Canadian Nursing Health Assessment

Contents
cknowledgments/Inspiration/Dedication v
ontributors vi
eviewers viii
eface ix
Unit 1 Foundations of Nursing Health
Assessment 1
1 Health Assessment in Nursing Practice 3
Professional Nursing Practice 4
Advocacy 5
Scholarship and Research 5
Registered Nurse and Advanced Practice Nurse Roles 5
Purposes of Health Assessment 6
Wellness and Health Promotion 6
Health Promotion and Health Assessment 6
Focused Health History Related to the Case Study 6
Risk Assessment and Health Promotion 7
The Nursing Process 7
Phases of the Nursing Process 7
Assessment 8
Analysis 8
Planning Goals and Outcomes 8
Planning Care 8
Intervention/Implementation 8
Evaluation 8
Critical Thinking 9
Clinical Reasoning 9
Types of Health Assessments 9
Urgent Assessment 9
Comprehensive Assessment 10
Focused Assessment 11
Priority-Setting 11
Frequency of Health Assessment 11
Lifespan Issues 12
Cultural and Environmental Considerations 12
Components of the Health Assessment 13
Documentation and Communication 14
Organizing Frameworks for Health Assessment 14
Evidence-Informed Critical Thinking 15
2 Interviewing and Therapeutic Communication 19
Communication Process 20
Nonverbal Communication Skills 22
Verbal Communication Skills 22
Active Listening 22
Restatement 23
Reflection 23
Elaboration (Facilitation) 23
Silence 23
Focusing 24
Clarification 24
Summarizing 24
Nontherapeutic Responses 24
Failing to Listen 24
False Reassurance 24
Sympathy 24
Giving Advice 24
Being Judgmental 25
Changes of Subject 25
Distractions 25
Technical or Overwhelming Language 26
Interrupting 26
Professional Expectations 26
Intercultural Communication 26
Patients with Limited Language Understanding 27
Working with an Interpreter 27
Gender and Sexual Orientation Issues 28
Phases of the Interview Process 28
Preinteraction Phase 28
Beginning Phase 29
Working Phase 29
Closing Phase 29
Lifespan Issues 30
Newborns and Infants 31
Children and Adolescents 31
Older Adults 31
Special Situations 32
Patients with Hearing Impairment 32
Patients with Altered Level of Consciousness 32
Patients with Cognitive Impairment 32
Patients with Mental Health Illness 32
Patients with Anxiety 33
Patients Who Are Crying 33
Patients Who Are Angry 33
Patients under the Influence of Alcohol or Drugs 33
Personal Questions 33
Sexual Aggression 33
3 The Health History 37
Subjective and Objective Data 38
Signs and Symptoms 38
Primary and Secondary Data Sources 39
Reliability of the Source 39
Components of the Health History 39
Date and Time of Health History 39
Demographic Data or Identifying Data 39
Reason for Seeking Care or Chief Concern 40
Present Illness 40
Pain Goal 42
Functional Goal 42
Past Health History 42Current Medications and Indications 42
Family History 43
Functional Health Assessment 44
Growth and Development 44
Review of Systems 46
Psychosocial and Lifestyle Factors 47
Social, Cultural, and Spiritual Assessment 48
Mental Health 48
Alcohol and Substance Use 48
Human Violence 48
Sexual History and Orientation 49
Lifespan Considerations 49
Women Who Are Pregnant 49
Newborns, Children, and Adolescents 49
Aging Adults 49
4 Physical Examination Techniques
and Equipment 53
Overview of Anatomical Terms 54
Anatomical Position 54
Anatomical Quadrants 54
Anatomical Regions 54
Anatomical Terms of Comparison and Movement 55
Routine Practices and Additional Precautions 55
Hand Hygiene 56
Routine Practices 57
Additional Precautions 58
Latex Allergy 58
Skin Reactions 59
Cultural Considerations 59
Subjective Data Collection 59
Objective Data Collection 60
Promoting Patient Comfort, Dignity, and Safety 60
Inspection 60
Palpation 61
Light Palpation 61
Deep Palpation 62
Characteristics of Sound and Sound Transmission 62
Percussion 62
Direct Percussion 63
Indirect Percussion 63
Auscultation 64
Advanced Techniques 65
Lifespan Considerations 66
Older Adults 66
Women Who Are Pregnant 67
Newborns and Infants 67
Children and Adolescents 67
5 Documentation and Interprofessional
Communication 70
Patient Health Record 71
Purposes of the Patient Health Record 71
Legal Document 71
Communication and Planning Care 71
Quality Assurance 71
Education 72
Research 72
Components of the Patient Health Record 72
Principles Governing Documentation 73
Confidential 73
Accurate and Complete 74
Organized 75
Timely 75
Concise 75
Critical Thinking and Clinical Judgment 76
Nursing Admission Assessment 76
Flow Sheets 76
Plan of Care/Clinical Pathway 81
Progress Notes 81
Narrative Notes 81
SOAP Notes 83
PIE Notes 83
Focus Notes 83
Charting by Exception 84
Discharge Note 84
Written Handoff Summary 84
Verbal Communication 84
Verbal Handoff 84
Reporting 85
Qualities of Effective Reporting 85
SBAR 85
Reporting with Other Health Care Professionals 85
Telephone Communication 86
Patient Rounds and Conferences 86
Critical Thinking and Clinical Judgment 87
Unit 2 General Examinations 91
6 General Survey and Vital Signs Assessment 93
Cultural Considerations 94
Urgent Assessment 94
Risk Assessment and Health Promotion 94
Objective Data Collection 95
Promoting Patient Comfort, Dignity, and Safety 95
General Survey: General Inspection 95
Anthropometric Measurements 97
Vital Signs 99
Temperature 100
Pulse 103
Respirations 106
Blood Pressure 107
Vital Signs Monitor 113
Doppler Technique 114
Evidence-Informed Critical Thinking 114
Lifespan Considerations 115
Older Adults 115
Infants and Children 117
7 Pain Assessment 126
Anatomy and Physiology and Theories of Pain 127
Gate Control Theory 128
Nociception: Peripheral Nervous System 128
Nociception: Central Nervous System 128
Pain Classification 129
Duration: Acute Pain 129
Duration: Chronic (Persistent) Pain 129Form: Nociceptive Pain 130
Form: Neuropathic Pain 130
Location 130
Etiology 130
Association with Cancer 131
Cultural Considerations 131
Urgent Assessment 131
Subjective Data Collection 131
Assessment of Risk Factors 131
Health Promotion 131
Focused Health History Related to Common Symptoms/
Signs 134
Pain Measurement Tools 135
One-Dimensional Pain Scales 135
Multidimensional Pain Scales 136
Special Situations 136
Patients Unable to Report Pain 136
Patients with Opioid Tolerance 137
Objective Data Collection 140
Equipment 140
Promoting Patient Comfort, Dignity, and Safety 140
Comprehensive Physical Examination: Pain 141
Evidence-Informed Critical Thinking 143
Clinical Reasoning 143
Reassessing and Documenting Pain 144
Lifespan Considerations 144
Older Adults 146
Anatomy and Physiology Overview 146
Subjective and Objective Data 147
Women Who Are Pregnant 147
Anatomy and Physiology Overview 147
Subjective and Objective Data 147
Newborns, Infants, and Children 148
Anatomy and Physiology Overview 148
Subjective and Objective Data 148
8 Nutrition Assessment 152
Nutritional Concepts 153
Primary Nutrients 153
Carbohydrates 153
Proteins 153
Lipids 153
Vitamins and Minerals 154
Water 155
Food, Nutrients, Supplements, and Drug
Interactions 156
Food Safety 156
Nutritional Guidelines 156
Types of Reference Values 156
Canada’s Food Guide 157
Nutrition Care Process 159
Collecting Nutritional Data 159
Sexual Orientation and Gender Identity
Considerations 160
Cultural Considerations 160
Urgent Assessment 160
Subjective Data Collection 160
Assessment of Risk Factors 160
Risk Assessment and Health Promotion 164
Focused Health History Related to Nutrition-Associated
Comprehensive Nutritional History 164
Dietary Assessment Tools 164
Direct Observation 166
Objective Data Collection 167
Promoting Patient Comfort, Dignity, and Safety 167
Initial Survey and Focused Physical
Examination 167
Evidence-Informed Critical Thinking 175
Organizing and Prioritizing 175
Common Laboratory and Diagnostic Testing 175
Serum Proteins 175
Hemoglobin and Hematocrit 175
Lymphocyte Count 175
Creatinine Excretion 175
Nitrogen Balance 175
Skin Testing 175
Serum Lipid Measurements 175
Other Laboratory Tests 176
Clinical Reasoning 176
Nursing Analysis, Outcomes, and Interventions 176
Lifespan Considerations 177
Older Adults 177
Anatomy and Physiology Overview 177
Objective Data Collection 178
Women Who Are Pregnant 179
Anatomy and Physiology Overview 179
Objective Data Collection 181
Infants and Children 181
Anatomy and Physiology Overview 181
Objective Data Collection 182
Adolescents 182
Anatomy and Physiology Overview 182
Objective Data Collection 184
9 Psychosocial and Cognitive Development 192
Subjective Data Collection 193
Psychosocial Development 193
Infant: Trust versus Mistrust 193
Toddler: Autonomy versus Shame and Doubt 193
Preschooler: Initiative versus Guilt 193
School-Age Child: Industry versus Inferiority 193
Adolescent: Identity versus Role Confusion 193
Early Adult: Intimacy versus Isolation 195
Middle Adult: Generativity versus
Self-Absorption 195
Late Adult: Ego Integrity versus Despair 195
Cognitive Development 196
Infant: Sensorimotor 196
Toddler and Preschooler: Preoperational 196
School-Age Child: Concrete Operational 197
Adolescent: Formal Operations 197
Young Adult: Formal Operations 198
Middle Adult: Cognitive Expertise 198
Older Adult: Wisdom 199
Language Development 200
Cultural Considerations 200
Urgent Assessment 202
Objective Data Collection 202
Physical Growth 202
Motor Development 203 10 Mental Health Assessment 210
Mental Health and Psychiatric Assessment in Nursing
Practice 212
Cultural Considerations 212
Urgent Assessment 212
Subjective Data Collection 213
Risk Assessment and Health Promotion 213
Anxiety 213
Depression 214
Suicide 214
Dementia 215
Substance Use Problems 216
Assessment of Risk and Protective Factors 217
Objective Data Collection 223
Initial Survey and Mental Status Assessment 223
Assessment of Dementia, Delirium, and Depression 232
Evidence-Informed Critical Thinking 234
Clinical Reasoning 234
11 Social, Cultural, and Spiritual
Health Assessment 246
Models of Health 247
Social Assessment 248
Social Assessment of the Individual 248
Social Assessment of the Community 249
Social Assessment at the Societal Level 249
Cultural Assessment 252
Characteristics of Culture 252
Goals of Cultural Assessment 253
Cultural Health Beliefs and Practices 253
Cultural Food and Nutrition Practices 254
Cultural Beliefs and Practices of Pregnancy and
Childbirth 255
Cultural Beliefs and Expressions of Illness and
Pain 255
Spiritual Assessment 256
Evidence-Informed Critical Thinking 259
Nursing Analysis, Outcomes, and Interventions 259
12 Human Violence Assessment 264
Types of Human Violence 265
Family Violence 265
Child Maltreatment 265
Sibling Violence 265
Intimate Partner Violence 265
Elder Abuse 267
Violence against Adults with Disabilities 267
Youth and School Violence 268
“Punking” and Bullying 268
Workplace Violence 268
Sexual Violence 268
Hate Crimes 268
Human Trafficking 268
War-Related and Military Violence 269
Importance of Violence/Safety Assessment 269
Trauma-Informed Care 269
Subjective Data Collection 270
Interviewing Patients about Human Violence 270
Objective Data Collection 272
Documentation 273
Mandated Reporting 273
Lifespan Considerations 274
Women Who Are Pregnant 274
Infants, Children, and Adolescents 274
Older Adults 275
Cultural Considerations 275
Evidence-Informed Critical Thinking 275
Nursing Analysis, Outcomes, and Interventions 275
Unit 3 Regional Examinations 283
13 Skin, Hair, and Nails Assessment 285
Anatomy and Physiology Overview 286
Skin 286
Epidermis 286
Dermis 287
Subcutaneous Layer 287
Hair 287
Nails 288
Sweat Glands 288
Cultural Considerations 288
Urgent Assessment 288
Subjective Data Collection 289
Assessment of Risk Factors 289
Risk Assessment and Health Promotion 296
Focused Health History Related to Common
Symptoms 297
Objective Data Collection 300
Promoting Patient Comfort, Dignity, and Safety 300
Common and Specialty or Advanced Techniques 300
Comprehensive Skin Assessment 300
Lifespan Considerations 304
Women Who Are Pregnant 304
Newborns and Infants 305
Newborns, Infants, Children, and Adolescents 305
Older Adults 306
Evidence-Informed Critical Thinking 309
Organizing and Prioritizing 309
Common Laboratory and Diagnostic Testing 309
Clinical Reasoning 309
Nursing Analysis, Outcomes, and
Interventions 309
14 Head and Neck with Lymphatics
and Vascular Assessment 343
Anatomy and Physiology Overview 344
The Head 344
The Neck 345
Trachea 346
Thyroid and Parathyroid Glands 347
Lymphatics 347
Cultural Considerations 347Urgent Assessment 347
Subjective Data Collection 348
Assessment of Risk Factors 348
Health Promotion 348
Focused Health History Related to Common
Symptoms 353
Objective Data Collection 353
Promoting Patient Comfort, Dignity, and Safety 353
Common and Advanced Techniques 353
Initial Survey 353
Evidence-Informed Critical Thinking 359
Organizing and Prioritizing 359
Common Laboratory and Diagnostic Testing 359
Clinical Reasoning 359
Nursing Analysis, Outcomes, and Interventions 359
Lifespan Considerations 361
Older Adults 361
Anatomy and Physiology Overview 361
Objective Data Collection 361
Women Who Are Pregnant 361
Anatomy and Physiology Overview 361
Objective Data Collection 362
Newborns and Infants 362
Anatomy and Physiology Overview 362
Objective Data Collection 363
Children and Adolescents 363
Anatomy and Physiology Overview 363
Objective Data Collection 363
15 Eyes and Vision Assessment 371
Anatomy and Physiology Overview 372
Extraocular Structures 372
Extraocular Muscle Function 372
Intraocular Structures 373
Vision 374
Cultural Considerations 374
Urgent Assessment 375
Subjective Data Collection 375
Assessment of Risk Factors 375
Health Promotion 375
Focused Health History Related to Common
Symptoms 375
Objective Data Collection 379
Promoting Patient Comfort, Dignity, and Safety 379
Common and Advanced Techniques 380
Assessment of Visual Acuity 380
Assessment of Visual Fields 380
Assessment of Extraocular Muscle Movements 388
Assessment of External Eyes 388
Assessment of Internal Ocular Structures 388
Evidence-Informed Critical Thinking 391
Organizing and Prioritizing 391
Common Lab and Diagnostic Tests 391
Lifespan Considerations 393
Older Adults 393
Women Who Are Pregnant 394
Anatomy and Physiology Overview 394
Objective Data Collection 396
Newborns, Preschoolers, Children, and Adolescents 396
Newborns 396
16 Ears and Hearing Assessment 410
Anatomy and Physiology Overview 411
External Ear 411
Middle Ear 411
Inner Ear 411
Hearing 411
Air and Bone Conduction 413
Hearing Disorders 413
Vestibular Function 414
Cultural Considerations 414
Urgent Assessment 414
Subjective Data Collection 415
Assessment of Risk Factors 415
Health Promotion 415
Focused Health History Related to Common
Symptoms 417
Objective Data Collection 419
Promoting Patient Comfort, Dignity,
and Safety 419
Evidence-Informed Critical Thinking 419
Organizing and Prioritizing 419
Common Laboratory and Diagnostic Testing 428
Clinical Reasoning 428
Lifespan Considerations 428
Older Adults 428
Women Who Are Pregnant 429
Newborns, Infants, and Children 429
Adolescents 431
17 Nose, Sinuses, Mouth,
and Throat Assessment 439
Anatomy and Physiology Overview 440
Nose 440
Sinuses 441
Mouth 442
Tongue 442
Salivary Glands 443
Teeth and Gums 444
Throat 444
Cultural Considerations 444
Urgent Assessment 445
Subjective Data Collection 445
Assessment of Risk Factors 446
Risk Assessment and Health Promotion 449
Focused Health History Related to Common
Symptoms/Signs 450
Cultural Considerations 452
Objective Data Collection 453
Promoting Patient Comfort, Dignity, and Safety 453
Common and Advanced Techniques 453
Comprehensive Physical Examination: Nose, Sinuses,
Mouth, and Throat 454
Cultural Considerations 459
Evidence-Informed Critical Thinking 460
Organizing and Prioritizing: Common Laboratory
and Diagnostic Testing 460
Clinical Reasoning: Nursing Analysis, Outcomes,
and Interventions 461
Lifespan Considerations 463Anatomy and Physiology Overview 463
Subjective Data Collection 463
Women Who Are Pregnant 464
Anatomy and Physiology Overview 464
Subjective Data Collection 464
Newborns and Infants 464
Anatomy and Physiology Overview 464
Objective Data Collection 465
Children and Adolescents 466
Anatomy and Physiology Overview 466
Subjective Data Collection 467
Objective Data Collection 467
18 Thorax, Lungs, and Respiratory Assessment 480
Anatomy and Physiology Overview 481
The Thorax 481
Anterior Thoracic Landmarks 481
Posterior Thoracic Landmarks 483
Reference Lines 483
Lobes of the Lungs 483
Lower Respiratory Tract 484
Upper Respiratory Tract 486
Mechanics of Respiration 486
Cultural Considerations 486
Urgent Assessment 486
Subjective Data Collection 487
Assessment of Risk Factors 487
Health Promotion 487
Smoking Cessation 487
Radon Detection in the Home 488
Prevention of Occupational Exposure 488
Prevention of Asthma 488
Immunizations 488
Focused Health History Related to Common
Symptoms 492
Objective Data Collection 496
Promoting Patient Comfort, Dignity, and Safety 496
Common and Advanced Techniques 497
Evidence-Informed Critical Thinking 509
Organizing and Prioritizing 509
Common Laboratory and Diagnostic Testing 509
Clinical Reasoning 510
Nursing Analysis, Outcomes, and Interventions 510
Lifespan Considerations 512
Older Adults 512
Anatomy and Physiology Overview 512
Objective Data Collection 512
Women Who Are Pregnant 512
Anatomy and Physiology 512
Objective Data Collection 513
Newborns and Infants 513
Anatomy and Physiology 513
Objective Data Collection 513
Children and Adolescents 514
Anatomy and Physiology 514
Subjective Data Collection 514
Objective Data Collection 515
19 Cardiovascular Assessment 525
Neck V essels 526
Heart Chambers 528
Valves 528
Heart Wall 528
Coronary Arteries and V eins 528
Conduction System 529
Physiology 529
Pulmonary and Systemic Circulation 529
Cardiac Cycle 529
Jugular Pulsations 531
Cultural Considerations 531
Urgent Assessment 532
Subjective Data Collection 534
Assessment of Risk Factors and Health Promotion 534
Smoking Cessation 534
Control of Blood Pressure and Cholesterol Level 534
Control of Weight and Stress 534
Focused Health History Related to Common Symptoms
and Signs 537
Objective Data Collection 540
Promoting Patient Comfort, Dignity, and Safety 540
Initial Survey 541
Auscultation of the Precordium 546
Extra Sounds 548
Murmurs 548
Evidence-Informed Critical Thinking 552
Organizing and Prioritizing 552
Common Laboratory and Diagnostic Testing 552
Clinical Reasoning 553
Lifespan Considerations 554
Older Adults 554
Anatomy and Physiology Overview 554
Objective Data Collection 555
Women Who Are Pregnant 555
Anatomy and Physiology Overview 555
Objective Data Collection 556
Newborns and Infants 556
Anatomy and Physiology Overview 556
Objective Data Collection 556
Children and Adolescents 556
Anatomy and Physiology Overview 556
Objective Data Collection 557
20 Peripheral Vascular and Lymphatic
Assessment 570
Anatomy and Physiology Overview 571
Arterial System 571
Venous System 571
Capillaries 572
Lymphatic System 573
Fascia Compartments of the Limbs 573
Cultural Considerations 574
Urgent Assessment 574
Subjective Data Collection 575
Assessment of Risk Factors 576
Risk Assessment and Health Promotion 577
Patients with Peripheral Arterial Disease 577
Patients with Venous Disease 578
Patients with Lymphatic Disorders 578
Focused Health History Related to Common Symptoms Objective Data Collection 581
Promoting Patient Comfort, Dignity, and Safety 581
Initial Survey 582
Evidence-Informed Critical Thinking 592
Organizing and Prioritizing 592
Common Laboratory and Diagnostic Testing 592
Clinical Reasoning 593
Nursing Analysis, Outcomes, and Interventions 593
Lifespan Considerations 594
Older Adults 594
Anatomy and Physiology Overview 594
Objective Data Collection 595
Women Who Are Pregnant 595
Anatomy and Physiology Overview 595
Objective Data Collection 595
Newborns, Children, and Adolescents 596
Anatomy and Physiology Overview 596
Objective Data Collection 596
21 Breasts and Axillae Assessment 607
Anatomy and Physiology Overview 608
Landmarks 608
Breast Structures 608
Axillae and Lymph Nodes 609
Cultural Considerations 611
Urgent Assessment 612
Subjective Data Collection 613
Assessment of Risk Factors and Health Promotion 613
Teaching the “Know Your Breasts” Approach 614
Focused Health History Related to Common Symptoms
and Signs 617
Objective Data Collection 621
Promoting Patient Comfort, Dignity, and Safety 621
Initial Survey 621
Evidence-Informed Critical Thinking 629
Organizing and Prioritizing 629
Laboratory and Diagnostic Testing 629
Clinical Reasoning 629
Nursing Analysis, Outcomes, and
Interventions 629
Lifespan Considerations 631
Older Adults 631
Women Who Are Pregnant/Lactating 631
Newborns and Infants 631
Children and Adolescents 631
22 Abdominal Assessment 638
Anatomy and Physiology Overview 639
Anatomical Landmarks 639
Reference Lines 639
Abdominal Organs 639
Gastrointestinal Organs 639
Genitourinary Organs 639
Blood Vessels, Peritoneum, and Muscles 642
Ingestion and Digestion 643
Absorption of Nutrients 643
Elimination 643
Cultural Considerations 643
Urgent Assessment 643
Subjective Data Collection 644
Assessment of Risk Factors 644
Health Promotion 644
Focused Health History Related to Common Symptoms/
Signs 648
Objective Data Collection 653
Promoting Patient Comfort, Dignity, and Safety 653
Initial Survey 653
Evidence-Informed Critical Thinking 666
Organizing and Prioritizing 666
Common Laboratory and Diagnostic Testing 667
Esophagogastroduodenoscopy 667
Barium Enema 667
Colonoscopy 667
Endoscopic Retrograde
Cholangiopancreatography 667
Computerized Tomography Scan 667
Magnetic Resonance Imaging 667
Clinical Reasoning 667
Lifespan Considerations 669
Older Adults 669
Anatomy and Physiology Overview 669
Objective Data Collection 670
Women Who Are Pregnant 670
Anatomy and Physiology Overview 670
Objective Data Collection 671
Newborns, Infants, and Children 671
Anatomy and Physiology Overview 671
Objective Data Collection 671
23 Musculoskeletal Assessment 684
Anatomy and Physiology Overview 685
Bones 685
Muscles 685
Joints 686
Temporomandibular Joint 686
Shoulder 686
Elbow 688
Wrist and Hand 688
Hip 689
Knee 689
Ankle and Foot 690
Spine 690
Cultural Considerations 691
Urgent Assessment 691
Subjective Data Collection 691
Assessment of Risk Factors 691
Health Promotion 691
Back Injury Prevention and Occupational
Hazards 692
Lifestyle Considerations 692
Fall Risk 692
Bone Density 692
Psychosocial History 693
Focused Health History Related to Common
Symptoms/Signs 695
Objective Data Collection 698
Promoting Patient Comfort, Dignity, and Safety 698
Advanced Techniques 698Comprehensive Physical Examination: The
Musculoskeletal System 701
Evidence-Informed Critical Thinking 721
Organizing and Prioritizing 721
Laboratory and Diagnostic Testing 721
Clinical Reasoning 721
Nursing Analysis, Outcomes, and Interventions 721
Lifespan Considerations 723
Older Adults 723
Anatomy and Physiology Overview 723
Subjective Data Collection 724
Objective Data Collection 724
Women Who Are Pregnant 724
Subjective Data Collection 724
Objective Data Collection 725
Newborn and Infants 725
Subjective Data Collection 725
Objective Data Collection 726
Children and Adolescents 726
Subjective Data Collection 726
Objective Data Collection 727
24 Neurological Assessment 739
Anatomy and Physiology Overview 740
Central Nervous System 740
Brain 740
Protective Structures of the CNS 744
Spinal Cord 744
Peripheral Nervous System 746
Cranial Nerves 747
Spinal Nerves 747
Autonomic Nervous System 747
Cultural Considerations 748
Urgent Assessment 749
Subjective Data Collection 750
Assessment of Risk Factors 750
Health Promotion 750
Stroke Prevention 750
Injury Prevention 751
Reduction of Risk for Seizure Activity 751
Focused Health History Related to Common
Symptoms 753
Objective Data Collection 755
Promoting Patient Comfort, Dignity, and Safety 755
Neurological Assessment in Selected Situations 755
Screening Examination of a Healthy Patient 755
Serial Neurological Assessment and
Documentation 755
Assessment of Meningeal Signs 755
Assessing the Unconscious Patient 755
Brain Herniation Syndromes 757
Initial Survey 757
Focused Physical Examination: Neurological
System 757
Evidence-Informed Critical Thinking 777
Organizing and Prioritizing 777
Common Laboratory and Diagnostic Testing 777
Clinical Reasoning 778
Lifespan Considerations 779
Older Adults 779
Women Who Are Pregnant 780
Anatomy and Physiology Overview 780
Objective Data Collection 781
Newborns and Infants 781
Anatomy and Physiology Overview 781
Objective Data Collection 781
Children and Adolescents 782
Anatomy and Physiology Overview 782
Objective Data Collection 783
25 Male Genitalia and Rectal Assessment 797
Anatomy and Physiology Overview 798
External Genitalia 798
Internal Genitalia 799
Testes 799
Ducts 799
Secretory Structures 800
Rectum and Anus 800
Rectum 800
Anal Canal and Anus 800
Cultural Considerations 800
Urgent Assessment 801
Subjective Data Collection 801
Risk Assessment and Health Promotion 801
Testicular Self-Examination (TSE) 802
Screening for Prostate Cancer 802
Safer Sexual Practices 802
Protection during Contact Sports 803
Focused Health History Related to Common Symptoms
and Signs 805
Cultural Considerations 807
Objective Data Collection 808
Promoting Patient Comfort, Dignity, and Safety 808
Focused Physical Assessment: Male Genitalia and Rectal
Assessment 808
Evidence-Informed Critical Thinking 816
Organizing and Prioritizing 816
Common Laboratory and Diagnostic Testing 816
Clinical Reasoning 817
Nursing Analysis, Outcomes, and
Interventions 817
Lifespan Considerations 818
Older Adult 818
Anatomy and Physiology Overview 818
Objective Data Collection 818
Infants and Children 818
Anatomy and Physiology Overview 818
Objective Data Collection 819
Adolescents 820
Anatomy and Physiology Overview 820
Objective Data Collection 821
26 Female Genitalia and Rectal Assessment 835
Anatomy and Physiology Overview 836
External Genitalia 836
Internal Genitalia 836
Vagina 836
Uterus 836
Cervix 836Rectum, Anal Canal, and Anus 837
Hormone Regulation 837
Cultural Considerations 838
Urgent Assessment 839
Excessive V aginal Bleeding 839
Abdominal Pain 839
Bartholin Gland Infection 839
Pelvic Inflammatory Disease 839
Ruptured Tubal Pregnancy 839
Subjective Data Collection 839
Human Papillomavirus 840
Risk Assessment and Health Promotion 845
Human Papillomavirus 845
Female Genital Mutilation 846
Focused Health History Related to Common Symptoms/
Signs 846
Objective Data Collection 850
Promoting Patient Comfort, Dignity, and Safety 850
Advanced Techniques 851
Evidence-Informed Critical Thinking 863
Common Laboratory and Diagnostic Testing 863
Nursing Analysis, Outcomes, and Interventions 863
Lifespan Considerations 864
Older Adults 864
Women Who Are Pregnant 865
Newborns and Infants 865
Children and Adolescents 865
Unit 4 Special Populations 881
27 Women Who Are Pregnant 883
Anatomy and Physiology Overview 884
Preconception 884
First Trimester 885
Second Trimester 885
Third Trimester 886
Determining Weeks of Gestation 886
Role of the Nurse in the Outpatient Setting 887
Cultural Considerations 888
Urgent Assessment 888
Subjective Data Collection 889
Assessment of Risk Factors 889
Risk Assessment and Health Promotion 891
Focused Health History Related to Common Symptoms/
Signs in Pregnancy 894
Objective Data Collection 897
Promoting the Woman’s Comfort, Dignity, and Safety 898
Assessment during the Initial Visit 898
Assessment during Routine Pregnancy Visits 901
Evidence-Informed Critical Thinking 906
Common Laboratory and Diagnostic Testing 906
Nonstress Test 906
Leopold Manoeuvres 906
Clinical Reasoning 909
Plan of Care, Interventions, and Outcomes 909
28 Newborns and Infants 914
Anatomy and Physiology Overview 915
Motor Development 915
Language, Psychosocial, and Cognitive
Development 915
Urgent Assessment 915
Emergent Concerns 915
Subjective Data Collection 916
Assessment of Risk Factors 916
Risk Assessment and Health Promotion 917
Safe Sleep Habits 917
Choking 918
Immunization Schedules 918
Child Safety Car Seat 919
Cardiopulmonary Resuscitation Training for
Parents 919
Poison Control 919
Breast-feeding and Iron-rich Foods 919
Baby Bottle Tooth Decay 920
Focused Health History Related to Common Symptoms/
Signs 920
Objective Data Collection 923
Promoting Patient Comfort, Dignity, and Safety 923
Comprehensive Physical Examination: Newborn and
Infant 923
Documentation of Examination Findings 941
Cultural Considerations 941
Evidence-Informed Critical Thinking 941
Organizing and Prioritizing 941
Common Laboratory and Diagnostic Testing 941
Clinical Reasoning 941
Nursing Analysis, Outcomes, and Interventions 941
29 Children and Adolescents 953
Anatomy and Physiology Overview 954
Physical Growth 954
Motor Development 954
Language 954
Psychosocial and Cognitive Development 955
Cultural Considerations 955
Urgent Assessment 955
Subjective Data Collection 955
Important Topics for Health Promotion 961
Focused Health History Related to Common
Symptoms 961
Cultural Considerations 963
Objective Data Collection 964
Equipment 964
Promoting Patient Comfort, Dignity, and Safety 964
Developmental Assessment 964
Evidence-Informed Critical Thinking 974
Common Laboratory and Diagnostic Testing 974
Clinical Reasoning 974
30 Older Adults 979
Anatomy and Physiology Overview 980
Skin, Hair, and Nails 980
Head and Neck 981
Eyes and Vision 981
Ears and Hearing 981
Nose, Mouth, and Throat 981Peripheral Vascular and Lymphatics 982
Breasts and Lymphatics 982
Abdomen, Metabolism, and Elimination 982
Musculoskeletal 982
Neurological 982
Male and Female Genitourinary 983
Endocrine 983
Immune System 983
Frailty and Geriatric Syndromes 983
Cultural Considerations 983
Urgent Assessment 983
Subjective Data Collection 984
Interviewing the Older Adult 984
Assessment of Risk Factors 984
Health Promotion 986
Cultural Considerations 992
Objective Data Collection 994
Promoting Patient Comfort, Dignity, and Safety 994
Comprehensive Physical Examination: The Older
Adult 994
Instruments 994
Evidence-Informed Critical Thinking 1007
Organizing and Prioritizing 1007
Common Laboratory and Diagnostic Testing 1007
Clinical Reasoning 1007
Nursing Analysis, Outcomes, and Interventions 1007
31 Individuals with Obesity 1012
Demographics of Obesity 1013
Measuring Obesity 1013
Edmonton Obesity Staging System 1013
Contributors to Obesity 1014
Day-to-Day Struggles 1014
Psychology of Obesity 1015
Social Injustice Related to Obesity 1015
Weight Bias 1015
RESPECT: A Model for the Sensitive Treatment of the
Bariatric Patient 1016
Anatomy and Physiology Overview 1016
Vital Signs 1016
Pain 1016
Blood Pressure 1017
Pulse 1017
Temperature 1017
Oxygen Saturation 1017
Respirations 1017
Skin 1017
Head and Neck 1017
Torso 1018
Extremities 1018
Genitalia 1018
Endocrine and Metabolic Functioning 1019
Dyslipidemia/Hyperlipidemia 1019
Cultural Considerations 1019
Urgent Assessment 1020
Subjective Data Collection 1020
Assessment of Risk Factors 1020
Health Promotion 1020
Building Self-Esteem and Confidence 1021
Physical Activity 1021
Nutrition Assessment 1021
Bariatric Consultation 1021
Medications 1021
Surgical Health-Promoting Options 1022
Gastric Bypass 1022
Vertical Sleeve Gastrectomy 1022
Duodenal Switch 1022
Focused Health History Related to Selected Common
Symptoms and Signs 1024
Objective Data Collection 1026
Promoting Patient Comfort, Dignity, and Safety 1026
Comprehensive Physical Examination: The Individual
with Obesity 1026
Initial Survey 1026
Physical Examination 1026
Evidence-Informed Critical Thinking 1029
Organizing and Prioritizing 1029
Common Laboratory and Diagnostic Testing 1029
Diagnostic Imaging 1029
Clinical Reasoning 1029
Lifespan Considerations 1030
Older Adults 1030
Women Who Are Pregnant 1031
Children and Adolescents 1031
Unit 5 Pulling It All Together 1037
32 A Complete Health Assessment 1039
Acute Assessment 1040
Subjective Data Collection 1040
Areas for Health Promotion 1040
Assessment of Risk Factors 1040
Demographic Data 1041
History of Present Concern or Illness 1041
Past Health History 1042
Growth and Development 1042
Review of Systems 1043
Psychosocial History 1043
Functional Health Status 1043
Activities of Daily Living 1044
Assessment of Risk Factors and Health Promotion 1044
Focused Health History Related to Common
Symptoms 1044
Objective Data Collection 1044
Promoting Patient Comfort, Dignity, and Safety 1045
Comprehensive Physical Examination 1045
Lifespan and Cultural Considerations 1054
Inpatient Assessment 1055
Comprehensive Admitting Assessment 1055
Screening Inpatient Assessment 1055
Focused Inpatient Assessment 1056
Evidence-Informed Critical Thinking 1056
Common Laboratory and Diagnostic Testing 1056
Clinical Reasoning 1056
Answers to Review Questions 1063
Illustration Credit List 1064
Index 1068