Health assessment is central to effective planning, implementation and evaluation of nursing care. All nurses are accountable for the care they provide and need to be able to accurately determine patient needs in order to plan and deliver evidence-based care. Vital notes for nurses: Health assessment provides students with the knowledge required to consider the many different factors which can influence patient's health, comfort, well-being and recovery and to confidently assess patient needs. Vital notes for nurses: Health assessment explores concepts of holism, health and illness, factorsto consider when assessing patients, communication skills needed for assessment, and all aspects of holistic assessment including physical, psychological, social, cultural and spiritual factors and nutritional needs.

Anna Crouch and Clency Meurier are both Senior Lecturers at University of Northampton.

Preface

xi

Acknowledgements

xii

Dedication

xiv

List of contributors

xv

The human body

1

(51)

C. Meurier

Section 1: Introduction

1

(10)

Anatomical terms

2

(2)

Levels of organisation of the body

4

(1)

Hierarchy of functions

5

(1)

The basic structure of cells

5

(3)

Homeostasis

8

(3)

Organ systems

11

(1)

Section 2: The integumentary system

11

(3)

Structure of the skin

12

(2)

Thermoregulation and the skin

14

(1)

Section 3: The musculoskeletal system

14

(3)

The human skeleton

14

(1)

Bone

14

(1)

Joints

15

(1)

Muscular tissue

16

(1)

Section 4: The nervous system

17

(7)

Structure and function of the nervous system

17

(2)

The central nervous system

19

(3)

The autonomic nervous system

22

(1)

Sensations

23

(1)

Somatic senses

23

(1)

Pain

23

(1)

Section 5: The special senses

24

(4)

The eye

24

(2)

The ear

26

(2)

Section 6: The endocrine system

28

(1)

Hormones

28

(1)

Negative and positive feedback mechanisms

28

(1)

Section 7: The respiratory system

28

(5)

The mechanism of breathing

31

(1)

The transport of oxygen

32

(1)

The transport of carbon dioxide

33

(1)

Section 8: The cardiovascular system

33

(5)

The blood

33

(1)

The heart

34

(3)

Blood vessels: arteries, capillaries and veins

37

(1)

Section 9: The lymphatic and immune system

38

(2)

Components

38

(1)

Functions

38

(2)

Section 10: The digestive system

40

(3)

Functions

40

(1)

Organs of the digestive system and their location

40

(3)

Section 11: The urinary system

43

(3)

The kidney and its functions

44

(2)

Section 12: The reproductive system

46

(6)

Female reproductive system

47

(2)

The male reproductive organs

49

(3)

Nursing assessment and care planning

52

(24)

J. Aldridge

A. Eshun

C. Meurier

Introduction

52

(1)

Nursing assessment and the nursing process

53

(18)

Advantages of using a conceptual model in assessment

71

(1)

Key issues and developments

72

(4)

Concepts of health, illness and holism

76

(19)

C. Meurier

Introduction

76

(1)

Being `healthy'

77

(3)

Health beliefs and health behaviour

80

(2)

Illness, sickness and disease

82

(2)

Seeing the person as a whole

84

(3)

Assessment

87

(8)

Factors to consider when assessing patients

95

(33)

A. Crouch

G. Rumbold

M. Thompson

W. Turner

Section 1: Introduction

95

(8)

Ethical aspects of assessment

95

(1)

Respect for persons -- definition

96

(2)

Privacy

98

(1)

Confidentiality

99

(2)

Respect for dignity

101

(1)

Truthfulness

102

(1)

Section 2: The environment, health status, age and cognitive ability of the patient, learning disability and health assessment

103

(11)

Environment

104

(1)

Health status of the patient

105

(1)

The patient's age

106

(2)

Cognitive development and ability

108

(4)

The assessment of children

112

(2)

Section 3: Gender and health assessment

114

(14)

Trends and patterns of health and disease among men and women

115

(1)

Health issues and dilemmas for men and women

116

(2)

A health assessment approach: some practical aspects to consider

118

(10)

Communication skills for holistic health assessment

128

(20)

A. Crouch

Introduction

128

(1)

Definition and classification

129

(2)

Factors that facilitate effective communication

131

(1)

Skills needed during holistic health assessment

132

(6)

Barriers to communication during holistic assessment

138

(6)

Record keeping

144

(4)

Physical assessment

148

(86)

C. Meurier

J. Brown

A. Crouch

Section 1: Introduction

148

(15)

The purpose of physical assessment

150

(1)

Approach to physical assessment

150

(1)

Preparation for physical assessment

150

(1)

Techniques of physical assessment

151

(3)

The general survey and vital signs

154

(9)

Section 2: Physical assessment of the integumentary system

163

(5)

The skin

164

(2)

Assessment of nails

166

(1)

Assessment of hair

167

(1)

Section 3: Physical assessment of the respiratory system

168

(3)

Taking a health history

168

(1)

Physical examination

169

(2)

Section 4: Physical assessment of the cardiovascular system

171

(7)

Relevant health history

172

(3)

Risk factors for coronary heart disease

175

(1)

Physical examination

175

(3)

Section 5: Physical assessment of the nervous system

178

(9)

Relevant health history

178

(1)

Examination

178

(9)

Section 6: Physical assessment of the eyes, ears, nose and throat

187

(8)

The eyes

187

(4)

The ears

191

(1)

The mouth, nose, sinuses and throat

192

(3)

Section 7: Physical assessment of the digestive system

195

(5)

Relevant health history

196

(1)

Risk factors

196

(1)

Physical assessment

197

(3)

Section 8: Physical assessment of the urinary tract system

200

(5)

Assessment of the urinary system

201

(3)

Assessment of the prostate gland

204

(1)

Section 9: Physical assessment of the musculoskeletal system

205

(5)

The musculoskeletal system

205

(1)

Assessment

206

(4)

Section 10: Physical assessment of the female and male reproductive systems

210

(24)

Examination of the breast

210

(4)

Examination of the female genitalia

214

(10)

Assessment of the male reproductive system

224

(4)

Record keeping

228

(6)

Assessment of nutritional status

234

(30)

M. Ingham

J. O'Reilly

Introduction

234

(1)

Purpose of nutritional assessment

235

(1)

Components of food

235

(10)

Nutritional requirements

245

(1)

Dietary guidelines

246

(1)

Assessing nutritional status

246

(11)

Dietary assessment

257

(2)

Nutritional interventions

259

(5)

Social assessment in healthcare

264

(24)

S. O'Brien

Introduction

264

(1)

The purpose of social assessment

265

(1)

Health policy: assessing social needs

266

(1)

Nursing models, social influences and assessment

267

(1)

Nursing and interprofessional approaches to social assessment

268

(3)

The social assessment/analysis framework

271

(13)

The levels of social assessment

284

(4)

Psychological assessment

288

(23)

J. H. Parkes

Introduction

288

(1)

What is psychological health?

289

(1)

Why conduct a psychological assessment?

290

(1)

What to assess

291

(8)

How to conduct the psychological assessment

299

(1)

Nurses' role in assessment

299

(1)

The assessment process

300

(7)

Accurate reporting and documentation

307

(4)

Cultural and spiritual health assessment

311

(20)

S. Allen

A. Crouch

Cultural health assessment

311

(7)

Spirituality and spiritual needs

318

(13)

Glossary

331

(8)

Index

339

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Health Assessment

9781405114585

1405114584

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