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Health Assessment and Physical Examination

by
Edition:
3rd
ISBN13:

9781401872069

ISBN10:
1401872069
Format:
Hardcover
Pub. Date:
7/6/2005
Publisher(s):
Cengage Learning
List Price: $134.95
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Summary

The premier book of its kind, Health Assessment & Physical Examination, third edition, is designed to teach you to assess a patient's physical, psychological, social, emotional, and spiritual dimensions of health as a foundation to nursing care. The skills of interviewing, documentation, inspection, percussion, palpation, and auscultation are refined to teach you to make effective clinical judgments that promote healthy positive outcomes.

Table of Contents

Contributors xiii
Reviewers xv
Preface xvi
How to Use This Text xxii
Acknowledgments xxvi
About the Author xxvii
UNIT 1: Laying the Foundation
1(84)
Critical Thinking and the Nursing Process
3(14)
Critical Thinking and Clinical Reasoning
4(2)
Components of Critical Thinking
5(1)
Universal Intellectual Standards for Critical Thinking
5(1)
Critical Thinking and the Nursing Process
6(7)
Assessment
7(1)
Nursing Diagnosis
8(2)
Outcomes Identification
10(1)
Planning
11(1)
Implementation
12(1)
Evaluation
12(1)
Critical Pathways
13(1)
Documenting the Nursing Process
13(4)
The Patient Interview
17(26)
The Patient Interview
18(1)
The Role of the Nurse
18(1)
The Role of the Patient
19(1)
Factors Influencing the Interview
19(2)
Approach
19(1)
Environment
20(1)
Confidentiality
20(1)
HIPAA
20(1)
Note Taking
21(1)
Time, Length, Duration
21(1)
Biases and Preconceptions
21(1)
Stages of the Interview Process
21(1)
Stage I
21(1)
Stage II
22(1)
Stage III
22(1)
Factors Affecting Communication
22(1)
Listening
22(1)
Nonverbal Cues
22(1)
Distance
23(1)
Personal Space
23(1)
Effective Interviewing Techniques
23(8)
Using Open-Ended Questions
23(1)
Using Closed Questions
24(1)
Facilitating
24(1)
Using Silence
24(1)
Grouping Communication Techniques
25(6)
Nontherapeutic Interviewing Techniques
31(5)
Requesting an Explanation
31(1)
Probing
31(1)
Offering False Reassurance
32(1)
Giving Approval or Disapproval
32(1)
Defending
33(1)
Advising
33(1)
Using Problematic Questioning Techniques
34(2)
Interviewing the Patient with Special Needs
36(7)
The Patient Who Is Hearing-Impaired
36(1)
The Patient Who Is Visually Impaired
36(1)
The Patient Who Is Speech-Impaired or Aphasic
36(1)
The Patient Who Is Non-English-Speaking
37(1)
The Patient Who Has a Low Level of Understanding
37(1)
The Patient Who Is Crying
37(1)
The Patient Who Is Anxious and Angry
38(1)
The Patient Who Is Hostile
38(1)
The Patient Who Is Sexually Aggressive
38(1)
The Patient Who Is under the Influence of Alcohol or Drugs
38(1)
The Patient Who Is Very III
39(1)
The Older Adult
39(4)
The Complete Health History Including Documentation
43(42)
Types of Health History
44(1)
Preparing for the Health History
44(1)
Computerized Health History
45(1)
Identifying Information
45(1)
Today's Date
45(1)
Biographical Data
46(1)
The Complete Health History Assessment Tool
46(23)
Source and Reliability of Information
46(1)
Patient Profile
46(1)
Reason for Seeking Health Care and Chief Complaint
46(1)
Present Health and History of the Present Illness
47(2)
Past Health History
49(6)
Family Health History
55(1)
Social History
56(8)
Health Maintenance Activities
64(3)
Review of Systems
67(2)
Concluding the Health History
69(1)
Documentation
69(2)
The System-Specific Health History
71(1)
Complete Health History: Well Patient
71(4)
Complete Health History: Ill Patient
75(10)
UNIT 2: Special Assessments
85(142)
Developmental Assessment
87(28)
Developmental Theories
88(6)
Ages and Stages Developmental Theories
89(5)
Developmental Stages, Tasks, and Life Events
94(12)
Developmental Tasks of Infants (Birth to 1 Year)
95(4)
Developmental Tasks of Toddlers (1 to 3 Years)
99(1)
Developmental Tasks of Preschoolers (3 to 6 Years)
100(1)
Developmental Tasks of School-Age Children (6 to 12 Years)
101(1)
Developmental Tasks of Adolescents (12 to 18 Years)
102(1)
Developmental Tasks of Young Adults (18 to 30 Years)
103(1)
Developmental Tasks of Early Middle Adulthood (30 to 50 Years)
103(1)
Developmental Tasks of Late Middle Adulthood (50 to 70 Years)
104(1)
Developmental Tasks of Late Adulthood (70 Years to Death)
105(1)
Stages of Family Development
106(1)
Developmental Assessment Tools
107(3)
Case Study: The Infant with Failure to Thrive
110(5)
Cultural Assessment
115(30)
Culturally Competent Nursing Care
116(2)
Basic Concepts Associated with Culturally Competent Assessments
118(20)
Culture
118(1)
Subculture
118(1)
Racial Groups
118(1)
Ethnic Groups
119(1)
Minority Groups
119(1)
Values, Norms, and Value Orientations
119(2)
Beliefs
121(5)
Customs and Rituals
126(12)
Case Study: A Young Egyptian American Woman with Oligomenorrhea
138(7)
Spiritual Assessment
145(32)
Spirituality and Religion
146(1)
Spiritual Theory
147(2)
Holistic Health and Spirituality
149(17)
Role of the Nurse in Spiritual Care
166(7)
Spiritual Assessment
167(2)
Nursing Diagnosis
169(1)
Planning and Implementation
170(2)
Evaluation
172(1)
Case Study: The Spiritual Side of the Withdrawal of Life Support
173(4)
Nutritional Assessment
177(50)
Dietary Guidelines
178(8)
Nutrients
186(6)
Carbohydrates
186(1)
Proteins
186(1)
Fats
187(1)
Vitamins
187(1)
Minerals
187(3)
Water
190(2)
Nutrition through the Life Cycle
192(8)
Children
192(3)
Adolescents
195(2)
Young and Middle-Aged Adults
197(1)
Pregnant and Lactating Women
198(1)
Older Adults
199(1)
Cultural Differences
200(1)
Health History
201(2)
Equipment
203(1)
Nutritional Assessment
203(14)
The Nutritional History
203(2)
Physical Assessment
205(1)
Anthropometric Measurements
206(6)
Laboratory Data
212(4)
Diagnostic Data
216(1)
Case Study: The Patient Who Is Obese
217(10)
UNIT 3: Physical Assessment
227(562)
Physical Assessment Techniques
229(16)
Aspects of Physical Assessment
230(2)
Role of the Nurse
230(1)
Standard Precautions and Transmission-Based Precautions
230(2)
Handwashing
232(1)
Legal Issues
232(1)
Assessment Techniques
232(8)
Inspection
233(1)
Palpation
233(2)
Percussion
235(3)
Auscultation
238(2)
Equipment
240(5)
General Survey, Vital Signs, and Pain
245(26)
General Survey
246(4)
Physical Presence
246(2)
Psychological Presence
248(1)
Distress
249(1)
Vital Signs
250(13)
Respiration
250(1)
Pulse
251(3)
Temperature
254(3)
Blood Pressure
257(6)
Pain
263(8)
Nociceptive Pain
263(1)
Neuropathic Pain
264(1)
Types of Pain
264(1)
Variables Affecting Pain
265(1)
Effects of Pain on the Body
265(1)
Assessing Pain
265(6)
Skin, Hair, and Nails
271(48)
Anatomy and Physiology
272(5)
Skin
272(3)
Hair
275(1)
Nails
275(1)
Function of Skin
276(1)
Function of Hair
276(1)
Function of Nails
276(1)
Health History
277(6)
Equipment
283(1)
Assessment of the Skin, Hair, and Nails
283(28)
Inspection of the Skin
283(20)
Palpation of the Skin
303(2)
Inspection of the Hair
305(2)
Palpation of the Hair
307(1)
Inspection of the Nails
308(3)
Palpation of the Nails
311(1)
Gerontological Variations
311(2)
Case Study: The Patient with Pityriasis Rosea
313(6)
Head, Neck, and Regional Lymphatics
319(22)
Anatomy and Physiology
320(2)
Skull
320(1)
Face
320(1)
Neck
321(1)
Thyroid
321(1)
Lymphatics
321(1)
Blood Supply
322(1)
Health History
322(4)
Equipment
326(1)
Assessment of the Head and Neck
327(8)
Inspection of the Shape of the Head
327(1)
Palpation of the Head
327(1)
Inspection and Palpation of the Scalp
327(1)
Inspection of the Face
328(2)
Palpation and Auscultation of the Mandible
330(1)
Inspection and Palpation of the Neck
331(1)
Inspection of the Thyroid Gland
332(1)
Palpation of the Thyroid Gland
332(1)
Auscultation of the Thyroid Gland
333(1)
Inspection of the Lymph Nodes
333(1)
Palpation of the Lymph Nodes
334(1)
Gerontological Variations
335(1)
Case Study: The Patient with Cervical Strain
335(6)
Eyes
341(34)
Anatomy and Physiology
342(3)
External Structures
342(1)
Internal Structures
343(1)
Visual Pathway
344(1)
Health History
345(3)
Equipment
348(1)
Assessment of the Eye
348(21)
Visual Acuity
349(2)
Visual Fields
351(1)
External Eye and Lacrimal Apparatus
352(3)
Extraocular Muscle Function
355(3)
Anterior Segment Structures
358(6)
Posterior Segment Structures
364(5)
Gerontological Variations
369(1)
Case Study: The Patient with Entropion
370(5)
Ears, Nose, Mouth, and Throat
375(38)
Anatomy and Physiology
376(5)
Ear
376(1)
Nose
377(1)
Sinuses
378(1)
Mouth and Throat
379(2)
Health History
381(5)
Equipment
386(1)
Assessment of the Ear
386(8)
Auditory Screening
386(1)
External Ear
387(2)
Otoscopic Assessment
389(5)
Assessment of the Nose
394(2)
External Inspection
394(1)
Patency
394(1)
Internal Inspection
394(2)
Assessment of the Sinuses
396(2)
Inspection
396(1)
Palpation and Percussion
396(2)
Assessment of the Mouth and Throat
398(9)
Assessment of the Mouth
398(7)
Inspection of the Throat
405(2)
Gerontological Variations
407(1)
Case Study: The Patient with Otitis Externa
407(6)
Breasts and Regional Nodes
413(26)
Anatomy and Physiology
414(3)
Breasts
414(3)
Regional Nodes
417(1)
Breast Development
417(1)
Health History
417(3)
Equipment
420(1)
Assessment of the Female Breasts and Regional Nodes
420(11)
Inspection of the Breasts
421(3)
Palpation
424(7)
Inspection and Palpation of the Male Breasts
431(1)
Diagnostic Techniques
431(1)
Gerontological Variations
431(2)
Case Study: The Patient with Spontaneous Nipple Discharge of the Left Breast
433(6)
Thorax and Lungs
439(44)
Anatomy
440(6)
Thorax
440(1)
Sternum
441(1)
Ribs
441(1)
Intercostal Spaces
441(1)
Lungs
441(4)
Pleura
445(1)
Mediastinum
445(1)
Bronchi
445(1)
Alveoli
445(1)
Diaphragm
445(1)
External Intercostal Muscles
446(1)
Accessory Muscles
446(1)
Physiology
446(1)
Ventilation
446(1)
External Respiration
446(1)
Internal Respiration
446(1)
Control of Breathing
446(1)
Health History
447(4)
Equipment
451(1)
Assessment of the Thorax and Lungs
451(25)
Inspection
451(10)
Palpation
461(4)
Percussion
465(3)
Auscultation
468(8)
Gerontological Variations
476(1)
Case Study: The Patient with Pneumonia
477(6)
Heart and Peripheral Vasculature
483(54)
Anatomy and Physiology
484(10)
Heart
484(2)
Coronary Circulation
486(1)
Cardiac Cycle
487(2)
Excitation of the Heart
489(1)
Peripheral Vasculature
490(4)
Epitrochlear Nodes
494(1)
Health History
494(13)
Equipment
507(1)
Assessment of the Precordium
507(12)
Inspection
508(3)
Palpation
511(2)
Auscultation
513(6)
Assessment of the Peripheral Vasculature
519(9)
Inspection of the Jugular Venous Pressure
519(2)
Inspection of the Hepatojugular Reflux
521(1)
Palpation and Auscultation of Arterial Pulses
521(3)
Inspection and Palpation of Peripheral Perfusion
524(4)
Palpation of the Epitrochlear Node
528(1)
Gerontological Variations
528(1)
Case Study: The Patient with Chest Pain
529(8)
Abdomen
537(40)
Anatomy and Physiology
538(7)
Abdominal Cavity
538(5)
Abdominal Viscera (Organs)
543(2)
Health History
545(6)
Equipment
551(1)
Assessment of the Abdomen
551(19)
Inspection
552(5)
Auscultation
557(2)
Percussion
559(3)
Palpation
562(8)
Gerontological Variations
570(1)
Case Study: The Patient with Appendicitis
571(6)
Musculoskeletal System
577(64)
Anatomy and Physiology
578(4)
Bones
578(1)
Muscles
578(1)
Tendons
579(1)
Cartilage
579(1)
Ligaments
579(1)
Bursae
580(1)
Joints
580(2)
Health History
582(5)
Equipment
587(1)
Assessment of the Musculoskeletal System
587(45)
General Assessment
588(3)
Inspection
591(4)
Palpation
595(2)
Range of Motion (ROM)
597(1)
Muscle Strength
598(1)
Examination of Joints
599(33)
Gerontological Variations
632(2)
Case Study: The Patient with Musculoskeletal Pain
634(7)
Mental Status and Neurological Techniques
641(56)
Anatomy and Physiology
642(7)
Macrostructure
642(1)
Meninges
642(1)
Central Nervous System
643(3)
Blood Supply
646(1)
Peripheral Nervous System
647(2)
Reflexes
649(1)
Health History
649(6)
Equipment
655(1)
Assessment of the Neurological System
655(33)
Mental Status
655(15)
Sensory Assessment
670(4)
Cranial Nerves
674(6)
Motor System
680(1)
Cerebellar Function (Coordination, Station, and Gait)
681(2)
Reflexes
683(5)
Gerontological Variations
688(1)
Case Study: The Patient with a Metastatic Brain Tumor
689(8)
Female Genitalia
697(40)
Anatomy and Physiology
698(4)
External Female Genitalia
698(1)
Internal Female Genitalia
699(3)
The Female Reproductive Cycle
702(2)
Health History
704(4)
Equipment
708(1)
Assessment of the Female Genitalia
709(21)
Inspection of the External Genitalia
711(5)
Palpation of the External Genitalia
716(2)
Speculum Examination of the Internal Genitalia
718(3)
Collecting Specimens for Cytological Smears and Cultures
721(4)
Inspection of the Vaginal Wall
725(1)
Bimanual Examination
725(4)
Rectovaginal Examination
729(1)
Gerontological Variations
730(1)
Case Study: The Patient with Herpes Simplex Virus
731(6)
Male Genitalia
737(30)
Anatomy
738(2)
Essential Organs
738(1)
Accessory Organs
738(1)
Ducts
738(2)
Supporting Structures
740(1)
Sexual Development
740(1)
Physiology
740(2)
Spermatogenesis
740(2)
Male Sexual Function
742(1)
Health History
742(4)
Equipment
746(1)
Assessment of the Male Genitalia
746(13)
Inspection
746(7)
Palpation
753(6)
Auscultation
759(1)
Gerontological Variations
759(2)
Case Study: The Patient with Erectile Dysfunction Due to Hypogonadism
761(6)
Anus, Rectum, and Prostate
767(22)
Anatomy and Physiology
768(2)
Rectum
768(1)
Anus
768(1)
Prostate
769(1)
Health History
770(4)
Equipment
774(1)
Assessment of the Anus, Rectum, and Prostate
774(8)
Inspection
775(2)
Palpation
777(5)
Gerontological Variations
782(1)
Case Study: The Patient with Acute Bacterial Prostatitis
782(7)
UNIT 4: Special Populations
789(102)
Pregnant Patient
791(38)
Anatomy and Physiology
792(6)
Skin and Hair
792(1)
Head and Neck
792(1)
Eyes, Ears, Nose, Mouth, and Throat
793(1)
Breasts
793(1)
Thorax and Lungs
793(1)
Heart and Peripheral Vasculature
793(1)
Abdomen
794(1)
Urinary System
795(1)
Musculoskeletal System
795(1)
Neurological System
795(1)
Female Genitalia
796(1)
Anus and Rectum
797(1)
Hematological System
797(1)
Endocrine System
797(1)
Health History
798(6)
Equipment
804(1)
Assessment of the Pregnant Patient
804(17)
General Assessment, Vital Signs, and Weight
805(3)
Skin and Hair
808(1)
Head and Neck
809(1)
Eyes, Ears, Nose, Mouth, and Throat
809(1)
Breasts
810(1)
Thorax and Lungs
810(1)
Heart and Peripheral Vasculature
810(1)
Abdomen
810(1)
Urinary System
811(1)
Musculoskeletal System
811(1)
Neurological System
812(1)
Female Genitalia
812(1)
Uterine Size
812(3)
Fetal Heart Rate
815(1)
Leopold's Maneuver
816(1)
Hematological System
817(1)
Endocrine System
818(1)
Nutritional Assessment
818(1)
Special Antepartum Tests and Evaluations
818(1)
Psychosocial Assessment and Learning Needs
818(3)
Subsequent or Return Prenatal Visits
821(1)
Case Study: The Pregnant Patient
821(8)
Pediatric Patient
829(62)
Physical Growth
830(5)
Anatomy and Physiology
835(4)
Structural and Physiological Variations
835(4)
Health History
839(9)
Growth and Development
845(1)
Developmental Assessment
845(3)
Equipment
848(1)
Physical Assessment
848(34)
Vital Signs
850(1)
Physical Growth
851(3)
Skin
854(2)
Hair
856(1)
Head
856(2)
Eyes
858(3)
Ears
861(2)
Mouth and Throat
863(1)
Neck
864(1)
Breasts
865(1)
Thorax and Lungs
865(2)
Heart and Peripheral Vasculature
867(3)
Abdomen
870(2)
Musculoskeletal System
872(3)
Neurological System
875(4)
Female Genitalia
879(1)
Male Genitalia
880(2)
Anus
882(1)
Case Study: The Patient with Hypoplastic Left Heart Syndrome (HLHS)
882(9)
UNIT 5: Putting It All Together
891(24)
The Complete Health History and Physical Examination
893(22)
Legal Considerations
895(1)
Ethical Considerations
895(1)
Health History
896(1)
Physical Assessment
896(8)
General Survey
896(1)
Neurological System
897(1)
Measurements
897(1)
Skin
897(1)
Head and Face
898(1)
Eyes
898(1)
Ears
898(1)
Nose and Sinuses
898(1)
Mouth and Throat
898(1)
Neck
899(1)
Upper Extremities
899(1)
Back, Posterior and Lateral Thoraxes
899(1)
Anterior Thorax
899(1)
Heart
900(1)
Female Breasts
900(1)
Male Breasts
900(1)
Jugular Veins
900(1)
Female and Male Breasts
900(1)
Heart
900(1)
Abdomen
901(1)
Inguinal Area
901(1)
Lower Extremities
901(1)
Neurological System
901(1)
Musculoskeletal System
902(1)
Neurological System
902(1)
Female Genitalia, Anus, and Rectum
902(1)
Male Genitalia
903(1)
Male Anus, Rectum, and Prostate
903(1)
Laboratory and Diagnostic Data
904(1)
Problem List
904(1)
Preparticipation Athletic Evaluation
905(1)
Healthy People 2010
905(1)
Role of Technology
905(1)
Conclusion
906(1)
Health History
906(1)
Case Study: The Patient with Multisystem Problems
906(9)
Appendix A: NANDA Nursing Diagnoses 2005--2006 915(2)
Appendix B: Functional Assessments 917(2)
Appendix C: ISMP List of Error-Prone Abbreviations, Symbols, and Dose Designations 919(2)
Glossary 921(20)
Index 941
Assessment in Brief Cards
Abbreviations and Symbols


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