asthma Atelectasis Chronic Bronchitis Emphysema Lobar Pneumonia Pleural Effusion Pneumothorax Left Heart Failure Valley Fever

Application Through Critical Thinking Case Study

Complete Documentation

Subjective Data: Objective Data:

Critical Thinking Questions

Prepare Teaching Plan

References

CHAPTER 18 Breasts and Axillae

Learning Outcomes Key Terms Anatomy and Physiology Review

Breasts Axillae and Lymph Nodes Muscles of the Chest Wall

Special Considerations

Health Promotion Considerations Lifespan Considerations

Infants and Children The Pregnant Female The Older Adult

Psychosocial Considerations Cultural and Environmental Considerations

Gathering the Data

Focused Interview

Laboratory Tests Diagnostic Tests General Questions Questions Related to Illness or Infection Questions Related to Symptoms or Behaviors Questions Related to Age Questions Related to the Environment

Patient-Centered Interaction

Interview Analysis

Patient Education Physical Assessment

Assessment Techniques and Findings

EQUIPMENT Inspection of the Breast Palpation of the Breast Examination of the Axillae Inspection of the Male Breast Palpation of the Male Breast and Axillae

Abnormal Findings

Application Through Critical Thinking Case Study

Complete Documentation

Subjective Data: Objective Data:

Critical Thinking Questions

Prepare Teaching Plan

Learning Need:

Goal: Objectives:

References

CHAPTER 19 Cardiovascular System

Learning Outcomes Key Terms Anatomy and Physiology Review

Pericardium Heart

Heart Wall Heart Chambers

Right Atrium Right Ventricle Left Atrium Left Ventricle

Valves

Atrioventricular Valves Semilunar Valves

Heart Sounds Additional Heart Sounds Coronary Arteries Cardiac Veins Cardiac Conduction System

Sinoatrial Node Intra-Atrial Conduction Pathway Atrioventricular Node and Bundle of His Right and Left Bundle Branches and Purkinje Fibers Cardiac Nerves

Pulmonary Circulation Systemic Circulation Landmarks for Cardiovascular Assessment Cardiac Cycle

Electrical and Mechanical Events

Period of Ventricular Filling Ventricular Systole Isovolumetric Relaxation

Electrical Representation of the Cardiac Cycle

P Wave PR Interval QRS Complex T Wave QT Interval

Measurements of Cardiac Function

Special Considerations

Health Promotion Considerations Lifespan Considerations

Infants and Children The Pregnant Female The Older Adult

Psychosocial Considerations Cultural and Environmental Considerations

Gathering the Data

Diagnostic Tests Focused Interview

General Questions Questions Related to Illness Questions Related to Symptoms or Behaviors Questions Related to Age Questions Related to the Environment

Patient-Centered Interaction

Interview Analysis

Patient Education Physical Assessment

Assessment Techniques and Findings

EQUIPMENT Inspection Palpation Auscultation

Abnormal Findings

Diseases of the Myocardium and Pumping Capacity of the Heart

Myocardial Ischemia Myocardial Infarction (MI) Heart Failure Ventricular Hypertrophy

Valvular Heart Disease

Mitral Stenosis Aortic Stenosis Mitral Regurgitation Pulmonic Stenosis Tricuspid Stenosis Mitral Valve Prolapse Aortic Regurgitation

Septal Defects

Ventricular Septal Defect Atrial Septal Defect

Congenital Heart Disease

Coarctation of the Aorta Patent Ductus Arteriosus Tetralogy of Fallot

Electrical Rhythm Disturbances

Ventricular Tachycardia Ventricular Fibrillation Heart Block Atrial Flutter Atrial Fibrillation

Application Through Critical Thinking Case Study

Complete Documentation

Subjective Data: Objective Data:

Critical Thinking Questions

Prepare Teaching Plan

References

CHAPTER 20 Peripheral Vascular System

Learning Outcomes Key Terms Anatomy and Physiology Review

Arteries Veins Capillaries Lymphatic System

Special Considerations

Health Promotion Considerations Lifespan Considerations

Infants and Children The Pregnant Female The Older Adult

Psychosocial Considerations Cultural and Environmental Considerations

Gathering the Data

Focused Interview

General Questions Questions Related to Illness Questions Related to Symptoms, Pain, and Behaviors Questions Related to Age Questions Related to the Environment

Patient-Centered Interaction

Interview Analysis

Patient Education Physical Assessment

Assessment Techniques and Findings

EQUIPMENT

Abnormal Findings

Arterial Insufficiency Arterial Aneurysm Venous Insufficiency Orthostatic Hypotension Varicose Veins Raynaud's Disease Deep Vein Thrombosis Arteriovenous Fistula Lymphedema

Application Through Critical Thinking Case Study

Complete Documentation

Subjective Data: Objective Data:

Critical Thinking Questions

Prepare Teaching Plan

Learning Need:

Goal: Objectives:

References

CHAPTER 21 Abdomen

Learning Outcomes Key Terms Anatomy and Physiology Review

Abdomen Alimentary Canal

Esophagus Stomach Small Intestine Large Intestine

Accessory Digestive Organs

Liver Gallbladder Pancreas

Other Related Structures

Peritoneum Muscles of the Abdominal Wall Aorta Kidneys, Ureters, and Bladder Spleen Reproductive Organs

Landmarks Special Considerations

Health Promotion Considerations Lifespan Considerations

Infants and Children The Pregnant Female The Older Adult

Psychosocial Considerations Cultural and Environmental Considerations

Gathering the Data

Diagnostic Tests Focused Interview

General Questions Questions Related to Illness or Infection Questions Related to Symptoms, Pain, and Behaviors Questions Related to Age Questions Related to the Environment

Patient-Centered Interaction

Interview Analysis

Patient Education Physical Assessment

Assessment Techniques and Findings

EQUIPMENT

Survey Inspection of the Abdomen Auscultation of the Abdomen Percussion of the Abdomen ADVANCED SKILL Percussion of the Liver ADVANCED SKILL Percussion of the Spleen Percussion of the Gastric Bubble Palpation of the Abdomen ADVANCED SKILL Palpation of the Liver ADVANCED SKILL Palpation of the Spleen Additional Procedures

Abnormal Findings

Abnormal Abdominal Sounds

Bowel Sounds Vascular Sounds Rubbing

Abdominal Pain Abdominal Distention

Obesity Gaseous Distention Abdominal Tumor Ascites

Abdominal Hernias

Umbilical Hernia Ventral (Incisional) Hernias Hiatal Hernia

Alterations of the Gastrointestinal Tract

Cancers

Hepatic Cancer Pancreatic Cancer Stomach Cancer Colorectal Cancer

Inflammatory Processes

Ulcerative Colitis Esophagitis Peritonitis Hepatitis Crohn's Disease

Application Through Critical Thinking Case Study

Complete Documentation

Subjective Data: Objective Data:

Critical Thinking Questions

Prepare Teaching Plan

References

CHAPTER 22 Urinary System

Learning Outcomes Key Terms Anatomy and Physiology Review

Kidneys Renal Arteries Ureters Urinary Bladder Urethra Landmarks

Special Considerations

Health Promotion Considerations Lifespan Considerations Infants and Children The Pregnant Female The Older Adult Psychosocial Considerations Cultural and Environmental Considerations

Gathering the Data

Diagnostic Tests Focused Interview

General Questions Questions Related to Illness or Infection Questions Related to Symptoms, Pain, and Behaviors Questions Related to Age Questions Related to the Environment

Patient-Centered Interaction

Interview Analysis

Patient Education Physical Assessment

Assessment Techniques and Findings

EQUIPMENT General Survey The Kidneys and Flanks ADVANCED SKILL THE LEFT KIDNEY Advanced Skill The Right Kidney The Urinary Bladder

Abnormal Findings

Application Through Critical Thinking Case Study

Complete Documentation

Subjective Data: Objective Data:

Critical Thinking Questions

Prepare Teaching Plan

References

CHAPTER 23 Male Reproductive System

Learning Outcomes Key Terms Anatomy and Physiology Review

Scrotum Testes Spermatic Cord Duct System

Epididymis Ductus Deferens Urethra

Accessory Glands

Seminal Vesicles Prostate Gland Bulbourethral Glands

Penis Inguinal Areas Perianal Area

Special Considerations

Health Promotion Considerations Lifespan Considerations

Infants and Children The Older Adult

Psychosocial Considerations Cultural and Environmental Considerations

Gathering the Data

Diagnostic Tests Focused Interview

General Questions Questions Related to Illness or Infection Questions Related to Symptoms, Pain, and Behaviors Questions Related to Age Questions Related to the Environment

Patient-Centered Interaction

Interview Analysis

Patient Education Physical Assessment

Assessment Techniques and Findings

EQUIPMENT Inspection Palpation

Abnormal Findings

Hypospadias Peyronie's Disease Carcinoma Genital Warts Syphilitic Chancre Genital Herpes Hydrocele Scrotal Hernia Testicular Tumor Orchitis Epididymitis Torsion of the Spermatic Cord Small Testes Cryptorchidism Scrotal Edema Pilonidal Cyst Anal Fissure Hemorrhoids (Internal) Hemorrhoids (External) Perianal Perirectal Abscess Prolapse of the Rectum

Application Through Critical Thinking Case Study

Complete Documentation

Subjective Data: Objective Data:

Critical Thinking Questions

Prepare Teaching Plan

References

CHAPTER 24 Female Reproductive System

Learning Outcomes Key Terms Anatomy and Physiology Review

External Genitalia

Mons Pubis Labia Majora and Labia Minora Skene's and Bartholin's Glands Clitoris Perianal Area

Internal Reproductive Organs

Vagina Uterus Uterine Tubes Ovaries

Special Considerations

Health Promotion Considerations Lifespan Considerations

Infants and Children The Pregnant Female The Older Adult

Psychosocial Considerations Cultural and Environmental Considerations

Gathering the Data

Focused Interview

Diagnostic Tests General Questions Questions Related to Illness or Infection Questions Related to Symptoms, Pain, and Behaviors Questions Related to Age Questions Related to the Environment

Patient-Centered Interaction

Interview Analysis

Patient Education Physical Assessment

Assessment Techniques and Findings

EQUIPMENT Inspection Palpation Inspection With a Speculum Obtaining the Pap Smear and Gonorrhea Culture Bimanual Palpation

Abnormal Findings

Pediculosis Pubis Herpes Simplex Syphilitic Lesion Human Papillomavirus (HPV) Abscess of Bartholin's Gland Cyanosis Diethylstilbestrol (DES) Syndrome Carcinoma Erosion Polyp Atrophic Vaginitis Chlamydia Pelvic Inflammatory Disease (PID) Candidiasis Gonorrhea Trichomoniasis Disorders of the Internal Reproductive Organs

Myomas/Fibroids Ovarian Cancer Ovarian Cysts

Application Through Critical Thinking Case Study

Complete Documentation

Subjective Data: Objective Data:

Critical Thinking Questions

Prepare Teaching Plan

References

CHAPTER 25 Musculoskeletal System

Learning Outcomes Key Terms Anatomy and Physiology Review

Bones Skeletal Muscles Joints

Temporomandibular Joint Shoulder Elbow Wrist and Hand Hip Knee Ankle and Foot Spine

Special Considerations

Health Promotion Considerations Lifespan Considerations

Infants and Children The Pregnant Female The Older Adult

Psychosocial Considerations Cultural and Environmental Considerations

Gathering the Data

Diagnostic Tests Focused Interview

General Questions Questions Related to Illness, Infection, or Injury Questions Related to Symptoms, Pain, and Behaviors Questions Related to Age Questions Related to the Environment

Patient-Centered Interaction

Interview Analysis

Patient Education Physical Assessment

Assessment Techniques and Findings

EQUIPMENT Survey Assessment of the Joints Shoulders Elbows Wrists and Hands Hips Knees Ankles and Feet Spine

Abnormal Findings

Kyphosis Scoliosis Lordosis Temporomandibular Joint Syndrome Rotator Cuff Tear Olecranon Bursitis Joint Effusion Rheumatoid Nodules Carpal Tunnel Syndrome Dupuytren's Contracture Ulnar Deviation Swan-Neck and Boutonnière Deformities Osteoarthritis Rheumatoid Arthritis Synovitis Gout Hallux Valgus (Bunion) Hammertoe

Application Through Critical Thinking Case Study

Complete Documentation

Subjective Data: Objective Data:

Critical Thinking Questions

Prepare Teaching Plan

References

CHAPTER 26 Neurologic System

Learning Outcomes Key Terms Anatomy and Physiology Review

Central Nervous System

Brain

Cerebrum Diencephalon Cerebellum Brain Stem

Spinal Cord

Reflexes Peripheral Nervous System

Cranial Nerves Spinal Nerves

Special Considerations

Health Promotion Considerations Lifespan Considerations

Infants and Children The Pregnant Female The Older Adult

Psychosocial Considerations Cultural and Environmental Considerations

Gathering the Data

Focused Interview

General Questions Questions Related to Illness, Infection, or Injury Questions Related to Symptoms, Pain, and Behaviors Questions Related to Age Questions Related to the Environment

Patient-Centered Interaction

Interview Analysis

Patient Education Physical Assessment

Assessment Techniques and Findings

EQUIPMENT Mental Status Cranial Nerves Motor Function Sensory Function Reflexes Additional Assessment Techniques

Meningeal Assessment

Abnormal Findings

Seizures Spinal Cord Injuries

Traumatic Brain Injury

Infections of the Neurologic System

Meningitis Myelitis Brain Abscess Lyme Disease

Degenerative Neurologic Disorders

Alzheimer's Disease Amyotrophic Lateral Sclerosis Huntington's Disease Multiple Sclerosis Myasthenia Gravis Parkinson's Disease

Application Through Critical Thinking Case Study

Complete Documentation

Subjective Data: Objective Data:

Critical Thinking Questions

Prepare Teaching Plan

References

CHAPTER 27 The Pregnant Female

Learning Outcomes Key Terms Anatomy and Physiology Review

The Placenta Fetal Development Reproductive System Changes

Uterus Cervix and Vagina

Changes in Breasts Respiratory System Changes Cardiovascular and Hematologic System Changes Integumentary System Changes Changes in the Ear, Nose, Throat, and Mouth Gastrointestinal System Changes Urinary System Changes Musculoskeletal Changes Neurologic System Changes Endocrine System Changes

Special Considerations

Health Promotion Considerations Developmental Considerations

Adolescent Females Older Women

The Postpartum Female

Anatomy and Physiology Review The BUBBLESHE Head-to-Toe Postpartum Assessment

Psychosocial Considerations Cultural and Environmental Considerations

Gathering the Data

Focused Interview

Questions Related to Confirmation of Pregnancy

Patient-Centered Interaction

Interview Analysis

Patient Education

Nutritional Assessment

Physical Assessment

Anthropometric Measurements Laboratory Measurements

Physical Assessment

Assessment Techniques and Findings

EQUIPMENT

For the pelvic assessment, the nurse will need the following materials:

General Survey Skin, Hair, and Nails Head and Neck Eyes, Ears, Nose, Mouth, and Throat Thorax and Lungs Heart Breasts and Axillae Extremities Neurologic System Abdomen and Fetal Assessment External Genitalia Inspection of Vagina and Cervix Palpation of Pelvis Palpation of Cervix, Uterus, Adnexa, and Vagina Anus and Rectum

Laboratory Tests in Pregnancy

Abnormal Findings

Common Complications in Pregnancy Common Complications in the Postpartum Period

Application Through Critical Thinking Case Study

Complete Documentation

Critical Thinking Questions

Prepare Teaching Plan

References

CHAPTER 28 The Hospitalized Patient

Learning Outcomes Introduction The Rapid Assessment

Sequence

The Routine or Initial Assessment Special Considerations Summary Application Through Critical Thinking Case Study

Complete Documentation

Subjective Data: Objective Data:

Critical Thinking Questions

Subjective Data: Objective Data:

Prepare Teaching Plan

CHAPTER 29 The Complete Health Assessment

Learning Outcomes Sequence Summary Application Through Critical Thinking Case Study

Complete Documentation

Subjective Data: Objective Data:

Prepare Teaching Plan

APPENDIX A Standard Precautions for Blood and Bodily Fluid Exposure APPENDIX B Standard Precautions for Infection Control APPENDIX C Blood Pressure Standards for Girls Ages 1 to 17 Years APPENDIX D Blood Pressure Standards for Boys Ages 1 to 17 Years APPENDIX E Mini Nutritional Assessment Glossary Chapter Opener Sources Patient-Centered Interaction Sources Case Study Sources Index

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