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Nursing Health Assessment A Best Practice Approach 3rd Edition

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Nursing Health Assessment A Best Practice Approach 3rd Edition

Author:  Sharon Jensen MN RN
Edition: 3th Edition
Year: 2019
Language: English
ISBN 13: 978-1496349170;
978-1496358417;
978-1496358431;
Publisher: Wolters Kluwer Health
ISBN 10: 1496349172
Pages: 1559
File: PDF
Price: 5.99$
Digital delivery: Via Email check your SPAM

Nursing Health Assessment A Best Practice Approach 3rd Edition

Develop the assessment knowledge and skills to excel in any clinical setting.

Updated to reflect today’s changing healthcare environment, this unique, modern approach to health assessment guides you progressively through realistic clinical case scenarios, emphasizing health promotion, risk factor reduction, evidence-based thinking, and diagnostic reasoning. Effective strategies help you adapt questions and techniques to confidently manage communication challenges, unexpected patient responses, changes in a patient’s condition over time, and more.

Highlights of the Third Edition

  • Progressive Case Studies in each chapter help you capably apply concepts to clinical practice through:
    • Therapeutic Dialogue displays hone the communication and critical thinking skills essential for gathering assessment data.
    • Progress Note sections that provide sample SOAP (Subjective data, Objective data, Analysis, and Plan) notes documenting summaries of findings, with accompanying critical thinking questions.
    • Documenting Case Study Findings boxes that summarize abnormal findings in the physical examination (determined through inspection, palpation, percussion, and auscultation).
    • Collaborating With the Interprofessional Team displays that feature SBAR (Situation, Background, Analysis or Assessment, and Recommendations) frameworks for effectively coordinating referrals or other patient advocacy needs.
    • Clinical Reasoning in Action sections demonstrates how to bring all the elements of assessment together to determine a nursing diagnosis and related goals, interventions, rationales, and evaluation criteria.

NEW! Unfolding case-based vignettes written by the National League for Nursing place concepts in a realistic context and encourage classroom discussion.

  • NEW! Concept Mastery Alerts clarify potentially confusing topics.
  • More than 70 NANDA-I Diagnoses with official definitions and defining characteristics
  • Learning Objectives focus on critical information and can help you study more effectively.
  • Clinical Significance boxes emphasize content critically related to clinical application.
  • Safety Alert boxes highlight areas of concern or results that require immediate intervention or adjustments.
  • Key Points summarized at the end of each chapter reinforce the most important content at a glance.
  • Review Questions help you identify content requiring additional review.
  • Tables of Abnormal Findings facilitate fast, effective assessments.
  • Accompanying interactive learning resources such as videos and animations, referenced with icons in the text, appeal to a variety of learning styles.

CONTRIBUTORS

CONTRIBUTORS TO THE THIRD EDITION

Kandice S. Bowman, RN, MSN, PNP, CPNP
Instructor
Division of Pediatric Otolaryngology
Oregon Health and Science University
Portland, Oregon
Chapter 14: Ear Assessment for Advanced and Specialty Practice

Yvonne D’Arcy, MS, APN-C, CNS, FAANP
Pain Management and Palliative Care Nurse Practitioner
Ponte Vedra Beach, Florida
Chapter 6: Pain Assessment

Monica Deshpande, MSN, FNP
Instructor
Division of Pediatric Otolaryngology
Oregon Health and Science University
Portland, Oregon
Chapter 14: Ear Assessment for Advanced and Specialty Practice

Jessica E. Gay, MSN, RNC-MNN
Clinical Assistant Professor
University of Kansas School of Nursing
Kansas City, Kansas
Chapter 25: Pregnant Woman

Nan M. Gaylord, Ph.D., RN, CPNP-PC
Professor
College of Nursing
University of Tennessee
Knoxville, Tennessee
Chapter 27: Children and Adolescents

Jane Leach, Ph.D., RN
Associate Professor
Wilson School of Nursing
Midwestern State University
Wichita Falls, Texas
Chapter 26: Newborns and Infants

Kari Magill, BSN, RN, CNOR
Retinal Service Lead, Operating Rooms
Kellogg Eye Center
Michigan Medicine
Ann Arbor, Michigan
Chapter 13: Eye Assessment for Advanced and Specialty Practice

Amy Metteer-Storer, MSN, RN
Assistant Professor
Department of Nursing
Cedar Crest College
Allentown, Pennsylvania
Chapter 2: The Health History and Interview
Chapter 18: Peripheral Vascular and Lymphatic Assessment

Jessica Nishikawa, DNP, NP-c
Nurse Practitioner
Straub Medical Center
Honolulu, Hawaii
Chapter 28: Older Adults

Barbara L. Parker, MS, FNP, CNM
Clinical Associate Professor
University of Kansas Medical Center
Kansas City, Kansas
Chapter 25: Pregnant Woman

Demetrius J. Porche, DNS, PhD, ANEF, FACHE, FAANP, FAAN
Dean and Professor
School of Nursing
Louisiana State University Health–New Orleans
New Orleans, Louisiana
Chapter 23: Male Genitalia and Rectal Assessment

Diane Marie Schadewald, DNP, MSN, WHNP, FNP
Clinical Associate Professor
College of Nursing
University of Wisconsin–Milwaukee
Milwaukee, Wisconsin
Chapter 24: Female Genitalia and Rectal Assessment

Debra Lee Servello, DNP, APRN, AGACNP-BC
Associate Professor and Chair
School of Nursing
Rhode Island College
Providence, Rhode Island

Mindy Stites, MSN, APRN, CCNS, ACNS-BC, CCRN
Chapter 5: Vital Signs and General Survey
Chapter 17: Heart and Neck Vessels Assessment
Chapter 20: Abdominal Assessment
Chapter 30: Head-to-Toe Assessment of the Adult

Franz H. Vergara, PhD, DNP, RN, ONC, CCM
Nurse Educator
Department of Central Nursing Administration
The Johns Hopkins Hospital
Baltimore, Maryland
Chapter 21: Musculoskeletal Assessment

Mary Viergutz, RN, MSN, JD
Former Director
Healthcare Risk Management
Milwaukee, Wisconsin
Chapter 10: Cultural Assessment
Chapter 29: Assessment of the Hospitalized Adult

Margaret A. Wallace, RN, FNP, CORLN
Nurse Practitioner
Department of Otolaryngology
Washington University School of Medicine
St. Louis, Missouri
Chapter 15: Nose, Sinuses, Mouth, and Throat

Yvette D. Wilson, MSN, APRN-CNS, CCRN
Clinical Nurse Specialist/Doctoral Candidate
Burn Intensive Care, Surgical Intensive Care, and Burn Wound Unit
Johns Hopkins Bayview Medical Center
Baltimore, Maryland
Chapter 11: Skin, Hair, and Nails Assessment

BRIEF TABLE OF CONTENTS

UNIT 1: Foundations of Nursing Health Assessment
1. The Nurse’s Role in Health Assessment
2. The Health History and Interview
3. Techniques of Assessment and Safety
4. Documentation and Interprofessional Communication
UNIT 2: General Examinations
5. Vital Signs and General Survey
6. Pain Assessment
7. Nutritional Assessment
8. Assessment of Developmental Stages
9. Mental Health, Violence, and Drug Abuse
10. Cultural Assessment
UNIT 3: Regional Examinations
11. Skin, Hair, and Nails Assessment
12. Head and Neck, With Vision and Hearing Basics
13. Eye Assessment for Advanced and Specialty Practice
14. Ear Assessment for Advanced and Specialty Practice
15. Nose, Sinuses, Mouth, and Throat
16. Thorax and Lung Assessment
17. Heart and Neck Vessels Assessment
18. Peripheral Vascular and Lymphatic Assessment
19. Breasts and Axillae Assessment
20. Abdominal Assessment
21. Musculoskeletal Assessment
22. Neurological and Mental Status
23. Male Genitalia and Rectal Assessment
24. Female Genitalia and Rectal Assessment
UNIT 4: Special Populations and Foci
25. Pregnant Women
26. Newborns and Infants
27. Children and Adolescents
28. Older Adults
UNIT 5: Putting It All Together
29. Assessment of the Hospitalized Adult
30. Head-to-Toe Assessment of the Adult
Appendix A: Answers to Review Questions
Appendix B: Definitions and Defining Characteristics for NANDA-I Diagnoses in This Title
Glossary
Illustration Credit List
Index

ORGANIZATION OF THE TEXT

Progressive Case Studies (woven throughout)
Each chapter presents a patient with a health concern corresponding to the chapter. Over the course of the chapter, the patient’s situation changes, and the nurse intervenes using a best practice approach.
Structure and Function
Reviews anatomy and physiology, with additional content on the older adult and culture. Useful real-world clinical significance applications are included.
Subjective Data
The “Urgent Assessment” section prioritizes signs and symptoms needing emergency interventions. Risk factor reduction and health promotion activities are separated from common signs and symptoms.
Objective Data
Covers techniques, equipment, preparation, normal findings, abnormal findings, and older adult and cultural adaptations. Recurring checklists differentiate registered nurse (RN)–level from advanced practice registered nurse (APRN)–level practice. Documentation is highlighted and carefully described for each technique.
Critical Thinking
Discusses key laboratory and diagnostic tests, diagnostic reasoning, and methods for organizing and prioritizing. The nursing process is used in a changing patient situation, with high-level and best-practice thinking.
Key Points
Key points of the chapter are summarized as reinforcement that the student has understood the most important information.
Review Questions
These questions are consistent with the objectives at the beginning of the chapter and review important points. Answers are found in Appendix A.
Tables of Abnormal Findings
These tables illustrate common abnormalities related to the assessment, with compare-and-contrast information on key data points. Photos of significant abnormal findings are an excellent resource.

CONTENTS

Contributors
Reviewers
Preface

UNIT 1: Foundations of Nursing Health Assessment
1. The Nurse’s Role in Health Assessment
STRUCTURE AND FUNCTION
Roles of the Professional Nurse
Provider of Care
Manager of Care
Member of a Profession
THE REGISTERED NURSE
THE ADVANCED PRACTICE REGISTERED NURSE
Registered Nurse Versus Specialty or Advanced Practice Assessments
Nursing and Health Promotion
Wellness and Illness
Risk Reduction: Healthy People Model
What Is Health Assessment?
Nursing Process
ASSESS
DIAGNOSE
IDENTIFY OUTCOMES
PLAN CARE
IMPLEMENT
EVALUATE
Critical Thinking
Diagnostic Reasoning
Types of Nursing Assessments
Emergency and Urgent Assessment
Comprehensive Assessment
Focused Assessment
Priority Setting
Frequency of Assessment
Life Span Issues
Cultural Considerations
Components of the Health Assessment
SUBJECTIVE DATA
Subjective Data Collection
OBJECTIVE DATA
Objective Data Collection
Documentation and Interprofessional Communication
Interprofessional Collaboration
Frameworks for Health Assessment
Functional Assessment
Head-to-Toe Assessment
Body Systems Approach
CRITICAL THINKING
Evidence-Based Practice
Review Questions
2. The Health History and Interview
STRUCTURE AND FUNCTION
The Communication Process
Therapeutic Communication
Nonverbal Communication Skills
Verbal Communication Skills
ACTIVE LISTENING
RESTATEMENT
REFLECTION
ELABORATION (FACILITATION)
SILENCE
FOCUSING
CLARIFICATION
SUMMARIZING
SUBJECTIVE DATA
Nontherapeutic Responses
False Reassurance
Sympathy
Unwanted Advice
Biased Questions
Changes of Subject
Distractions
Technical or Overwhelming Language
Interrupting
Professional Expectations and Boundaries
Intercultural Communication
Patients With Limited English Skills
Working With an Interpreter
Gender and Sexual Orientation Issues
OBJECTIVE DATA
Phases of the Interview Process
Preinteraction Phase
Beginning Phase
Working Phase
Closing Phase
Health History Sources
Primary and Secondary Data Sources
Reliability of the Source
Components of the Health History
Demographic Data
Reason for Seeking Care
History of Present Illness
LOCATION
ONSET/DURATION/TIMING
INTENSITY
QUALITY/DESCRIPTION
AGGRAVATING/ASSOCIATED/ALLEVIATING FACTORS
PAIN GOAL
FUNCTIONAL GOAL
Past Health History
CHILDHOOD ILLNESSES
PAST ILLNESSES
SURGERIES
INJURIES AND TRAUMA
OBSTETRIC HISTORY
HEALTH SCREENING
GENOMICS
Current Medications With Indications
Allergies
Family History
Functional Health Assessment
Growth and Development
Review of Systems
Psychosocial And Lifestyle Factors
Social, Cultural, and Spiritual Assessment
Mental Health Assessment
Human Violence Assessment
Sexual History and Orientation
Life Span Considerations
Situational Considerations
HEARING IMPAIRMENT
LOW LEVEL OF CONSCIOUSNESS
COGNITIVE IMPAIRMENT
MENTAL ILLNESS
ANXIETY
CRYING
ANGER
ALCOHOL OR DRUG USE
PERSONAL QUESTIONS
SEXUAL AGGRESSION
Older Adults
Cultural Considerations
CRITICAL THINKING
REVIEW QUESTIONS
3. Techniques of Assessment and Safety
STRUCTURE AND FUNCTION
Safety Precautions to Prevent Infection
Hand Hygiene
Use of Gloves
WHEN TO CHANGE GLOVES
GLOVE REMOVAL
Standard Precautions
Latex Allergy
Skin Reactions
SUBJECTIVE DATA
OBJECTIVE DATA
Inspection
Palpation
Light Palpation
Moderate Palpation
Bimanual Deep Palpation
Percussion
Direct Percussion
Indirect Percussion
Percussion Sounds
Auscultation
The Stethoscope
Advanced Techniques and Special Equipment
Ophthalmoscope
Otoscope
Tuning Fork
Reflex Hammer
Equipment For A Complete Physical Assessment
Older Adults
Cultural Considerations
CRITICAL THINKING
Review Questions
4. Documentation and Interprofessional Communication
STRUCTURE AND FUNCTION
Patient Medical Record
Purposes of the Medical Record
LEGAL DOCUMENT
COMMUNICATION AND CARE PLANNING
QUALITY ASSURANCE
FINANCIAL REIMBURSEMENT
EDUCATION
RESEARCH
Components of the Medical Record
Electronic Medical Record
SUBJECTIVE DATA
Urgent Assessment
OBJECTIVE DATA
Principles Governing Documentation
Confidentiality
Accuracy and Completeness
Logical Organization
Timeliness
Conciseness
Documentation of Critical Thinking
Nursing Admission Assessment
Flow Sheets
Plan of Care and Clinical Pathway
Progress or Case Note
Narrative Notes
SOAP Notes
PIE Notes
DAR NOTE
Charting by Exception
Discharge Note
Home Care Documentation
Long-Term Care Documentation
Written Handoff Summary
Verbal Communication
Verbal Handoff Summary
Reporting
QUALITIES OF EFFECTIVE REPORTING
CRITICAL THINKING
SBAR Model
Reporting to the Primary Health Care Provider
Telephone Communication
Patient Rounds and Conferences
Collaborating for the Handoff
Review Questions

UNIT 2: General Examinations
5. Vital Signs and General Survey
STRUCTURE AND FUNCTION
SUBJECTIVE DATA
Urgent Assessment
Subjective Data Collection
Assessment of Risk Factors
Risk Reduction and Health Promotion
Common Symptoms
OBJECTIVE DATA
Objective Data Collection
Screening and Advanced Techniques
Equipment
Preparation
General Survey
Anthropometric Measurements
Vital Signs
TEMPERATURE
PULSE
RESPIRATIONS
OXYGEN SATURATION
BLOOD PRESSURE
VITAL SIGNS MONITOR
DOPPLER TECHNIQUE
OLDER ADULTS
Cultural Considerations
CRITICAL THINKING
Critical Thinking: A Best Practice Approach
Diagnostic Reasoning
Review Questions
Tables of Abnormal Findings
6. Pain Assessment
STRUCTURE AND FUNCTION
Neuroanatomy of Pain
Peripheral Nervous System
Central Nervous System
Gate Control Theory
Nociception
Types of Pain
Acute Pain
Chronic Pain
Neuropathic Pain
Older Adults
Cultural Considerations
SUBJECTIVE DATA
Urgent Assessment
Subjective Data Collection
Pain Is What the Patient Says It Is
Common Pain Symptoms
OBJECTIVE DATA
Objective Data Collection
Pain Assessment Tools
ONE-DIMENSIONAL PAIN SCALES
MULTIDIMENSIONAL PAIN SCALES
Lifespan Considerations
NEWBORNS, INFANTS, AND CHILDREN
OLDER ADULTS
Special Considerations
PATIENTS UNABLE TO REPORT PAIN
THE OPIOID DILEMMA
PATIENTS WITH OPIOID TOLERANCE
Reassessing and Documenting Pain
Barriers to Pain Assessment
CRITICAL THINKING
Critical Thinking: A Best Practice Approach
Laboratory and Diagnostic Testing
Diagnostic Reasoning
Review Questions
7. Nutritional Assessment
STRUCTURE AND FUNCTION
Nutritional Concepts
Primary Nutrients
CARBOHYDRATES
PROTEINS
LIPIDS
VITAMINS AND MINERALS
SUPPLEMENTS
FLUID AND ELECTROLYTES
Food Safety and Food Security
FOOD-BORNE PATHOGENS
ORGANIC FOOD
FOOD SECURITY
Nutritional Guidelines
Lifespan Considerations
WOMEN WHO ARE PREGNANT
INFANTS, CHILDREN, AND ADOLESCENTS
OLDER ADULTS
Cultural Considerations
SUBJECTIVE DATA
Urgent Assessment
Subjective Data Collection
Assessment of Risk Factors
Risk Assessment and Health Promotion
Focused Health History Related to Common Symptoms
Comprehensive Nutritional History
FOOD RECORDS
DIRECT OBSERVATION
OBJECTIVE DATA
Objective Data Collection
Screening and Advanced Techniques
Equipment
Preparation
Comprehensive Physical Assessment
Older Adults
Cultural Considerations
CRITICAL THINKING
Critical Thinking: A Best Practice Approach
Common Laboratory and Diagnostic Testing
SERUM PROTEINS
HEMOGLOBIN AND HEMATOCRIT
LYMPHOCYTE COUNT
CREATININE EXCRETION
NITROGEN BALANCE
SKIN TESTING
LIPID MEASUREMENTS
OTHER LABORATORY TESTS
Diagnostic Reasoning
Review Questions
Tables of Abnormal Findings
8. Assessment of Developmental Stages
STRUCTURE AND FUNCTION
Psychosocial Development
Infant: Trust Versus Mistrust: Stage I
Toddler: Autonomy Versus Shame and Doubt: Stage II
Preschooler: Initiative Versus Guilt: Stage III
School-Age Child: Industry Versus Inferiority: Stage IV
Adolescent: Identity Versus Role Confusion: Stage V
Early Adult: Intimacy Versus Isolation: Stage VI
Middle Adult: Generativity Versus Stagnation: Stage VII
Late Adult: Ego Integrity Versus Despair: Stage VIII
Cognitive Development
Infant: Sensorimotor Stage I
Toddler and Preschooler: Preoperational Stage II
School-Age Child: Concrete Operations III
Adolescent: Formal Operations IV
Young Adult: Formal Operations
Development of Wisdom and Values in Adults
Middle Adult: Cognitive Expertise
Older Adult: Wisdom
Physical Development
Newborn and Infant
Child and Adolescent
Adults and Older Adults
Cultural Considerations
SUBJECTIVE DATA
Urgent Assessment
Subjective Data Collection
Assessment of Risk Factors
Risk Reduction and Health Promotion
INFANTS, CHILDREN, AND ADOLESCENTS
ADOLESCENTS
OLDER ADULTS
OBJECTIVE DATA
Objective Data Collection
Comprehensive Physical Assessment
Cultural Considerations
CRITICAL THINKING
Critical Thinking: A Best Practice Approach
Laboratory and Diagnostic Testing
Diagnostic Reasoning
Review Questions
9. Mental Health, Violence, and Drug Abuse
STRUCTURE AND FUNCTION
Role of the Nurse in Mental Health
Violence
Family and Intimate Partner Violence
Sexual Violence
Human Trafficking
Child Abuse
Sibling Violence
Youth and School Violence
Elder Abuse
Adults With Disabilities
Hate Crimes
Drug Abuse and Addiction
Definitions
Statistics
Health Effects
Diagnosis
TRENDS AND ALERTS IN DRUG ABUSE
SUBJECTIVE DATA
Urgent Assessment
Subjective Data Collection
Dementia, Confusion, Delirium, and Depression Assessment
Interviewing Patients About Violence
DOCUMENTATION AND LEGAL ISSUES RELATED TO VIOLENCE
Alcohol and Drug Abuse Interview
Assessment of Risk Factors for Mental Health Conditions
Risk Reduction and Health Promotion
Common Symptoms
OBJECTIVE DATA
Objective Data Collection
Comprehensive Mental Health Assessment
CRITICAL THINKING
Critical Thinking: A Best Practice Approach
Laboratory and Diagnostic Testing
Diagnostic Reasoning
Review Questions
Tables of Abnormal Findings
10. Cultural Assessment
STRUCTURE AND FUNCTION
Cultural Assessment and Cultural Competency
Characteristics of Culture
Nursing Models for Cultural Assessment and Care
LEININGER’S CULTURAL CARE DIVERSITY AND UNIVERSALITY THEORY/MODEL
PURNELL’S MODEL OF TRANSCULTURAL HEALTH CARE
CAMPINHA-BACOTE’S MODEL OF CULTURAL COMPETENCE
GIGER AND DAVIDHIZAR’S MODEL OF TRANSCULTURAL NURSING
SUBJECTIVE DATA
Cultural Data Collection
Aims of Cultural Assessment
Implementing the Cultural Assessment: Practical Aspects
Cultural Health Beliefs and Practices
CULTURAL FOOD AND NUTRITION PRACTICES
CULTURAL BELIEFS AND PRACTICES OF PREGNANCY AND CHILDBIRTH
CULTURAL BELIEFS AND EXPRESSIONS OF PAIN
CULTURAL BELIEFS DURING DEATH AND GRIEVING
ASSESSMENT OF SPIRITUALITY AND RELIGIOUS BELIEFS
OBJECTIVE DATA
Social Assessment
Social Assessment of the Individual
Social Assessment of the Community
Social Assessment at the Societal Level
CRITICAL THINKING
Diagnostic Reasoning
Review Questions

UNIT 3: Regional Examinations
11. Skin, Hair, and Nails Assessment
STRUCTURE AND FUNCTION
Structure and Function: Foundation for Assessment
Skin
EPIDERMIS
DERMIS
SUBCUTANEOUS LAYER
Hair
Nails
Glands
Older Adults
Cultural Considerations
SUBJECTIVE DATA
Urgent Assessment
Subjective Data Collection
Assessment of Risk Factors
Risk Assessment and Health Promotion
Common Integumentary Symptoms
OBJECTIVE DATA
Objective Data Collection
Screening and Advanced Techniques
Equipment
Preparation
Comprehensive Skin Assessment
Older Adults
Cultural Considerations
CRITICAL THINKING
Critical Thinking: A Best Practice Approach
Laboratory and Diagnostic Testing
Diagnostic Reasoning
Review Questions
Tables of Abnormal Findings
12. Head and Neck, With Vision and Hearing Basics
STRUCTURE AND FUNCTION
Structure and Function: Foundation for Assessment
The Head
SKELETAL STRUCTURE
MUSCLES
BLOOD SUPPLY
NERVE SUPPLY
SALIVARY GLANDS
Vision
Hearing
The Neck
TRACHEA
THYROID AND PARATHYROID GLANDS
Lymphatics
Older Adults
Cultural Considerations
SUBJECTIVE DATA
Urgent Assessment
Subjective Data Collection
Assessment of Risk Factors
Risk Reduction and Health Promotion
Common Symptoms
OBJECTIVE DATA
Objective Data Collection
Screening and Advanced Techniques
Equipment
Preparation
Comprehensive Physical Examination
Older Adults
Cultural Considerations
CRITICAL THINKING
Critical Thinking: A Best Practice Approach
Laboratory and Diagnostic Testing
Diagnostic Reasoning
Review Questions
Tables of Abnormal Findings
13. Eye Assessment for Advanced and Specialty Practice
STRUCTURE AND FUNCTION
Structure and Function: Foundation for Assessment
Extraocular Structures
Extraocular Muscle Function
Intraocular Structures
Vision
Older Adults
Cultural Considerations
SUBJECTIVE DATA
Urgent Assessment
Subjective Data Collection
Assessment of Risk Factors
Risk Reduction and Health Promotion
Common Symptoms
OBJECTIVE DATA
Objective Data Collection
Screening and Advanced Techniques
Equipment (for Advanced Practice Assessment)
Preparation
Assessment of Visual Acuity
Assessment of Visual Fields
Assessment of Extraocular Muscle Movements
Assessment of External Eyes
Assessment of Exterior Ocular Structures
Special Techniques
Assessment of Internal Ocular Structures
Older Adults
Cultural Considerations
CRITICAL THINKING
Critical Thinking: A Best Practice Approach
Laboratory and Diagnostic Testing
Diagnostic Reasoning
Review Questions
Tables of Abnormal Findings
14. Ear Assessment for Advanced and Specialty Practice
STRUCTURE AND FUNCTION
Structure and Function
External Ear
Middle Ear
Inner Ear
Hearing
AIR AND BONE CONDUCTION
HEARING DIFFICULTIES
Vestibular Function
Older Adults
Cultural Considerations
SUBJECTIVE DATA
Urgent Assessment
Subjective Data Collection
Assessment of Risk Factors
Risk Reduction and Health Promotion
Common Symptoms
OBJECTIVE DATA
Objective Data Collection
Screening and Advanced Techniques
Equipment (for Advanced Practice Assessment)
Preparation
Comprehensive Physical Assessment
Older Adults
Cultural Considerations
CRITICAL THINKING
Critical Thinking: A Best Practice Approach
Laboratory and Diagnostic Testing
Diagnostic Reasoning
NURSING DIAGNOSIS, OUTCOMES, AND INTERVENTIONS
Review Questions
Tables of Abnormal Findings
15. Nose, Sinuses, Mouth, and Throat
STRUCTURE AND FUNCTION
Structure and Function
Nose
NERVE AND BLOOD SUPPLY
LYMPH DRAINAGE
Sinuses
Mouth
TONGUE
SALIVARY GLANDS
TEETH AND GUMS
Throat, Tonsils, and Adenoids
Older Adults
Cultural Considerations
ORAL HEALTH
CONGENITAL DEFECTS
CANCER
SLEEP-DISORDERED BREATHING
SUBJECTIVE DATA
Urgent Assessment
Subjective Data Collection
Assessment of Risk Factors
Risk Reduction and Health Promotion
TOBACCO USE
SLEEP DISORDERS
CANCER
ORAL HEALTH
HEREDITARY HEMORRHAGIC TELANGIECTASIA
Common Symptoms
OBJECTIVE DATA
Objective Data Collection
Screening and Advanced Techniques
Equipment
Preparation
Comprehensive Physical Assessment
Older Adults
Cultural Considerations
CRITICAL THINKING
Critical Thinking: A Best Practice Approach
Laboratory and Diagnostic Testing
Diagnostic Reasoning
Review Questions
Tables of Abnormal Findings
16. Thorax and Lung Assessment
STRUCTURE AND FUNCTION
Structure and Function: Foundation for Assessment
The Thorax
ANTERIOR THORACIC LANDMARKS
POSTERIOR THORACIC LANDMARKS
REFERENCE LINES
Lobes of the Lungs
Lower Respiratory Tract
Upper Respiratory Tract
Mechanics of Respiration
Older Adults
Cultural Considerations
SUBJECTIVE DATA
Urgent Assessment
Subjective Data Collection
Assessment of Risk Factors
Risk Reduction and Health Promotion
SMOKING CESSATION
PREVENTION OF OCCUPATIONAL EXPOSURE
PREVENTION OF ASTHMA
IMMUNIZATIONS
Common Symptoms
OBJECTIVE DATA
Objective Data Collection
Screening and Advanced Techniques
Equipment
Preparation
Comprehensive Physical Assessment
Older Adults
Cultural Considerations
CRITICAL THINKING
Critical Thinking: A Best Practice Approach
Laboratory and Diagnostic Testing
Diagnostic Reasoning
Review Questions
Tables of Abnormal Findings
17. Heart and Neck Vessels Assessment
STRUCTURE AND FUNCTION
Structure and Function: Foundation for Assessment
Anatomy
NECK VESSELS
HEART CHAMBERS
VALVES
HEART WALL
CORONARY ARTERIES AND VEINS
Conduction System
Physiology
PULMONARY AND SYSTEMIC CIRCULATION
CARDIAC CYCLE
JUGULAR PULSATIONS
Older Adults
Cultural Considerations
SUBJECTIVE DATA
Urgent Assessment
Subjective Data Collection
Assessment of Risk Factors
Risk Reduction and Health Promotion
SMOKING CESSATION
CONTROL OF BP AND CHOLESTEROL LEVEL
Common Symptoms
OBJECTIVE DATA
Objective Data Collection
Screening and Advanced Techniques
Equipment
Preparation
Comprehensive Physical Assessment
Precordium
AUSCULTATION
VARIATIONS IN HEART SOUNDS
Older Adults
Cultural Considerations
CRITICAL THINKING
Critical Thinking: A Best Practice Approach
Laboratory and Diagnostic Testing
LIPID PROFILE
CARDIAC ENZYMES AND PROTEINS
ELECTROCARDIOGRAM
CHEST X-RAY
ECHOCARDIOGRAM
HEMODYNAMIC MONITORING
STRESS TEST
CARDIAC CATHETERIZATION AND CORONARY ANGIOGRAPHY
CARDIAC ELECTROPHYSIOLOGY
Diagnostic Reasoning
Review Questions
Tables of Abnormal Findings
18. Peripheral Vascular and Lymphatic Assessment
STRUCTURE AND FUNCTION
Structure and Function: Foundation for Assessment
Arterial System
Venous System
Capillaries
Lymphatic System
Older Adults
Cultural Considerations
SUBJECTIVE DATA
Urgent Assessment
Subjective Data Collection
Assessment of Risk Factors
Risk Reduction and Health Promotion
PATIENTS WITH PAD
PATIENTS WITH VENOUS DISEASE
PATIENTS WITH LYMPHATIC DISORDERS
Common Symptoms
OBJECTIVE DATA
Objective Data Collection
Screening and Advanced Techniques
Equipment
Preparation
Comprehensive Physical Assessment
Older Adults
Cultural Considerations
CRITICAL THINKING
Critical Thinking: A Best Practice Approach
Laboratory and Diagnostic Testing
Diagnostic Reasoning
Review Questions
Tables of Abnormal Findings
19. Breasts and Axillae Assessment
STRUCTURE AND FUNCTION
Structure and Function: Foundation for Assessment
Landmarks
Breast Structures
Axillae and Lymph Nodes
Lifespan Considerations
PREGNANT WOMEN
NEWBORNS AND INFANTS
CHILDREN AND ADOLESCENTS
OLDER ADULTS
Male Breasts
Cultural Considerations
SUBJECTIVE DATA
Urgent Assessment
Subjective Data Collection
Assessment of Risk Factors
Risk Reduction and Health Promotion
Common Symptoms
OBJECTIVE DATA
Objective Data Collection
Common and Specialty or Advanced Techniques
Equipment
Preparation
Comprehensive Physical Assessment
Teaching the Self-Breast Examination
Lifespan Considerations
PREGNANT OR LACTATING WOMEN
NEWBORNS AND INFANTS
CHILDREN AND ADOLESCENTS
OLDER ADULTS
CULTURAL CONSIDERATIONS
CRITICAL THINKING
Critical Thinking: A Best Practice Approach
Laboratory and Diagnostic Testing
Diagnostic Reasoning
Review Questions
Tables of Abnormal Findings
20. Abdominal Assessment
STRUCTURE AND FUNCTION
Structure and Function: Foundation for Assessment
Anatomical Landmarks
Reference Lines
Abdominal Organs
GASTROINTESTINAL ORGANS
GENITOURINARY ORGANS
BLOOD VESSELS, PERITONEUM, AND MUSCLES
Ingestion and Digestion
Absorption of Nutrients
Elimination
Older Adults
Cultural Considerations
SUBJECTIVE DATA
Urgent Assessment
Subjective Data Collection
Assessment of Risk Factors
Risk Reduction and Health Promotion
COLORECTAL CANCER
FOOD-BORNE ILLNESSES
HEPATITIS
Common Symptoms
OBJECTIVE DATA
Objective Data Collection
Screening and Advanced Techniques
Equipment
Preparation
Comprehensive Physical Assessment
Older Adults
Cultural Considerations
CRITICAL THINKING
Critical Thinking: A Best Practice Approach
Laboratory and Diagnostic Testing
ESOPHAGOGASTRODUODENOSCOPY
BARIUM ENEMA
COLONOSCOPY
ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY
COMPUTED TOMOGRAPHY SCAN
MAGNETIC RESONANCE IMAGING
Diagnostic Reasoning
Review Questions
Tables of Abnormal Findings
21. Musculoskeletal Assessment
STRUCTURE AND FUNCTION
Structure and Function: Foundation for Assessment
Bones
Muscles
Joints
TEMPOROMANDIBULAR JOINT
SHOULDER
ELBOW
WRIST AND HAND
HIP
KNEE
ANKLE AND FOOT
SPINE
Older Adults
Cultural Considerations
SUBJECTIVE DATA
Urgent Assessment
Subjective Data Collection
Assessment of Risk Factors
Risk Reduction and Health Promotion
BONE DENSITY
SCOLIOSIS SCREENING
Common Symptoms
OBJECTIVE DATA
Objective Data Collection
Screening and Advanced Techniques
Equipment
Preparation
Initial Survey
Comprehensive Physical Examination
Risk for Falling
Older Adults
Cultural Considerations
CRITICAL THINKING
Critical Thinking: A Best Practice Approach
Laboratory and Diagnostic Testing
Diagnostic Reasoning
Review Questions
Tables of Abnormal Findings
22. Neurological and Mental Status
STRUCTURE AND FUNCTION
Structure and Function: Foundation for Assessment
Central Nervous System
BRAIN
PROTECTIVE STRUCTURES OF THE CENTRAL NERVOUS SYSTEM
SPINAL CORD
Peripheral Nervous System
CRANIAL NERVES
SPINAL NERVES
AUTONOMIC NERVOUS SYSTEM
REFLEXES
Older Adults
Cultural Considerations
SUBJECTIVE DATA
Urgent Assessment
Subjective Data Collection
Assessment of Risk Factors
Risk Reduction and Health Promotion
STROKE PREVENTION
INJURY PREVENTION
CHRONIC NEUROLOGICAL CONDITIONS
Common Symptoms
OBJECTIVE DATA
Objective Data Collection
Screening and Advanced Techniques
Equipment
Preparation
Comprehensive Physical Assessment
Older Adults
Cultural Considerations
Neurological Assessment in Selected Situations
SCREENING EXAMINATION OF A HEALTHY PATIENT
SERIAL NEUROLOGICAL ASSESSMENT AND DOCUMENTATION
ASSESSMENT OF MENINGEAL SIGNS
ASSESSING THE UNCONSCIOUS PATIENT
BRAIN HERNIATION SYNDROMES
CRITICAL THINKING
Critical Thinking: A Best Practice Approach
Laboratory and Diagnostic Testing
ANATOMICAL IMAGING
ELECTRICAL CONDUCTION TESTING
CEREBROSPINAL FLUID/SPINAL PROCEDURES
Diagnostic Reasoning
Review Questions
Tables of Abnormal Findings
23. Male Genitalia and Rectal Assessment
STRUCTURE AND FUNCTION
Structure and Function: Foundation for Assessment
External Genitalia
Internal Genitalia
TESTES
DUCTS
GLANDS
Rectum and Anus
RECTUM
ANAL CANAL AND ANUS
Lifespan Considerations
NEWBORNS AND INFANTS
CHILDREN AND ADOLESCENTS
OLDER ADULTS
Cultural Considerations
SUBJECTIVE DATA
Urgent Assessment
Subjective Data Collection
Assessment of Risk Factors
Sexual History
COMPONENTS OF A SEXUAL HISTORY
Risk Reduction and Health Promotion
HEALTH GOALS
TESTICULAR SELF-EXAMINATION
SCREENING FOR PROSTATE CANCER
Common Symptoms
OBJECTIVE DATA
Objective Data Collection
Screening and Advanced Techniques
Equipment
Preparation
Comprehensive Physical Assessment
Additional Techniques
Older Adults
Cultural Considerations
CRITICAL THINKING
Critical Thinking: A Best Practice Approach
Laboratory and Diagnostic Testing
Diagnostic Reasoning
Review Questions
Tables of Abnormal Findings
24. Female Genitalia and Rectal Assessment
STRUCTURE AND FUNCTION
Structure and Function: Foundation for Assessment
External Genitalia
Internal Genitalia
VAGINA
UTERUS
CERVIX
FALLOPIAN TUBES
OVARIES
Rectum, Anal Canal, and Anus
RECTUM
ANAL CANAL AND ANUS
Hormone Regulation
Lifespan Considerations
WOMEN WHO ARE PREGNANT
INFANTS, CHILDREN, AND ADOLESCENTS
OLDER ADULTS
CULTURAL CONSIDERATIONS
SUBJECTIVE DATA
Urgent Assessment
Subjective Data Collection
Assessment of Risk Factors
Risk Reduction and Health Promotion
Common Symptoms
Lifespan Considerations
OBJECTIVE DATA
Objective Data Collection
Screening and Advanced Techniques
Equipment
Preparation
Comprehensive Physical Assessment
Lifespan Considerations
WOMEN WHO ARE PREGNANT
CHILDREN
ADOLESCENTS
OLDER ADULTS
CULTURAL CONSIDERATIONS
CRITICAL THINKING
Critical Thinking: A Best Practice Approach
Laboratory and Diagnostic Testing
Diagnostic Reasoning
Review Questions
Tables of Abnormal Findings

UNIT 4: Special Populations and Foci
25. Pregnant Women
Structure and Function
Structure and Function: Foundation for Assessment
Preconception
First Trimester (0 to 13 weeks)
Second Trimester (13 to 26 weeks)
Third Trimester (26 to 40 weeks)
Determining Weeks of Gestation
Role of the Registered Nurse in the Outpatient Setting
Cultural Considerations
SUBJECTIVE DATA
Urgent Assessment
Subjective Data Collection
Assessment of Risk Factors
Risk Reduction and Health Promotion
Common Symptoms
OBJECTIVE DATA
Objective Data Collection
Screening and Advanced Techniques
Equipment
Preparation
Comprehensive Physical Assessment
Cultural Considerations
CRITICAL THINKING
Critical Thinking: A Best Practice Approach
Laboratory and Diagnostic Testing
Advanced Assessments
NONSTRESS TEST
LEOPOLD MANEUVERS
Advanced Assessments: Abnormal Findings
Diagnostic Reasoning
Review Questions
Tables of Abnormal Findings
26. Newborns and Infants
STRUCTURE AND FUNCTION
Structure and Function: Foundation for Assessment
Physical Growth
Motor Development
Language Development
Psychosocial and Cognitive Development
SUBJECTIVE DATA
Urgent Assessment
Subjective Data Collection
Assessment of Risk Factors
Risk Reduction and Health Promotion
SAFE SLEEP HABITS
CHOKING
CARDIOPULMONARY RESUSCITATION TRAINING FOR PARENTS
IMMUNIZATION SCHEDULES
CHILD SAFETY CAR SEAT
POISON CONTROL
BREASTFEEDING
FORMULA FEEDING
TOOTH DECAY
Common Symptoms
OBJECTIVE DATA
Objective Data Collection
Equipment
Preparation
Comprehensive Physical Assessment
Cultural Considerations
CRITICAL THINKING
Critical Thinking: A Best Practice Approach
Laboratory and Diagnostic Testing
Diagnostic Reasoning
Review Questions
Tables of Abnormal Findings
27. Children and Adolescents
STRUCTURE AND FUNCTION
Structure and Function: Foundation for Assessment
Physical Growth
Motor Development
Language
Psychosocial and Cognitive Development
Cultural Considerations
SUBJECTIVE DATA
Urgent Assessment
Subjective Data Collection
Assessment of Risk Factors
Risk Reduction and Health Promotion
IMMUNIZATION SCHEDULES
CAR SAFETY
AMERICAN ASSOCIATION OF POISON CONTROL CENTERS
SAFETY AT HOME
FIRE SAFETY
WATER SAFETY
OUTDOOR SAFETY
PREVENTION OF DRUG AND ALCOHOL USE
NUTRITION AND PREVENTION OF OBESITY
PREVENTION OF DENTAL CARIES
MENTAL HEALTH ISSUES
PROMOTION OF CONTRACEPTION AND SEXUALLY TRANSMITTED INFECTION PREVENTION
Common Symptoms
OBJECTIVE DATA
Objective Data Collection
Equipment
Preparation
Developmental Screening
Comprehensive Physical Assessment
CRITICAL THINKING
Critical Thinking: A Best Practice Approach
Laboratory and Diagnostic Testing
Diagnostic Reasoning
Review Questions
28. Older Adults
STRUCTURE AND FUNCTION
Structure and Function: Foundation for Assessment
Skin, Hair, and Nails
Head and Neck
Eyes and Vision
Ears and Hearing
Nose, Sinuses, Mouth, and Throat
Thorax and Lungs
Heart and Neck Vessels
Peripheral Vascular System and Lymphatics
Breasts and Lymphatics
Abdomen, Metabolism, and Elimination
Musculoskeletal System
Neurological System
Male and Female Genitourinary Systems
Endocrine System
Cultural Considerations
SUBJECTIVE DATA
Urgent Assessment
Subjective Data Collection
Interviewing the Older Adult
Advance Care Planning
ASSESSMENT OF RISK FACTORS
Risk Reduction and Health Promotion
SKIN CANCERS
NUTRITION
MEDICATIONS
SAFETY
Common Symptoms
Cultural Considerations
OBJECTIVE DATA
Objective Data Collection
Equipment
Preparation
Comprehensive Physical Assessment
Cultural Considerations
CRITICAL THINKING
Critical Thinking: A Best Practice Approach
Laboratory and Diagnostic Testing
Diagnostic Reasoning
Review Questions

UNIT 5: Putting It All Together
29. Assessment of the Hospitalized Adult
STRUCTURE AND FUNCTION
Types of Hospital Assessments
SUBJECTIVE DATA
Urgent Assessment
Subjective Data Collection
Past Medical History
Patient Safety and Risk Reduction in the Hospital Setting
SAFETY INTERVENTIONS FOR HOSPITALIZED PATIENTS
OBJECTIVE DATA
Objective Data Collection
Equipment
Preparation
Communicating the Assessment
Comprehensive Admitting Assessment
Shift and Focused Hospital Assessments
GENERAL SHIFT ASSESSMENT
FOCUSED SHIFT ASSESSMENT
Specialized Assessments for the Hospitalized Patient
Older Adults
Cultural Considerations for Hospital Assessments
CRITICAL THINKING
Critical Thinking: A Best Practice Approach
Laboratory and Diagnostic Testing
Diagnostic Reasoning
Review Questions
30. Head-to-Toe Assessment of the Adult
SUBJECTIVE DATA
Urgent Assessment
Subjective Data Collection
Focused History
Past Medical History
Review of Systems
PSYCHOSOCIAL HISTORY
FUNCTIONAL HEALTH STATUS
ACTIVITIES OF DAILY LIVING
Risk Reduction and Health Promotion
Common Symptoms
OBJECTIVE DATA
Objective Data Collection
Equipment
Preparation
Comprehensive Physical Assessment
CRITICAL THINKING
Critical Thinking: A Best-Practice Approach
Laboratory and Diagnostic Testing
Diagnostic Reasoning
Review Questions

Appendix A: Answers to Review Questions
Appendix B: Definitions and Defining Characteristics for NANDA-I Diagnoses in This Title
Glossary
Illustration Credit List
Index

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Author:

Sharon Jensen MN RN

Edition:

3th Edition

Year:

2019

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English

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Wolters Kluwer Health

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