NURSES' HANDBOOK OF HEALTH ASSESSMENT This title has been archived.

Author: Janet Weber, EdD, RN
Affiliation: Southeast Missouri State University; Cape Girardeau, MO
Publisher: Lippincott Williams & Wilkins
Publication Date: 2008
ISBN 10: 078176632X
ISBN 13: 9780781766326
Edition: 6th

Description:

Renowned for its holistic perspective and "see and do" approach, this full-color, pocket-sized handbook offers step-by-step guidance on every phase of the nursing assessment-for adults, children, and special populations. The focus is on what nurses need to know to assess clients: the health history, physical examination, normal and abnormal findings, nursing interventions, and nursing diagnoses. This edition features new chapters on pain assessment and domestic violence assessment, a new Spanish-to-English terminology appendix, more illustrations of examination techniques, and greater emphasis on deviations from normal findings.

Table of Contents

Front Matter

  • ABOUT
  • DISCLAIMER
  • DEDICATION
  • Contributors
  • Preface

THE NURSING HEALTH HISTORY

  • DEFINITION AND PURPOSE
  • NURSING MODEL VERSUS MEDICAL MODEL
  • GUIDELINES FOR OBTAINING A NURSING HEALTH HISTORY

COMPONENTS OF THE NURSING HEALTH HISTORY

  • HEALTH HISTORY BY FUNCTIONAL HEALTH PATTERN
  • CLIENT PROFILE
  • DEVELOPMENTAL HISTORY
  • HEALTH PERCEPTION–HEALTH MANAGEMENT PATTERN
  • NUTRITIONAL–METABOLIC PATTERN
  • ELIMINATION PATTERN
  • ACTIVITY–EXERCISE PATTERN
  • SEXUALITY–REPRODUCTION PATTERN
  • SLEEP–REST PATTERN
  • SENSORY–PERCEPTUAL PATTERN
  • COGNITIVE PATTERN
  • ROLE–RELATIONSHIP PATTERN
  • SELF-PERCEPTION–SELF-CONCEPT PATTERN
  • COPING–STRESS TOLERANCE PATTERN
  • VALUE–BELIEF PATTERN

PHYSICAL ASSESSMENT

  • PHYSICAL ASSESSMENT SKILLS
  • BASIC GUIDELINES FOR PHYSICAL ASSESSMENT
  • VARIATIONS IN PHYSICAL ASSESSMENT OF THE PEDIATRIC CLIENT
  • VARIATIONS IN PHYSICAL ASSESSMENT OF THE GERIATRIC CLIENT

GENERAL PHYSICAL SURVEY

  • Equipment Needed
  • Subjective Data: Focus Questions
  • Objective Data: Assessment Techniques
  • GENERAL PHYSICAL SURVEY
  • PEDIATRIC VARIATIONS
  • GERIATRIC VARIATIONS
  • CULTURAL VARIATIONS
  • TEACHING TIPS FOR SELECTED NURSING DIAGNOSES AND COLLABORATIVE PROBLEMS

PAIN ASSESSMENT: THE FIFTH VITAL SIGN

  • EQUIPMENT/TOOLS NEEDED
  • CLASSIFICATION OF PAIN
  • PHYSIOLOGIC RESPONSES TO PAIN
  • SUBJECTIVE DATA: FOCUS QUESTIONS
  • PRESENT HEALTH CONCERNS
  • PAST HEALTH HISTORY
  • FAMILY HISTORY
  • LIFESTYLE AND HEALTH PRACTICES
  • COLLECTING OBJECTIVE DATA
  • GENERAL OBSERVATION
  • VITAL SIGNS
  • TEACHING TIPS FOR SELECTED NURSING DIAGNOSES

NUTRITIONAL ASSESSMENT

  • Equipment Needed
  • Subjective Data: Focus Questions
  • Objective Data: Assessment Techniques
  • GENERAL INSPECTION
  • ANTHROPOMETRIC MEASUREMENTS
  • DIETARY ASSESSMENT
  • PEDIATRIC VARIATIONS
  • GERIATRIC VARIATIONS
  • CULTURAL VARIATIONS
  • TEACHING TIPS FOR SELECTED NURSING DIAGNOSES

SKIN, HAIR, AND NAIL ASSESSMENT

  • ANATOMY OVERVIEW
  • SKIN INSPECTION AND PALPATION
  • HAIR INSPECTION AND PALPATION
  • SCALP INSPECTION AND PALPATION
  • NAIL INSPECTION AND PALPATION
  • PEDIATRIC VARIATIONS
  • GERIATRIC VARIATIONS
  • CULTURAL VARIATIONS
  • TEACHING TIPS FOR SELECTED NURSING DIAGNOSES

HEAD AND NECK ASSESSMENT

  • ANATOMY OVERVIEW
  • SCALP, FACE, AND NECK INSPECTION AND PALPATION
  • TRACHEA, THYROID, AND LYMPH NODE PALPATION
  • PEDIATRIC VARIATIONS
  • GERIATRIC VARIATIONS
  • TEACHING TIPS FOR SELECTED NURSING DIAGNOSES

EYE ASSESSMENT

  • ANATOMY OVERVIEW
  • EXTERNAL EYE EXAMINATION
  • EYE FUNCTION TESTING
  • PEDIATRIC VARIATIONS
  • GERIATRIC VARIATIONS
  • CULTURAL VARIATIONS
  • TEACHING TIPS FOR SELECTED NURSING DIAGNOSES

EAR ASSESSMENT

  • ANATOMY OVERVIEW
  • PEDIATRIC VARIATIONS
  • GERIATRIC VARIATIONS
  • CULTURAL VARIATIONS
  • TEACHING TIPS FOR SELECTED NURSING DIAGNOSES

MOUTH, THROAT, NOSE, AND SINUS ASSESSMENT

  • ANATOMY OVERVIEW
  • MOUTH AND OROPHARYNX ASSESSMENT
  • INSPECTION AND PALPATION
  • PEDIATRIC VARIATIONS
  • GERIATRIC VARIATIONS
  • CULTURAL VARIATIONS
  • TEACHING TIPS FOR SELECTED NURSING DIAGNOSES AND COLLABORATIVE PROBLEMS
  • NOSE AND SINUS ASSESSMENT
  • INSPECTION
  • PALPATION
  • PERCUSSION
  • GERIATRIC VARIATIONS
  • TEACHING TIPS FOR SELECTED NURSING DIAGNOSES AND COLLABORATIVE PROBLEMS

THORACIC AND LUNG ASSESSMENT

  • ANATOMY OVERVIEW
  • INSPECTION
  • PALPATION
  • PERCUSSION
  • AUSCULTATION
  • PEDIATRIC VARIATIONS
  • GERIATRIC VARIATIONS
  • CULTURAL VARIATIONS
  • TEACHING TIPS FOR SELECTED NURSING DIAGNOSES

BREAST ASSESSMENT

  • ANATOMY OVERVIEW
  • INSPECTION
  • PALPATION
  • MALE VARIATIONS
  • PEDIATRIC VARIATIONS
  • GERIATRIC VARIATIONS
  • CULTURAL VARIATIONS
  • TEACHING TIPS FOR SELECTED NURSING DIAGNOSES

HEART ASSESSMENT

  • ANATOMY OVERVIEW
  • INSPECTION
  • PALPATION
  • PERCUSSION
  • AUSCULTATION
  • PEDIATRIC VARIATIONS
  • GERIATRIC VARIATIONS
  • CULTURAL VARIATIONS
  • TEACHING TIPS FOR SELECTED NURSING DIAGNOSES

PERIPHERAL VASCULAR ASSESSMENT

  • ANATOMY OVERVIEW
  • INSPECTION, PALPATION, AND AUSCULTATION OF CIRCULATION TO ARMS AND NECK
  • INSPECTION AND PALPATION OF JUGULAR VENOUS PRESSURE AND CIRCULATION OF LOWER EXTREMITIES
  • CULTURAL VARIATIONS
  • GERIATRIC VARIATIONS
  • TEACHING TIPS FOR SELECTED NURSING DIAGNOSES AND COLLABORATIVE PROBLEMS

ABDOMINAL ASSESSMENT

  • ANATOMY OVERVIEW
  • INSPECTION
  • AUSCULTATION
  • PERCUSSION
  • PALPATION
  • PEDIATRIC VARIATIONS
  • INSPECTION
  • PALPATION
  • GERIATRIC VARIATIONS
  • TEACHING TIPS FOR SELECTED NURSING DIAGNOSES

GENITOURINARY ASSESSMENT

  • ASSESSMENT OF FEMALE GENITALIA
  • INSPECTION
  • PALPATION
  • BIMANUAL EXAMINATION
  • ASSESSMENT OF MALE GENITALIA
  • INSPECTION
  • PALPATION
  • ASSESSMENT OF INGUINAL AREA
  • INSPECTION
  • PALPATION
  • ASSESSMENT OF RECTUM
  • INSPECTION
  • PEDIATRIC VARIATIONS
  • CULTURAL VARIATIONS
  • GERIATRIC VARIATIONS
  • TEACHING TIPS FOR SELECTED NURSING DIAGNOSES AND COLLABORATIVE PROBLEMS

MUSCULOSKELETAL ASSESSMENT

  • OVERVIEW OF ANATOMY
  • INSPECTION OF STANCE AND GAIT
  • INSPECTION OF THE SPINE, SHOULDER, AND POSTERIOR ILIAC CREST
  • PALPATION OF THE SPINE, SHOULDER, AND POSTERIOR ILIAC CREST
  • INSPECTION OF THE HEAD, THORAX, AND NECK
  • PALPATION OF THE HEAD, THORAX, AND NECK
  • INSPECTION OF THE UPPER EXTREMITIES
  • PALPATION OF THE UPPER EXTREMITIES
  • INSPECTION OF THE LOWER EXTREMITIES
  • PALPATION OF THE LOWER EXTREMITIES
  • PEDIATRIC VARIATIONS
  • GERIATRIC VARIATIONS
  • CULTURAL VARIATIONS
  • TEACHING TIPS FOR SELECTED NURSING DIAGNOSES

NEUROLOGIC ASSESSMENT

  • ANATOMY OVERVIEW
  • MENTAL STATUS ASSESSMENT
  • PEDIATRIC VARIATIONS
  • NORMAL VARIATIONS
  • CULTURAL VARIATIONS
  • GERIATRIC VARIATIONS
  • TEACHING TIPS FOR SELECTED NURSING DIAGNOSES
  • CRANIAL NERVE ASSESSMENT
  • GERIATRIC VARIATIONS
  • TEACHING TIPS FOR SELECTED NURSING DIAGNOSES
  • SENSORY NERVE ASSESSMENT
  • GERIATRIC VARIATIONS
  • TEACHING TIPS FOR SELECTED NURSING DIAGNOSES
  • MOTOR ASSESSMENT
  • CEREBELLAR ASSESSMENT
  • GERIATRIC VARIATIONS
  • REFLEX ASSESSMENT
  • PEDIATRIC VARIATIONS: BIRTH TO 1 YEAR
  • GERIATRIC VARIATIONS
  • TEACHING TIPS FOR SELECTED NURSING DIAGNOSIS

ASSESSMENT OF THE CHILDBEARING WOMAN

  • PRENATAL MATERNAL ASSESSMENT
  • PRENATAL FETAL ASSESSMENT
  • CULTURAL VARIATIONS
  • TEACHING TIPS FOR SELECTED NURSING DIAGNOSES
  • INTRAPARTUM MATERNAL ASSESSMENT
  • TEACHING TIPS FOR SELECTED NURSING DIAGNOSES
  • POSTPARTUM MATERNAL ASSESSMENT
  • TEACHING TIPS FOR SELECTED NURSING DIAGNOSES

ASSESSMENT OF NEWBORNS AND INFANTS

  • Equipment Needed
  • Subjective Data: Focus Questions
  • Objective Data: Assessment Techniques
  • APGAR SCORE ASSESSMENT
  • ASSESSMENT OF VITAL SIGNS AND MEASUREMENTS
  • ASSESSMENT OF GESTATIONAL AGE
  • PHYSICAL ASSESSMENT
  • TEACHING TIPS FOR SELECTED NURSING DIAGNOSES

ASSESSMENT OF FAMILIES USING VIOLENCE

  • OVERVIEW OF FAMILY VIOLENCE
  • ASSESSMENT PROCEDURE
  • PEDIATRIC VARIATIONS
  • GERIATRIC VARIATIONS
  • CULTURAL VARIATIONS
  • TEACHING TIPS FOR SELECTED NURSING DIAGNOSES

Appendices

    APPENDIX 1 Nursing Assessment Form Based on Functional Health Patterns

    APPENDIX 2 Physical Assessment Guide

    APPENDIX 3 Developmental Information—Age 1 Month to 18 Years

    APPENDIX 4 Recommended Childhood and Adolescent Immunization Schedule

    APPENDIX 5 Recommended Adult Immunization Schedules

    APPENDIX 6 Psychosocial Development

    APPENDIX 7 Height–Weight–Head Circumference Charts for Children

    APPENDIX 8 How to Examine Your Own Skin

    APPENDIX 9 Breast Self-Examination (BSE)

    APPENDIX 10 Testicular Self-Examination

    APPENDIX 11 Classification and Management of Blood Pressure for Adults*

    APPENDIX 12 Sample Adult Nursing Health History and Physical Assessment

    APPENDIX 13 Assessment of Family Functional Health Patterns

    APPENDIX 14 Nursing Diagnoses (Wellness, Risk, and Actual) Grouped According to Functional Health Patterns

    APPENDIX 15 Collaborative Problems

    APPENDIX 16 Spanish Translation for Nursing Health History and Physical Examination

References and Bibliography