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Contributors xiii Reviewers xv Preface xvi How to UseThis Text xxii Acknowledgments xxvi About the Author xxvii Unit 1: Laying the Foundation 1 Chapter 1: Critical Thinking and the Nursing Process 3 Critical Thinking and Clinical Reasoning 4 Components of Critical Thinking 5 Universal Intellectual Standards for Critical Thinking 5 Critical Thinking and the Nursing Process 6 Assessment 7 Nursing Diagnosis 8 Outcomes Identification 10 Planning 11 Implementation 12 Evaluation 12 Critical Pathways 13 Documenting the Nursing Process 13 Chapter 2: The Patient Interview 17 The Patient Interview 18 The Role of the Nurse 18 The Role of the Patient 19 Factors Influencing the Interview 19 Approach 19 Environment 20 Confidentiality 20 HIPAA 20 Note Taking 21 Time, Length, Duration 21 Biases and Preconceptions 21 Stages of the Interview Process 21 Stage I 21 Stage II 22 Stage III 22 Factors Affecting Communication 22 Listening 22 Nonverbal Cues 22 Distance 23 Personal Space 23 Effective Interviewing Techniques 23 Using Open-Ended Questions 23 Using Closed Questions 24 Facilitating 24 Using Silence 24 Grouping Communication Techniques 25 Nontherapeutic Interviewing Techniques 31 Requesting an Explanation 31 Probing 31 Offering False Reassurance 32 Giving Approval or Disapproval 32 Defending 33 Advising 33 Using Problematic Questioning Techniques 34 Interviewing the Patient with Special Needs 36 The Patient Who Is Hearing-Impaired 36 The Patient Who Is Visually Impaired 36 The Patient Who Is Speech-Impaired or Aphasic 36 The Patient Who Is Non-English-Speaking 37 The Patient Who Has a Low Level of Understanding 37 The Patient Who Is Crying 37 The Patient Who Is Anxious and Angry 38 The Patient Who Is Hostile 38 The Patient Who Is Sexually Aggressive 38 The Patient Who Is under the Influence of Alcohol or Drugs 38 The Patient Who Is Very Ill 39 The Older Adult 39 Chapter 3: The Complete Health History Including Documentation 43 Types of Health History 44 Preparing for the Health History 44 Computerized Health History 45 Identifying Information 45 Today's Date 45 Biographical Data 46 The Complete Health History Assessment Tool 46 Source and Reliability of Information 46 Patient Profile 46 Reason for Seeking Health Care and Chief Complaint 46 Present Health and History of the Present Illness 47 Past Health History 49 Family Health History 55 Social History 56 Health Maintenance Activities 64 Review of Systems 67 Concluding the Health History 69 Documentation 69 The System-Specific Health History 71 Complete Health History: Well Patient 71 Complete Health History: Ill Patient 75 Unit 2: Special Assessments 85 Chapter 4: Developmental Assessment 87 Developmental Theories 88 Ages and Stages Developmental Theories 89 Developmental Stages, Tasks, and Life Events 94 Developmental Tasks of Infants (Birth to 1 Year) 95 Developmental Tasks of Toddlers (1 to 3 Years) 99 Developmental Tasks of Preschoolers (3 to 6 Years) 100 Developmental Tasks of School-Age Children (6 to 12 Years) 101 Developmental Tasks of Adolescents (12 to 18 Years) 102 Developmental Tasks of Young Adults (18 to 30 Years) 103 Developmental Tasks of Early Middle Adulthood (30 to 50 Years) 103 Developmental Tasks of Late Middle Adulthood (50 to 70 Years) 104 Developmental Tasks of Late Adulthood (70 Years to Death) 105 Stages of Family Development 106 Developmental Assessment Tools 107 Case Study: The Infant with Failure to Thrive 110 Chapter 5: Cultural Assessment 115 Culturally Competent Nursing Care 116 Basic Concepts Associated with Culturally Competent Assessments 118 Culture 118 Subculture 118 Racial Groups 118 Ethnic Groups 119 Minority Groups 119 Values, Norms, and Value Orientations 119 Beliefs 121 Customs and Rituals 126 Case Study: A Young Egyptian American Woman with Oligomenorrhea 138 Chapter 6: Spiritual Assessment 145 Spirituality and Religion 146 Spiritual Theory 147 Holistic Health and Spirituality 149 Role of the Nurse in Spiritual Care 166 Spiritual Assessment 167 Nursing Diagnosis 169 Planning and Implementation 170 Evaluation 172 Case Study: The Spiritual Side of the Withdrawal of Life Support 173 Chapter 7: Nutritional Assessment 177 Dietary Guidelines 178 Nutrients 186 Carbohydrates 186 Proteins 186 Fats 187 Vitamins 187 Minerals 187 Water 190 Nutrition through the Life Cycle 192 Children 192 Adolescents 195 Young and Middle-Aged Adults 197 Pregnant and Lactating Women 198 Older Adults 199 Cultural Differences 200 Health History 201 Equipment 203 Nutritional Assessment 203 The Nutritional History 203 Physical Assessment 205 Anthropometric Measurements 206 Laboratory Data 212 Diagnostic Data 216 Case Study: The Patient Who Is Obese 217 Unit 3: Physical Assessment 227 Chapter 8: Physical Assessment Techniques 229 Aspects of Physical Assessment 230 Role of the Nurse 230 Standard Precautions and Transmission-Based Precautions 230 Handwashing 232 Legal Issues 232 Assessment Techniques 232 Inspection 233 Palpation 233 Percussion 235 Auscultation 238 Equipment 240 Chapter 9: General Survey, Vital Signs, and Pain 245 General Survey 246 Physical Presence 246 Psychological Presence 248 Distress 249 Vital Signs 250 Respiration 250 Pulse 251 Temperature 254 Blood Pressure 257 Pain 263 Nociceptive Pain 263 Neuropathic Pain 264 Types of Pain 264 Variables Affecting Pain 265 Effects of Pain on the Body 265 Assessing Pain 265 Chapter 10: Skin, Hair, and Nails 271 Anatomy and Physiology 272 Skin 272 Hair 275 Nails 275 Function of Skin 276 Function of Hair 276 Function of Nails 276 Health History 277 Equipment 283 Assessment of the Skin, Hair, and Nails 283 Inspection of the Skin 283 Palpation of the Skin 303 Inspection of the Hair 305 Palpation of the Hair 307 Inspection of the Nails 308 Palpation of the Nails 311 Gerontological Variations 311 Case Study: The Patient with Pityriasis Rosea 313 Chapter 11: Head, Neck, and Regional Lymphatics 319 Anatomy and Physiology 320 Skull 320 Face 320 Neck 321 Thyroid 321 Lymphatics 321 Blood Supply 322 Health History 322 Equipment 326 Assessment of the Head and Neck 327 Inspection of the Shape of the Head 327 Palpation of the Head 327 Inspection and Palpation of the Scalp 327 Inspection of the Face 328 Palpation and Auscultation of the Mandible 330 Inspection and Palpation of the Neck 331 Inspection of the Thyroid Gland 332 Palpation of the Thyroid Gland 332 Auscultation of the Thyroid Gland 333 Inspection of the Lymph Nodes 333 Palpation of the Lymph Nodes 334 Gerontological Variations 335 Case Study: The Patient with Cervical Strain 335 Chapter 12: Eyes 341 Anatomy and Physiology 342 External Structures 342 Internal Structures 343 Visual Pathway 344 Health History 345 Equipment 348 Assessment of the Eye 348 Visual Acuity 349 Visual Fields 351 External Eye and Lacrimal Apparatus 352 Extraocular Muscle Function 355 Anterior Segment Structures 358 Posterior Segment Structures 364 Gerontological Variations 369 Case Study: The Patient with Entropion 370 Chapter 13: Ears, Nose, Mouth, and Throat 375 Anatomy and Physiology 376 Ear 376 Nose 377 Sinuses 378 Mouth and Throat 379 Health History 381 Equipment 386 Assessment of the Ear 386 Auditory Screening 386 External Ear 387 Otoscopic Assessment 389 Assessment of the Nose 394 External Inspection 394 Patency 394 Internal Inspection 394 Assessment of the Sinuses 396 Inspection 396 Palpation and Percussion 396 Assessment of the Mouth and Throat 398 Assessment of the Mouth 398 Inspection of the Throat 405 Gerontological Variations 407 Case Study: The Patient with Otitis Externa 407 Chapter 14: Breasts and Regional Nodes 413 Anatomy and Physiology 414 Breasts 414 Regional Nodes 417 Breast Development 417 Health History 417 Equipment 420 Assessment of the Female Breasts and Regional Nodes 420 Inspection of the Breasts 421 Palpation 424 Inspection and Palpation of the Male Breasts 431 Diagnostic Techniques 431 Gerontological Variations 431 Case Study: The Patient with Spontaneous Nipple Discharge of the Left Breast 433 Chapter 15: Thorax and Lungs 439 Anatomy 440 Thorax 440 Sternum 441 Ribs 441 Intercostal Spaces 441 Lungs 441 Pleura 445 Mediastinum 445 Bronchi 445 Alveoli 445 Diaphragm 445 External Intercostal Muscles 446 Accessory Muscles 446 Physiology 446 Ventilation 446 External Respiration 446 Internal Respiration 446 Control of Breathing 446 Health History 447 Equipment 451 Assessment of the Thorax and Lungs 451 Inspection 451 Palpation 461 Percussion 465 Auscultation 468 Gerontological Variations 476 Case Study: The Patient with Pneumonia 477 Chapter 16: Heart and Peripheral Vasculature 483 Anatomy and Physiology 484 Heart 484 Coronary Circulation 486 Cardiac Cycle 487 Excitation of the Heart 489 Peripheral Vasculature 490 Epitrochlear Nodes 494 Health History 494 Equipment 507 Assessment of the Precordium 507 Inspection 508 Palpation 511 Auscultation 513 Assessment of the Peripheral Vasculature 519 Inspection of the Jugular Venous Pressure 519 Inspection of the Hepatojugular Reflux 521 Palpation and Auscultation of Arterial Pulses 521 Inspection and Palpation of Peripheral Perfusion 524 Palpation of the Epitrochlear Node 528 Gerontological Variations 528 Case Study: The Patient with Chest Pain 529 Chapter 17: Abdomen 537 Anatomy and Physiology 538 Abdominal Cavity 538 Abdominal Viscera (Organs) 543 Health History 545 Equipment 551 Assessment of the Abdomen 551 Inspection 552 Auscultation 557 Percussion 559 Palpation 562 Gerontological Variations 570 Case Study: The Patient with Appendicitis 571 Chapter 18: Musculoskeletal System 577 Anatomy and Physiology 578 Bones 578 Muscles 578 Tendons 579 Cartilage 579 Ligaments 579 Bursae 580 Joints 580 Health History 582 Equipment 587 Assessment of the Musculoskeletal System 587 General Assessment 588 Inspection 591 Palpation 595 Range of Motion (ROM) 597 Muscle Strength 598 Examination of Joints 599 Gerontological Variations 632 Case Study: The Patient with Musculoskeletal Pain 634 Chapter 19: Mental Status and Neurological Techniques 641 Anatomy and Physiology 642 Macrostructure 642 Meninges 642 Central Nervous System 643 Blood Supply 646 Peripheral Nervous System 647 Reflexes 649 Health History 649 Equipment 655 Assessment of the Neurological System 655 Mental Status 655 Sensory Assessment 670 Cranial Nerves 674 Motor System 680 Cerebellar Function (Coordination, Station, and Gait) 681 Reflexes 683 Gerontological Variations 688 Case Study: The Patient with a Metastatic Brain Tumor 689 Chapter 20: Female Genitalia 697 Anatomy and Physiology 698 External Female Genitalia 698 Internal Female Genitalia 699 The Female Reproductive Cycle 702 Health History 704 Equipment 708 Assessment of the Female Genitalia 709 Inspection of the External Genitalia 711 Palpation of the External Genitalia 716 Speculum Examination of the Internal Genitalia 718 Collecting Specimens for Cytological Smears and Cultures 721 Inspection of the Vaginal Wall 725 Bimanual Examination 725 Rectovaginal Examination 729 Gerontological Variations 730 Case Study: The Patient with Herpes Simplex Virus 731 Chapter 21: Male Genitalia 737 Anatomy 738 Essential Organs 738 Accessory Organs 738 Ducts 738 Supporting Structures 740 Sexual Development 740 Physiology 740 Spermatogenesis 740 Male Sexual Function 742 Health History 742 Equipment 746 Assessment of the Male Genitalia 746 Inspection 746 Palpation 753 Auscultation 759 Gerontological Variations 759 Case Study: The Patient with Erectile Dysfunction Due to Hypogonadism 761 Chapter 22: Anus, Rectum, and Prostate 767 Anatomy and Physiology 768 Rectum 768 Anus 768 Prostate 769 Health History 770 Equipment 774 Assessment of the Anus, Rectum, and Prostate 774 Inspection 775 Palpation 777 Gerontological Variations 782 Case Study: The Patient with Acute Bacterial Prostatitis 782 Unit 4: Special Populations 789 Chapter 23: Pregnant Patient 791 Anatomy and Physiology 792 Skin and Hair 792 Head and Neck 792 Eyes, Ears, Nose, Mouth, and Throat 793 Breasts 793 Thorax and Lungs 793 Heart and Peripheral Vasculature 793 Abdomen 794 Urinary System 795 Musculoskeletal System 795 Neurological System 795 Female Genitalia 796 Anus and Rectum 797 Hematological System 797 Endocrine System 797 Health History 798 Equipment 804 Assessment of the Pregnant Patient 804 General Assessment, Vital Signs, and Weight 805 Skin and Hair 808 Head and Neck 809 Eyes, Ears, Nose, Mouth, and Throat 809 Breasts 810 Thorax and Lungs 810 Heart and Peripheral Vasculature 810 Abdomen 810 Urinary System 811 Musculoskeletal System 811 Neurological System 812 Female Genitalia 812 Uterine Size 812 Fetal Heart Rate 815 Leopold's Maneuver 816 Hematological System 817 Endocrine System 818 Nutritional Assessment 818 Special Antepartum Tests and Evaluations 818 Psychosocial Assessment and Learning Needs 818 Subsequent or Return Prenatal Visits 821 Case Study: The Pregnant Patient 821 Chapter 24: Pediatric Patient 829 Physical Growth 830 Anatomy and Physiology 835 Structural and Physiological Variations 835 Health History 839 Growth and Development 845 Developmental Assessment 845 Equipment 848 Physical Assessment 848 Vital Signs 850 Physical Growth 851 Skin 854 Hair 856 Head 856 Eyes 858 Ears 861 Mouth and Throat 863 Neck 864 Breasts 865 Thorax and Lungs 865 Heart and Peripheral Vasculature 867 Abdomen 870 Musculoskeletal System 872 Neurological System 875 Female Genitalia 879 Male Genitalia 880 Anus 882 Case Study: The Patient with Hypoplastic Left Heart Syndrome (HLHS) 882 Unit 5: Putting It All Together 891 Chapter 25: The Complete Health History and Physical Examination 893 Legal Considerations 895 Ethical Considerations 895 Health History 896 Physical Assessment 896 General Survey 896 Neurological System 897 Measurements 897 Skin 897 Head and Face 898 Eyes 898 Ears 898 Nose and Sinuses 898 Mouth and Throat 898 Neck 899 Upper Extremities 899 Back, Posterior and Lateral Thoraxes 899 Anterior Thorax 899 Heart 900 Female Breasts 900 Male Breasts 900 Jugular Veins 900 Female and Male Breasts 900 Heart 900 Abdomen 901 Inguinal Area 901 Lower Extremities 901 Neurological System 901 Musculoskeletal System 902 Neurological System 902 Female Genitalia, Anus, and Rectum 902 Male Genitalia 903 Male Anus, Rectum, and Prostate 903 Laboratory and Diagnostic Data 904 Problem List 904 Preparticipation Athletic Evaluation 905 Healthy People 2010 905 Role of Technology 905 Conclusion 906 Health History 906 Case Study: The Patient with Multisystem Problems 906 Appendix A: NANDA Nursing Diagnoses 2005/2006 915 Appendix B: Functional Assessments 917 Appendix C: ISMP List of Error-Prone Abbreviations, Symbols, and Dose Designations 919 Glossary 921 Index 941 Perforated Pages at Back of Book 000 Assessment in Brief 000 Family Health History 000 Review of Symptoms 000 Health History Forms 000 Abbreviations and Symbols Inside Back Cover
Library of Congress Subject Headings for this publication:
Nursing assessment.
Physical diagnosis.
Nursing Assessment.
Physical Examination -- nursing.