Health and Physical Assessment in Nursing

by D'Amico, Donita; Barbarito, Colleen

Edition:

2nd

ISBN13:

9780130493736

ISBN10:

0130493732

Format:

Hardcover

Pub. Date:

1/1/2012

Publisher(s):

Prentice Hall

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Summary

Undergraduate nursingin physical and health assessment,the text begins with introductory concepts, such as overall health assessment, conducting a health interview and health history, as well as documentation. The second half is organized by body systems, and each chapter reviews anatomy and physiology, teaches students how to conduct an interview, and walks students through the examination for that body system.With our three step approach, we will help students prepare for success. Learn the techniques Demonstrate your skills Practice and test yourselfThisis a program that combines thetext and mediain order tocreateanintegrated teaching and learning system. Media is a driving force in this course,possibly more than any other nursing course. With our program,the difference is,the media is chapter specific.

Preface

viii

UNIT I INTRODUCTION TO HEALTH ASSESSMENT

(94)

Health Assessment

(21)

Healthy People 2010

(1)

Health

(1)

Definitions of Health

(1)

Models of Health

(1)

Health Assessment

(7)

The Interview

(1)

The Health History

(1)

The Focused Interview

(1)

Physical Assessment

(1)

Documentation

(3)

Interpretation of Findings

(3)

Nursing Process

(2)

Assessment

(1)

Diagnosis

(2)

Planning

(1)

Implementation

(1)

Evaluation

(1)

Critical Thinking

(4)

Collection of Information

(1)

Analysis of the Situation

(1)

Generation of Alternatives

(1)

Selection of Alternatives

(1)

Evaluation

(1)

Role of the Professional Nurse

(4)

Teacher

(2)

Caregiver

(1)

Advanced Practice Roles

(2)

Application Through Critical Thinking

(1)

Case Study

(1)

Critical Thinking Questions

(1)

Wellness and Health Promotion

(24)

Wellness

(2)

Wellness Theories

(2)

Health Promotion

(3)

Definition

(1)

Perspectives on Health Promotion

(3)

Healthy People 2010

(9)

Leading Health Indicators

(8)

Health Promotion and the Nursing Process

(7)

Assessment

(7)

Plan Development

(1)

Roles of the Professional Nurse

(1)

Application Through Critical Thinking

(1)

Case Study

(2)

Critical Thinking Questions

(1)

Health Assessment Across the Life Span

(23)

Principles of Growth and Development

(1)

Theories of Development

(1)

Cognitive Theory

(1)

Psychoanalytic Theory

(1)

Psychosocial Theory

(1)

Stages of Development

(17)

Infants

(3)

Toddlers

(2)

Preschool Children

(2)

School-Age Children

(2)

Adolescents

(3)

Young Adults

(1)

Middle-Aged Adults

(2)

Older Adults

(3)

Growth and Development in Health Assessment

(1)

Factors That Influence Growth and Development

(2)

Nutrition

(1)

Family

(1)

Culture

(1)

Socioeconomic Status

(1)

Application Through Critical Thinking

(1)

Case Study

(1)

Critical Thinking Questions

(1)

Cultural Considerations

(11)

Cultural Competence

(1)

Culture

(1)

Terms Related to Culture

(2)

Race

(1)

Ethnicity

(1)

Diversity

(1)

Assimilation

(1)

Cultural Phenomena That Impact Healthcare

(5)

Communication

(3)

Temporal Relationships

(1)

Family Patterns

(1)

Dietary Patterns

(1)

Health Beliefs and Health Practices

(1)

Culture in Comprehensive Health Assessment

(1)

Application Through Critical Thinking

(1)

Case Study

(1)

Critical Thinking Questions

(1)

Psychosocial Assessment

(15)

Psychosocial Health

(1)

Factors That Influence Psychosocial Health

(5)

Internal Factors

(1)

External Factors

(1)

Additional Factors in Psychosocial Health

(3)

The Nursing Process in Psychosocial Assessment

(7)

Assessment

(7)

Organizing the Data

(1)

Application Through Critical Thinking

(1)

Case Study

(2)

Critical Thinking Questions

(2)

UNIT II INTRODUCTION TO PHYSICAL ASSESSMENT

(87)

Techniques and Equipment

(13)

Basic Techniques of Physical Assessment

(4)

Inspection

(1)

Palpation

(1)

Percussion

(2)

Auscultation

100

(1)

Equipment

100

(5)

Stethoscope

100

(3)

Doppler Ultrasonic Stethoscope

103

(1)

Ophthalmoscope

103

(1)

Otoscope

104

(1)

Professional Responsibilities

105

(2)

Cues

105

(1)

Critical Thinking

105

(1)

Providing a Safe and Comfortable Environment

105

(1)

Standard Precautions

106

(1)

Application Through Critical Thinking

107

(1)

Case Study

107

(1)

Critical Thinking Questions

107

(1)

General Survey

108

(15)

Components of the General Survey

109

(2)

Physical Appearance

109

(1)

Mental Status

109

(1)

Mobility

110

(1)

Behavior of the Client

110

(1)

Age-Related Considerations

110

(1)

Measuring Height and Weight

111

(2)

Height

111

(1)

Weight

111

(1)

Age-Related Considerations

112

(1)

Measuring Vital Signs

113

(6)

Measuring Body Temperature

113

(1)

Measuring the Pulse Rate

114

(2)

Measuring Respiratory Rate

116

(1)

Measuring Blood Pressure

116

(2)

Age-Related Considerations

118

(1)

Pain---The Fifth Vital Sign

119

(1)

Pain Assessment

119

(1)

The Functional Assessment as Part of the General Survey

120

(2)

Functional Assessment Defined

120

(1)

Functional Assessment During the General Survey

120

(1)

Critical Thinking

120

(2)

Application Through Critical Thinking

122

(1)

Case Study

122

(1)

Critical Thinking Questions

122

(1)

Pain Assessment

123

(12)

Definition of Pain

124

(1)

Physiology of Pain

124

(3)

Theories of Pain

124

(1)

Nervous System

125

(2)

Nature of Pain

127

(1)

Types of Pain

127

(1)

Concepts Associated with Pain

128

(1)

Factors Influencing Pain

128

(2)

Developmental Considerations

128

(1)

Psychosocial Considerations

129

(1)

Environmental Considerations

130

(1)

Assessment

130

(2)

Pain History

131

(1)

Focused Interview

131

(1)

Physiological Responses

132

(1)

Assessment Tools

132

(1)

Unidimensional Tools

132

(1)

Multidimensional Tools

133

(1)

Application Through Critical Thinking

133

(1)

Case Study

133

(2)

Critical Thinking Questions

133

(1)

Applying Nursing Diagnoses

133

(2)

Nutritional Assessment

135

(21)

Defining Nutritional Health

136

(1)

Nutritional Assessment

137

(14)

Nutritional History

138

(1)

Physical Assessment

139

(10)

Biochemical Assessment---Laboratory Measurements

149

(1)

Cultural Considerations for the Nutritional Assessment

149

(1)

Nutritional Assessment Across the Life Span

149

(2)

Nutritional Screening and Assessment Tools

151

(2)

Food Guide Pyramid

151

(1)

Other Assessment Tools

152

(1)

Health Promotion

153

(1)

Application Through Critical Thinking

154

(1)

Case Study

154

(2)

Complete Documentation

155

(1)

Critical Thinking Questions

155

(1)

Applying Nursing Diagnoses

155

(1)

The Health History

156

(26)

Communication Skills

157

(3)

Interactional Skills

157

(3)

Barriers to Effective Client Interaction

160

(1)

False Reassurance

160

(1)

Interrupting or Changing the Subject

160

(1)

Passing Judgment

160

(1)

Cross-Examination

160

(1)

Technical Terms

160

(1)

Sensitive Issues

160

(1)

The Influence of Culture on Nurse-Client Interactions

161

(1)

Diversity

161

(1)

Body Language

161

(1)

Communicating with Language Differences

162

(1)

Professional Characteristics to Enhance the Nurse-Client Interaction

162

(1)

Positive Regard

162

(1)

Empathy

163

(1)

Genuineness

163

(1)

Concreteness

163

(1)

The Health History Interview

163

(3)

Sources of Information

163

(1)

Phases of the Health Assessment Interview

164

(2)

The Health History

166

(9)

Components of the Health History

167

(8)

Documentation

175

(5)

Nursing Considerations

180

(1)

Application Through Critical Thinking

180

(1)

Case Study

180

(2)

Critical Thinking Questions

181

(1)

UNIT III PHYSICAL ASSESSMENT

182

(600)

Skin, Hair, and Nails

182

(52)

Anatomy and Physiology Review

183

(2)

Skin and Glands

183

(1)

Subcutaneous Tissue

184

(1)

Cutaneous Glands

184

(1)

Oil Glands

184

(1)

Hair

185

(1)

Nails

185

(1)

Special Considerations

185

(6)

Developmental Considerations

185

(3)

Psychosocial Considerations

188

(1)

Cultural and Environmental Considerations

188

(3)

Gathering the Data

191

(1)

Focused Interview

191

(1)

Skin

192

(5)

Questions Related to Illness or Infection

192

(1)

Questions Related to Symptoms or Behaviors

193

(2)

Questions Related to Age

195

(1)

Questions Related to the Environment

196

(1)

Hair

197

(1)

Nails

198

(2)

Physical Assessment

200

(9)

Assessment Techniques and Findings

200

(1)

Survey

200

(1)

Inspection of the Skin

201

(1)

Palpation of the Skin

202

(3)

Inspection of the Scalp and Hair

205

(2)

Assessment of the Nails

207

(2)

Abnormal Findings

209

(1)

Vascular Lesions

209

(3)

Hemangioma

209

(1)

Port-Wine Stain

209

(1)

Spider Angioma

210

(1)

Venous Lake

210

(1)

Petechiae

210

(1)

Purpura

211

(1)

Ecchymosis

211

(1)

Hematoma

212

(1)

Primary Lesions

212

(2)

Macule, Patch

212

(1)

Papule, Plaque

212

(1)

Nodule, Tumor

213

(1)

Vesicle, Bulla

213

(1)

Wheal

213

(1)

Pustule

214

(1)

Cyst

214

(1)

Secondary Lesions

214

(3)

Atrophy

214

(1)

Erosion

215

(1)

Lichenification

215

(1)

Scales

215

(1)

Crust

216

(1)

Ulcer

216

(1)

Fissure

216

(1)

Scar

217

(1)

Keloid

217

(1)

Configurations and Shapes of Lesions

217

(3)

Annular

217

(1)

Confluent

218

(1)

Discrete

218

(1)

Grouped

218

(1)

Gyrate

219

(1)

Target

219

(1)

Linear

219

(1)

Polycyclic

220

(1)

Zosteriform

220

(1)

Common Skin Lesions

220

(4)

Tinea

220

(1)

Measles (Rubeola)

221

(1)

German Measles (Rubella)

221

(1)

Chickenpox (Varicella)

221

(1)

Herpes Simplex

222

(1)

Herpes Zoster

222

(1)

Psoriasis

222

(1)

Contact Dermatitis

223

(1)

Eczema

223

(1)

Impetigo

223

(1)

Malignant Skin Lesions

224

(1)

Basal Cell Carcinoma

224

(1)

Squamous Cell Carcinoma

224

(1)

Malignant Melanoma

224

(1)

Kaposi's Sarcoma

225

(1)

Abnormalities of the Hair

225

(2)

Seborrheic Dermatitis

225

(1)

Tinea Capitis

225

(1)

Alopecia Areata

226

(1)

Folliculitis

226

(1)

Furuncle/Abscess

226

(1)

Hirsutism

227

(1)

Abnormalities of the Nails

227

(2)

Spoon Nails

227

(1)

Paronychia

227

(1)

Beau's Line

228

(1)

Splinter Hemorrhage

228

(1)

Clubbing

228

(1)

Onycholysis

228

(1)

Health Promotion

229

(2)

Application Through Critical Thinking

231

(1)

Case Study

231

(3)

Complete Documentation

231

(1)

Critical Thinking Questions

231

(1)

Applying Nursing Diagnoses

231

(1)

Prepare Teaching Plan

232

(2)

Head, Neck, and Related Lymphatics

234

(29)

Anatomy and Physiology Review

235

(5)

Head

235

(1)

Neck

236

(3)

Lymphatics

239

(1)

Special Considerations

240

(1)

Developmental Considerations

240

(1)

Psychosocial Considerations

241

(1)

Cultural and Environmental Considerations

241

(1)

Gathering the Data

241

(1)

Focused Interview

241

(5)

General Questions

242

(1)

Questions Related to Illness, Infection, or Injury

243

(1)

Questions Related to Symptoms or Behaviors

243

(1)

Questions Related to Age

244

(1)

Questions Related to the Environment

245

(1)

Physical Assessment

246

(7)

Assessment Techniques and Findings

246

(1)

The Head

247

(2)

The Neck

249

(4)

Abnormal Findings

253

(1)

Headaches

253

(1)

Classic Migraine

253

(1)

Cluster Headache

254

(1)

Tension Headache

254

(1)

Abnormalities of the Skull and Face

254

(4)

Hydrocephalus

254

(1)

Craniosynostosis

254

(1)

Acromegaly

255

(1)

Bell's Palsy

255

(1)

Cushing's Syndrome

255

(1)

Down Syndrome

256

(1)

Parkinson's Disease

256

(1)

Brain Attack

257

(1)

Fetal Alcohol Syndrome

257

(1)

Torticollis

257

(1)

Thyroid Abnormalities

258

(1)

Hyperthyroidism

258

(1)

Hypothyroidism

258

(1)

Thyroiditis

258

(1)

Health Promotion

259

(1)

Application Through Critical Thinking

260

(1)

Case Study

260

(3)

Complete Documentation

260

(1)

Critical Thinking Questions

261

(1)

Applying Nursing Diagnoses

261

(1)

Prepare Teaching Plan

261

(2)

Eye

263

(41)

Anatomy and Physiology Review

264

(2)

Eye

264

(1)

Refraction of the Eye

265

(1)

Visual Pathways

265

(1)

Accessory Structures of the Eye

266

(1)

Special Considerations

266

(3)

Developmental Considerations

266

(3)

Psychosocial Considerations

269

(1)

Cultural and Environmental Considerations

269

(1)

Gathering the Data

269

(1)

Focused Interview

269

(7)

General Questions

270

(1)

Questions Related to Illness or Infection

270

(1)

Questions Related to Symptoms or Behaviors

271

(2)

Questions Related to Age

273

(1)

Questions Related to the Environment

274

(2)

Physical Assessment

276

(13)

Assessment Techniques and Findings

276

(1)

Testing Visual Acuity

276

(2)

Testing Visual Fields by Confrontation

278

(1)

Testing the Six Cardinal Fields of Gaze

279

(1)

Assessment of Corneal Light Reflex

280

(1)

Perform the Cover Test

281

(1)

Inspection of the Pupils

281

(1)

Evaluation of Pupillary Response

281

(1)

Testing for Accommodation of Pupil Response

282

(1)

Testing of the Corneal Reflex

282

(1)

Inspection of the External Eye

283

(1)

Palpation of the Eye

283

(1)

Examination of the Conjunctiva and Sclera Under the Lower Eyelid

284

(1)

Inspection of the Fundus with the Ophthalmoscope

285

(4)

Abnormal Findings

289

(4)

Visual Acuity

289

(1)

Visual Fields

290

(1)

Cardinal Fields of Gaze

291

(2)

Abnormal Pupillary Response

293

(1)

Adie's Pupil

293

(1)

Argyll Robertson Pupils

293

(1)

Anisocoria

293

(1)

Cranial Nerve III Damage

293

(1)

Horner's Syndrome

293

(1)

Mydriasis

294

(1)

Miosis

294

(1)

Monocular Blindness

294

(1)

Abnormalities of the Structures of the External Eye

294

(4)

Acute Glaucoma

294

(1)

Basal Cell Carcinoma

295

(1)

Blepharitis

295

(1)

Cataract

295

(1)

Chalazion

296

(1)

Conjunctivitis

296

(1)

Ectropion

296

(1)

Entropion

297

(1)

Hordeolum (Style)

297

(1)

Iritis

297

(1)

Periorbital Edema

298

(1)

Ptosis

298

(1)

Abnormalities of the Fundus

298

(1)

Diabetic Retinopathy

298

(1)

Hypertensive Retinopathy

298

(1)

Macular Degeneration

299

(1)

Health Promotion

299

(2)

Application Through Critical Thinking

301

(1)

Case Study

301

(3)

Complete Documentation

301

(1)

Critical Thinking Questions

302

(1)

Applying Nursing Diagnoses

303

Prepare Teaching Plan

302

(2)

Ears, Nose, Mouth, and Throat

304

(44)

Anatomy and Physiology Review

305

(5)

Ear

305

(1)

Nose and Sinuses

306

(1)

Mouth

307

(3)

Throat

310

(1)

Special Considerations

310

(2)

Developmental Considerations

311

(1)

Psychosocial Considerations

311

(1)

Cultural and Environmental Considerations

312

(1)

Gathering The Data

312

(1)

Focused Interview

312

(7)

General Questions

313

(1)

Questions Related to Illness or Infection

313

(1)

Questions Related to Symptoms or Behaviors

314

(1)

Questions Related to the Environment

314

(1)

Questions Related to Age

315

(1)

Nose and Sinuses

316

(1)

Mouth and Throat

317

(2)

Physical Assessment

319

(14)

Assessment Techniques and Findings

319

(1)

Ear

320

(6)

Nose and Sinuses

326

(4)

Mouth and Throat

330

(3)

Abnormal Findings

333

(1)

Ear

333

(2)

Hemotympanum

333

(1)

Otitis Externa

333

(1)

Otitis Media

334

(1)

Perforation of the Tympanic Membrane

334

(1)

Scarred Tympanic Membrane

334

(1)

Tophi

335

(1)

Tympanostomy Tubes

335

(1)

Nose and Sinuses

335

(4)

Epistaxis

335

(1)

Rhinitis

336

(1)

Sinusitis

337

(1)

Deviated Septum

337

(1)

Nasal Polyps

338

(1)

Perforated Septum

338

(1)

Mouth and Throat

339

(4)

Ankyloglossia

339

(1)

Aphthous Ulcers

339

(1)

Black Hairy Tongue

340

(1)

Gingival Hyperplasia

340

(1)

Gingivitis

340

(1)

Tonsillitis

341

(1)

Smooth Tongue

341

(1)

Herpes Simplex

341

(1)

Carcinoma

342

(1)

Leukoplakia

342

(1)

Health Promotion

343

(1)

Application Through Critical Thinking

344

(1)

Case Study

344

(4)

Complete Documentation

345

(1)

Critical Thinking Questions

345

(1)

Applying Nursing Diagnoses

345

(1)

Prepare Teaching Plan

345

(3)

Respiratory System

348

(49)

Anatomy and Physiology Review

349

(4)

Lower Respiratory Tract

350

(2)

Respiratory Process

352

(1)

Landmarks

353

(6)

Special Considerations

359

(2)

Developmental Considerations

359

(1)

Psychosocial Considerations

360

(1)

Cultural and Environmental Considerations

360

(1)

Gathering the Data

361

(1)

Focused Interview

361

(8)

General Questions

362

(1)

Questions Related to Illness or Infection

363

(1)

Questions Related to Symptoms or Behaviors

363

(3)

Questions Related to Age

366

(1)

Questions Related to the Environment

367

(2)

Physical Assessment

369

(19)

Assessment Techniques and Findings

369

(1)

Survey

370

(1)

Inspection of the Anterior Thorax

370

(1)

Inspection of the Posterior Thorax

371

(1)

Palpation of the Posterior Thorax

372

(2)

Percussion of the Posterior Thorax

374

(2)

Auscultation of the Posterior Thorax

376

(3)

Assessment of Voice Sounds

379

(1)

Assessment of the Anterior Thorax

379

(1)

Palpation of the Anterior Thorax

379

(3)

Percussion of the Anterior Thorax

382

(1)

Auscultation of the Anterior Thorax

383

(5)

Abnormal Findings

388

(1)

Respiratory Disorders

388

(4)

Asthma

388

(1)

Atelectasis

388

(1)

Chronic Bronchitis

389

(1)

Emphysema

389

(1)

Lobar Pneumonia

390

(1)

Pleural Effusion

390

(1)

Pneumothorax

391

(1)

Congestive Heart Failure

391

(1)

Health Promotion

392

(2)

Application Through Critical Thinking

394

(1)

Case Study

394

(3)

Complete Documentation

395

(1)

Critical Thinking Questions

395

(1)

Applying Nursing Diagnoses

395

(1)

Prepare Teaching Plan

395

(2)

Breasts and Axillae

397

(28)

Anatomy and Physiology Review

398

(3)

Breasts

398

(1)

Axillae and Lymph Nodes

399

(2)

Muscles of the Chest Wall

401

(1)

Special Considerations

401

(2)

Developmental Considerations

401

(1)

Psychosocial Considerations

402

(1)

Cultural and Environmental Considerations

402

(1)

Gathering the Data

403

(1)

Focused Interview

403

(5)

General Questions

404

(1)

Questions Related to Illness or Infection

404

(1)

Questions Related to Symptoms or Behaviors

404

(1)

Questions Related to Age

405

(1)

Questions Related to the Environment

406

(2)

Physical Assessment

408

(9)

Assessment Techniques and Findings

408

(1)

Inspection of the Breast

408

(4)

Palpation of the Breast

412

(3)

Examination of the Axillae

415

(1)

Inspection of the Male Breast

416

(1)

Palpation of the Male Breast and Axillae

416

(1)

Abnormal Findings

417

(3)

Benign Breast Disease

417

(1)

Fibroadenoma

418

(1)

Intraductal Papilloma

418

(1)

Mammary Duct Ectasia

418

(1)

Carcinoma of the Breast

419

(1)

Abnormalities of the Male Breast

419

(1)

Health Promotion

420

(3)

Application Through Critical Thinking

423

(1)

Case Study

423

(2)

Complete Documentation

423

(1)

Critical Thinking Questions

423

(1)

Applying Nursing Diagnoses

423

(1)

Prepare Teaching Plan

423

(2)

Cardiovascular System

425

(51)

Anatomy and Physiology Review

426

(14)

Pericardium

426

(1)

Heart

426

(2)

Valves

428

(1)

Heart Sounds

429

(2)

Additional Heart Sounds

431

(1)

Coronary Arteries

431

(3)

Cardiac Veins

434

(1)

Cardiac Conduction System

434

(2)

Pulmonary Circulation

436

(1)

Systemic Circulation

436

(1)

Landmarks for Cardiovascular Assessment

436

(1)

Cardiac Cycle

437

(2)

Measurements of Cardiac Function

439

(1)

Special Considerations

440

(3)

Developmental Considerations

440

(2)

Psychosocial Considerations

442

(1)

Cultural and Environmental Considerations

442

(1)

Gathering the Data

443

(1)

Focused Interview

444

(7)

Questions Related to Illness

445

(1)

Questions Related to Symptoms or Behaviors

445

(2)

Questions Related to Age

447

(2)

Questions Related to the Environment

449

(2)

Physical Assessment

451

(12)

Assessment Techniques and Findings

451

(1)

Inspection

451

(6)

Palpation

457

(2)

Percussion

459

(1)

Auscultation

460

(3)

Abnormal Findings

463

(1)

Diseases of the Myocardium and Pumping Capacity of the Heart

463

(1)

Myocardial Ischemia

463

(1)

Myocardial Infarction

463

(1)

Congestive Heart Disease

463

(1)

Ventricular Hypertrophy

463

(1)

Valvular Disease

464

(3)

Valvular Heart Disease

464

(1)

Mitral Stenosis

464

(1)

Aortic Stenosis

464

(1)

Mitral Regurgitation

465

(1)

Pulmonic Stenosis

465

(1)

Tricuspid Stenosis

466

(1)

Mitral Valve Prolapse

466

(1)

Aortic Regurgitation

467

(1)

Septal Defects

467

(1)

Ventricular Septal Defect

467

(1)

Atrial Septal Defect

468

(1)

Congenital Heart Disease

468

(2)

Coarctation of the Aorta

468

(1)

Patent Ductus Arteriosus

469

(1)

Tetralogy of Fallot

469

(1)

Electrical Rhythm Disturbances

470

(1)

Ventricle Tachycardia

470

(1)

Ventricular Fibrillation

470

(1)

Heart Block

470

(1)

Atrial Flutter

471

(1)

Atrial Fibrillation

471

(1)

Health Promotion

471

(2)

Application Through Critical Thinking

473

(1)

Case Study

473

(3)

Complete Documentation

474

(1)

Critical Thinking Questions

474

(1)

Applying Nursing Diagnoses

474

(1)

Prepare Teaching Plan

474

(2)

Peripheral Vascular System

476

(34)

Anatomy and Physiology Review

477

(2)

Arteries

477

(1)

Veins

478

(1)

Capillaries

478

(1)

Lymphatic System

478

(1)

Special Considerations

479

(2)

Developmental Considerations

479

(2)

Psychosocial Considerations

481

(1)

Cultural and Environmental Considerations

481

(1)

Gathering the Data

481

(1)

Focused Interview

481

(4)

General Questions

482

(1)

Questions Related to Illness

482

(1)

Questions Related to Symptoms or Behaviors

482

(2)

Questions Related to Age

484

(1)

Questions Related to the Environment

484

(1)

Physical Assessment

485

(16)

Assessment Techniques and Findings

485

(1)

Blood Pressure

486

(2)

Carotid Arteries

488

(1)

Arms

489

(3)

Legs

492

(9)

Abnormal Findings

501

(4)

Arterial Insufficiency

502

(1)

Arterial Aneurysm

502

(1)

Venous Insufficiency

503

(1)

Varicose Veins

503

(1)

Raynaud's Disease

504

(1)

Deep Vein Thrombosis

504

(1)

Lymphedema

504

(1)

Health Promotion

505

(1)

Application Through Critical Thinking

506

(1)

Case Study

506

(4)

Complete Documentation

507

(1)

Critical Thinking Questions

507

(1)

Applying Nursing Diagnoses

507

(1)

Prepare Teaching Plan

507

(3)

Abdomen

510

(44)

Anatomy and Physiology Review

511

(5)

Abdomen

511

(1)

Alimentary Canal

511

(2)

Accessory Digestive Organs

513

(1)

Other Related Structures

513

(1)

Landmarks

514

(2)

Special Considerations

516

(3)

Developmental Considerations

516

(3)

Psychosocial Considerations

519

(1)

Cultural and Environmental Considerations

519

(1)

Gathering the Data

519

(1)

Focused Interview

519

(9)

General Questions

520

(1)

Questions Related to Illness or Infection

521

(1)

Questions Related to Symptoms or Behaviors

522

(2)

Questions Related to Age

524

(2)

Questions Related to the Environment

526

(2)

Physical Assessment

528

(14)

Assessment Techniques and Findings

528

(1)

Survey

529

(1)

Inspection of the Abdomen

529

(2)

Auscultation of the Abdomen

531

(2)

Percussion of the Abdomen

533

(2)

Percussion of the Liver

535

(1)

Percussion of the Spleen

536

(1)

Percussion of the Gastric Bubble

537

(1)

Palpation of the Abdomen

537

(2)

Palpation of the Liver

539

(1)

Palpation of the Spleen

539

(1)

Additional Procedures

540

(2)

Abnormal Findings

542

(1)

Abnormal Abdominal Sounds

542

(1)

Abdominal Pain

543

(1)

Abdominal Distention

544

(2)

Obesity

544

(1)

Gaseous Distention

545

(1)

Tumor

545

(1)

Ascites

546

(1)

Abdominal Hernias

546

(2)

Umbilical Hernia

547

(1)

Ventral (Incisional) Hernias

547

(1)

Hiatal Hernia

547

(1)

Alterations of the Gastrointestinal Tract

548

(1)

Nutritional Problems

548

(1)

Eating Disorders

548

(1)

Cancers

548

(1)

Inflammatory Processes

549

(1)

Health Promotion

549

(2)

Application Through Critical Thinking

551

(1)

Case Study

551

(3)

Complete Documentation

552

(1)

Critical Thinking Questions

552

(1)

Applying Nursing Diagnoses

552

(1)

Prepare Teaching Plan

552

(2)

Urinary System

554

(28)

Anatomy and Physiology Review

555

(2)

Kidneys

555

(2)

Renal Arteries

557

(1)

Ureters

557

(1)

Urinary Bladder

557

(1)

Urethra

557

(1)

Landmarks

557

(1)

Special Considerations

557

(4)

Developmental Considerations

557

(3)

Psychosocial Considerations

560

(1)

Cultural and Environmental Considerations

560

(1)

Gathering the Data

561

(1)

Focused Interview

561

(7)

General Questions

561

(1)

Questions Related to Illness or Infection

562

(1)

Questions Related to Symptoms or Behaviors

563

(3)

Questions Related to Age

566

(1)

Questions Related to the Environment

567

(1)

Physical Assessment

568

(9)

Assessment Techniques and Findings

568

(1)

General Survey

569

(2)

The Kidneys and Flanks

571

(2)

The Left Kidney

573

(2)

The Right Kidney

575

(1)

The Urinary Bladder

575

(2)

Abnormal Findings

577

(1)

Bladder Cancer

577

(1)

Glomerulonephritis

577

(1)

Renal Calculi

577

(1)

Renal Tumor

577

(1)

Renal Failure

577

(1)

Urinary Tract Infection

577

(1)

Changes in Urinary Elimination

577

(1)

Health Promotion

578

(2)

Application Through Critical Thinking

580

(1)

Case Study

580

(2)

Complete Documentation

580

(1)

Critical Thinking Questions

580

(1)

Applying Nursing Diagnoses

580

(1)

Prepare Teaching Plan

580

(2)

Male Reproductive System

582

(42)

Anatomy and Physiology Review

583

(3)

Male Reproductive System

583

(2)

Duct System

585

(1)

Accessory Glands

585

(1)

Penis

586

(1)

Inguinal Areas

586

(1)

Perianal Area

586

(1)

Special Considerations

586

(4)

Developmental Considerations

586

(2)

Psychosocial Considerations

588

(1)

Cultural and Environmental Considerations

589

(1)

Gathering the Data

590

(1)

Focused Interview

590

(8)

General Questions

591

(2)

Questions Related to Illness or Infection

593

(1)

Questions Related to Symptoms or Behaviors

593

(3)

Questions Related to Age

596

(1)

Questions Related to Environment

597

(1)

Physical Assessment

598

(12)

Assessment Techniques and Findings

598

(1)

Inspection

599

(4)

Palpation

603

(7)

Abnormal Findings

610

(1)

Abnormalities of the Penis

610

(2)

Hypospadias

610

(1)

Peyronie's Disease

610

(1)

Carcinoma

611

(1)

Genital Warts

611

(1)

Syphilitic Chancre

611

(1)

Genital Herpes

612

(1)

Abnormal Findings in the Scrotum

612

(4)

Hydrocele

612

(1)

Scrotal Hernia

613

(1)

Testicular Tumor

613

(1)

Orchitis

613

(1)

Epididymitis

614

(1)

Torsion of the Spermatic Cord

614

(1)

Small Testes

614

(1)

Cryptorchidism

615

(1)

Scrotal Edema

615

(1)

Abnormalities of the Perianal Area

616

(3)

Pilonidal Cyst

616

(1)

Anal Fissure

616

(1)

Hemorrhoids

617

(1)

Prolapse of the Rectum

618

(1)

Perianal Perirectal Abscess

618

(1)

Health Promotion

619

(1)

Application Through Critical Thinking

620

(1)

Case Study

620

(4)

Complete Documentation

621

(1)

Critical Thinking Questions

621

(1)

Applying Nursing Diagnoses

622

(1)

Prepare Teaching Plan

622

(2)

Female Reproductive System

624

(42)

Anatomy and Physiology Review

625

(3)

External Genitalia

625

(1)

Internal Reproductive Organs

626

(2)

Special Considerations

628

(2)

Developmental Considerations

628

(1)

Psychosocial Considerations

629

(1)

Cultural and Environmental Considerations

630

(1)

Gathering the Data

630

(1)

Focused Interview

631

(9)

General Questions

631

(2)

Questions Related to Illness or Infection

633

(1)

Questions Related to Symptoms or Behaviors

634

(3)

Questions Related to Age

637

(1)

Questions Related to Environment

638

(2)

Physical Assessment

640

(15)

Assessment Techniques and Findings

640

(1)

Inspection

640

(4)

Palpation

644

(1)

Inspection with a Speculum

645

(2)

Obtaining the Pap Smear and Gonorrhea Culture

647

(2)

Bimanual Palpation

649

(6)

Abnormal Findings

655

(1)

External Genitalia

655

(1)

Pediculosis Pubis

655

(1)

Herpes Simplex

655

(1)

Syphilitic Lesion

656

(1)

Human Papillomavirus (HPV)

656

(1)

Abscess of Bartholin's Gland

656

(1)

Cervix

656

(1)

Cyanosis

656

(1)

Carcinoma

656

(1)

Erosion

657

(1)

Polyp

657

(1)

Diethylstilbestrol (DES) Syndrome

657

(1)

Internal Reproductive Organs

657

(2)

Myomas/Fibroids

657

(1)

Ovarian Cancer

658

(1)

Ovarian Cysts

658

(1)

Inflammatory Processes

659

(2)

Atrophic Vaginitis

659

(1)

Candidiasis

659

(1)

Chlamydia

660

(1)

Gonorrhea

660

(1)

Trichomoniasis

660

(1)

Health Promotion

661

(2)

Application Through Critical Thinking

663

(1)

Case Study

663

(3)

Complete Documentation

663

(1)

Critical Thinking Questions

664

(1)

Applying Nursing Diagnoses

664

(1)

Prepare Teaching Plan

664

(2)

Musculoskeletal System

666

(64)

Anatomy and Physiology Review

667

(13)

Bones

667

(1)

Skeletal Muscles

667

(1)

Joints

667

(13)

Special Considerations

680

(3)

Developmental Considerations

680

(2)

Psychosocial Considerations

682

(1)

Cultural and Environmental Considerations

682

(1)

Gathering the Data

683

(1)

Focused Interview

683

(6)

General Questions

684

(1)

Questions Related to Illness, Infection, or Injury

684

(1)

Questions Related to Symptoms or Behaviors

685

(1)

Questions Related to Age

686

(1)

Questions Related to the Environment

687

(2)

Physical Assessment

689

(27)

Assessment Techniques and Findings

689

(1)

Survey

689

(1)

Assessment of the Joints

690

(1)

The Shoulders

691

(4)

Elbows

695

(3)

Wrists and Hands

698

(5)

Hips

703

(3)

Knees

706

(3)

Ankles and Feet

709

(2)

Spine

711

(5)

Abnormal Findings

716

(1)

Abnormalities of the Spine

717

(1)

Kyphosis

717

(1)

Scoliosis

717

(1)

Lordosis

718

(1)

Joint Disorders

718

(6)

Head and Neck

718

(1)

Shoulder

718

(1)

Elbow

719

(1)

Wrist and Hand

719

(3)

Knee

722

(1)

Foot

722

(2)

Health Promotion

724

(3)

Application Through Critical Thinking

727

(1)

Case Study

727

(3)

Complete Documentation

727

(1)

Critical Thinking Questions

727

(1)

Applying Nursing Diagnoses

727

(1)

Prepare Teaching Plan

728

(2)

Neurologic System

730

(52)

Anatomy and Physiology Review

731

(2)

Central Nervous System

731

(2)

Reflexes

733

(1)

Peripheral Nervous System

733

(1)

Special Considerations

733

(4)

Developmental Considerations

734

(2)

Psychosocial Considerations

736

(1)

Cultural and Environmental Considerations

736

(1)

Gathering the Data

737

(1)

Focused Interview

737

(6)

General Questions

738

(1)

Questions Related to Illness, Infection, or Injury

738

(1)

Questions Related to Symptoms or Behaviors

739

(1)

Questions Related to Age

740

(2)

Questions Related to the Environment

742

(1)

Physical Assessment

743

(31)

Assessment Techniques and Findings

743

(1)

Mental Status

744

(3)

Cranial Nerves

747

(10)

Motor Function

757

(4)

Sensory Function

761

(5)

Reflexes

766

(6)

Carotid Auscultation

772

(1)

Meningeal Assessment

772

(1)

Use of the Glasgow Coma Scale

773

(1)

Abnormal Findings

774

(1)

Seizures

775

(1)

Spinal Cord Injuries

775

(1)

Infections of the Neurologic System

775

(1)

Meningitis

775

(1)

Myelitis

775

(1)

Brain Abscess

775

(1)

Lyme Disease

775

(1)

Degenerative Neurologic Disorders

776

(1)

Alzheimer's Disease

776

(1)

Amyotrophic Lateral Sclerosis

776

(1)

Huntington's Disease

776

(1)

Multiple Sclerosis

776

(1)

Myasthenia Gravis

776

(1)

Parkinson's Disease

776

(1)

Health Promotion

777

(1)

Application Through Critical Thinking

778

(1)

Case Study

778

(4)

Complete Documentation

779

(1)

Critical Thinking Questions

779

(1)

Applying Nursing Diagnoses

779

(1)

Prepare Teaching Plan

779

(3)

UNIT IV PHYSICAL ASSESSMENT ACROSS THE LIFE SPAN

782

Assessment of Infants, Children, and Adolescents

782

(39)

Childhood Developmental Stages

783

(1)

Nutritional Assessment

783

(3)

Nutritional History

784

(1)

Physical Assessment

784

(1)

Laboratory Measurements

785

(1)

Physical Variants in Childhood

786

(9)

Integument

786

(1)

Head, Eyes, Ears, Nose, and Throat

786

(3)

Vital Signs

789

(1)

Respiratory System

789

(1)

Cardiovascular System

790

(1)

Breasts

791

(1)

Abdomen

792

(1)

Genitourinary and Reproductive Systems

792

(1)

Musculoskeletal System

792

(1)

Neurologic System

793

(2)

Special Considerations

795

(1)

Psychosocial Considerations

795

(1)

Cultural Considerations

795

(1)

Gathering the Data

796

(1)

Focused Interview

797

(3)

Questions About the Birth History

797

(1)

Questions Related to Illness or Infection

798

(1)

Questions Related to Well Children and Health Promotion

799

(1)

Physical Assessment

800

(14)

Assessment Techniques and Findings

800

(1)

General Survey

801

(1)

Growth and Development

801

(2)

Skin, Hair, and Nails

803

(1)

Head and Neck

803

(1)

Eyes and Vision

804

(1)

Ears and Hearing

805

(1)

Nose and Sinuses

806

(1)

Mouth and Throat

806

(1)

Chest and Lungs

806

(1)

Cardiovascular

807

(1)

Abdomen

807

(1)

Genitalia

808

(2)

Musculoskeletal

810

(3)

Neurologic

813

(1)

Abnormal Findings

814

(2)

Otitis Media

814

(1)

Allergic Rhinitis

814

(1)

Asthma

814

(1)

Acne Vulgaris

815

(1)

Scalp Ringworm (Tinea Capitis)

815

(1)

Acute Gastroenteritis

815

(1)

Health Promotion

816

(2)

Application Through Critical Thinking

818

(1)

Case Study

818

(3)

Complete Documentation

818

(1)

Critical Thinking Questions

818

(1)

Applying Nursing Diagnoses

818

(1)

Prepare Teaching Plan

819

(2)

The Pregnant Female

821

(53)

Nutritional Assessment

822

(2)

Physical Assessment

822

(1)

Laboratory Measurements

823

(1)

Anatomy and Physiology Review

824

(9)

The Placenta

824

(1)

Fetal Development

825

(1)

Reproductive System Changes

825

(2)

Changes in Breasts

827

(1)

Respiratory System Changes

828

(1)

Cardiovascular and Hematologic System Changes

828

(1)

Integumentary System Changes

829

(1)

Changes in the Ear, Nose, Throat, and Mouth

830

(1)

Gastrointestinal System Changes

830

(1)

Urinary System Changes

830

(1)

Musculoskeletal Changes

831

(1)

Neurologic System Changes

831

(1)

Endocrine System Changes

832

(1)

Cultural Variations

833

(1)

Laboratory Tests in Pregnancy

833

(1)

The Postpartum Female

833

(4)

Anatomy and Physiology Review

833

(1)

The BUBBLESHE Head-to-Toe Postpartum Assessment

833

(4)

Gathering the Data

837

(1)

Focused Interview

837

(13)

Confirmation of Pregnancy

838

(1)

Demographics

838

(1)

Menstrual History

839

(1)

Obstetrical and Gynecological History

840

(1)

Reaction to Pregnancy

840

(1)

Past Obstetrical History

840

(1)

Past Gynecological History

841

(1)

Past Medical History and Family History

842

(2)

Genetic Information

844

(2)

Lifestyle and Social Health Practices

846

(1)

Nutrition and Exercise History

846

(2)

Environmental Exposure

848

(2)

Physical Assessment

850

(16)

General Survey

851

(1)

Skin, Hair, and Nails

851

(1)

Head and Neck

852

(1)

Eyes, Ears, Nose, Mouth, and Throat

852

(1)

Thorax and Lungs

852

(1)

The Heart

852

(1)

Breasts and Axillae

853

(1)

Extremities

853

(1)

Neurologic System

853

(1)

Abdomen and Fetal Assessment

853

(5)

External Genitalia

858

(2)

Inspection of Vagina and Cervix

860

(1)

Palpation of Pelvis

860

(3)

Palpation of Cervix, Uterus, Adnexa, and Vagina

863

(2)

Anus and Rectum

865

(1)

Abnormal Findings

866

(2)

Common Complications in Pregnancy

866

(1)

Common Complications in the Postpartum Period

867

(1)

Health Promotion

868

(3)

Application Through Critical Thinking

871

(1)

Case Study

871

(3)

Complete Documentation

871

(1)

Critical Thinking Questions

871

(1)

Applying Nursing Diagnoses

871

(1)

Prepare Teaching Plan

871

(3)

Assessing the Older Adult

874

Theories of Aging

875

(1)

Anatomy and Physiology Review with Changes of Aging

876

(5)

Integumentary System

876

(1)

Mouth, Nose, and Throat

876

(1)

Eyes

876

(1)

Ears

877

(1)

Respiratory System

877

(1)

Cardiovascular System

877

(1)

Gastrointestinal System

877

(2)

Genitourinary System

879

(1)

Endocrine System

880

(1)

Musculoskeletal System

880

(1)

Neurologic System

881

(1)

Gathering the Data

881

(1)

Guidelines for Interviewing Older Adults

881

(1)

Focused Interview

882

(5)

Questions for the Client

882

(3)

Questions for Family Members or Caregivers

885

(2)

Physical Assessment

887

(13)

Assessment Techniques and Findings

887

(1)

General Survey

887

(2)

Integumentary System

889

(1)

Head and Neck

890

(2)

Eye

892

(1)

Ear

893

(1)

Respiratory System

893

(1)

Breasts

894

(1)

Cardiovascular System

895

(1)

Abdomen

895

(1)

Genitourinary System

896

(1)

Musculoskeletal System

897

(1)

Neurologic System

898

(2)

Abnormal Findings

900

(1)

Skin Lesions

900

(1)

Insulin Resistance Syndrome

900

(1)

Diabetes Mellitus

900

(1)

Drug and Alcohol Abuse

901

(1)

Health Promotion

901

(2)

Application Through Critical Thinking

903

(1)

Case Study

903

Complete Documentation

904

(1)

Critical Thinking Questions

904

(1)

Applying Nursing Diagnoses

904

(1)

Prepare Teaching Plan

905

Appendix A 2005--2006 North American Nursing Diagnosis Association (NANDA) Approved Nursing Diagnoses

(1)

Appendix B Standard Precautions for Blood and Bodily Fluid Exposure

(1)

Appendix C Standard Precautions for Infection Control

(1)

Appendix D Blood Pressure Standards for Girls Ages I to 17 Years

(1)

Appendix E Blood Pressure Standards for Boys Ages 1 to 17 Years

(1)

Appendix F Denver Developmental Screening

(1)

Appendix G Mini Nutritional Assessment

(1)

Glossary

(1)

References

(1)

Credits

(1)

Index

Health and Physical Assessment in Nursing

9780130493736

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