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Nurses' Handbook of Health Assessment
9. NANDA Approved Nursing Diagnoses 2015-2017
Table of Contents
Free Topics
1-1 Generic Nursing History Format Summary - Assessment Tool(s)
1-1 Sample Application of COLDSPA: Exploring the Symptoms of Back Pain - Box
16: Assessing Breasts and Lymphatic System
2-4 Types of Percussion - Table
2-6 Uses for Diaphragm and Bell of Stethoscope - Table
3: Validating, Analyzing, Documenting, and Communicating Data
3-1 Differentiation of Nursing Diagnoses from Collaborative Problems - Fig
4-1 Freud's Psychosexual Stages of Development - Table
4-3 Jean Piaget's Stages of Cognitive Development - Table
4-3 This Father, in his Early Middle Adult Years, Enjoys Traveling with his Teenage Daughter and Sharing with Her his Knowledge of History and Culture - Fig
5: Assessing Mental Status and Substance Abuse
6-3 Timing the Radial Pulse Rate - Fig
6-5 Measuring the Circumference of an Infant's Head - Fig
7-1 Faces Pain Rating Scale - Box
7-2 Areas of Referred Pain - Fig
8: Assessing for Violence
9-3 Myplate/Mywins - Fig
9-5 Mid-Arm Muscle Circumference (MAMC) Standard Reference - Table
Anthropometric Measurements
Calculator - APGAR Score - Calculator
Calculator - GDS-5/15 Geriatric Depression Scale - Calculator
Contributors
Functional Health Pattern Framework
Guidelines for Obtaining a Nursing Health History
Introduction
Nursing Assessment
Nursing Assessment of the Newborn and Infant
Preface
Reviewers
Structure and Function Overview
Teaching Tips for Selected Nursing Diagnoses
Teaching Tips For Selected Nursing Diagnoses
Teaching Tips for Selected Nursing Diagnoses and Collaborative Problems
Validating Data
Unit 1. Nursing Data Collection, Documentation, and Analysis
1: Obtaining a Nursing Health History: Guidelines and Frameworks
1: Obtaining a Nursing Health History: Guidelines and Frameworks
1-1 Generic Nursing History Format Summary - Assessment Tool(s)
1-1 Sample Application of COLDSPA: Exploring the Symptoms of Back Pain - Box
1-2 Example of Observations and Questions to Ask a Client From Another Culture - Box
1-3 Subjective and Objective Assessment Focus for Functional Health Patterns - Box
Frameworks for Collecting Client Data
Functional Health Pattern Framework
Guidelines for Obtaining a Nursing Health History
Introduction
2: Performing the Physical Assessment: Skills and Techniques
2: Performing the Physical Assessment: Skills and Techniques
2-1 Comparing Subjective and Objective Data - Table
2-2 Sensitivity of Parts of the Hand - Table
2-3 Types of Palpation - Table
2-4 Types of Percussion - Table
2-5 Sounds (Tones) Elicited by Percussion - Table
2-6 Uses for Diaphragm and Bell of Stethoscope - Table
Basic Guidelines for Physical Assessment
Physical Assessment Skills
3: Validating, Analyzing, Documenting, and Communicating Data
3: Validating, Analyzing, Documenting, and Communicating Data
3-1 Comparison of Health Promotion, Risk, Actual, and Syndrome Nursing Diagnoses - Table
3-1 Differentiation of Nursing Diagnoses from Collaborative Problems - Fig
3-1 SBAR (Situation, Background, Assessment, and Recommendation) - Box
3-2 Comparison of Nursing Diagnoses and Collaborative Problems - Table
3-3 Examples of Nursing Diagnoses, Collaborative Problems, and Medical Diagnoses - Table
3-4 Examples of Vague Versus Clear and Concise Documentation of Data - Table
Analyzing Data: Identifying Nursing Diagnoses, Collaborative Problems, and Medical Diagnoses or Referrals
Documenting Data
Introduction
Validating Data
Unit 1. Nursing Data Collection, Documentation, and Analysis
Unit 2. Integrative Holistic Nursing Assessment
4: Assessing Psychosocial, Cognitive, and Moral Development
4: Assessing Psychosocial, Cognitive, and Moral Development
4-1 Freud's Psychosexual Stages of Development - Table
4-1 Stereotypical Images of the Older Adult as Narrow Minded, Forgetful, Sexless, and Dependent are Untrue for Most of the Older Adult Population - Fig
4-2 Erik Erikson's Stages of Psychosocial Development - Table
4-2 This Young Couple Has Reached Erikson's Stage of Intimacy - Fig
4-3 Jean Piaget's Stages of Cognitive Development - Table
4-3 This Father, in his Early Middle Adult Years, Enjoys Traveling with his Teenage Daughter and Sharing with Her his Knowledge of History and Culture - Fig
4-4 Lawrence Kohlberg's Stages of Moral Development - Table
4-4 Older Adulthood Can be a Rich and Rewarding Time to Review Life Events - Fig
4-5 The Middle-Aged Adult is Able to Mentor Young Adults in the Workplace Because He or She Has Increased Problem Solving Abilities and Life Experience - Fig
4-6 The Young Adult who Continually Exhibits Behavior That Negatively Affects the Comfort Zone of Others or Infringes on the Rights of Others is not Normal - Fig
Growth and Development Overview
Nursing Assessment
Teaching Tips for Selected Nursing Diagnoses
5: Assessing Mental Status and Substance Abuse
5: Assessing Mental Status and Substance Abuse
5-1 Glasgow Coma Scale - Box
5-2 Mental Status Examinations Tools - Box
5-3 Quick Inventory of Depressive Symptomatology (Self-Report) - Box
5-4 Sad Persons Suicide Risk Assessment Tool - Box
Conceptual Foundations
Nursing Assessment
Teaching Tips for Selected Nursing Diagnoses
6: Assessing General Health Status and Vital Signs
6: Assessing General Health Status and Vital Signs
6-1 Deviations Related to Physical Development, Body Build, and Fat Distribution - Abnormal Finding(s)
6-1 Mobile Monitoring System - Fig
6-1 Types of Respirations - Table
6-2 Categories for Blood Pressure Levels in Adults (Ages 18 and Older) - Table
6-2 Taking a Tympanic Temperature - Fig
6-3 Recommendations for Follow-Up Based on Initial Blood Pressure Measurements for Adults Without Acute End-Organ Damage - Table
6-3 Timing the Radial Pulse Rate - Fig
6-4 Pulse Rate in Child - Fig
6-5 Measuring the Circumference of an Infant's Head - Fig
Nursing Assessment
Structure and Function Overview
Teaching Tips for Selected Nursing Diagnoses and Collaborative Problems
7: Assessing Pain: The Fifth Vital Sign
7: Assessing Pain: The Fifth Vital Sign
7-1 Faces Pain Rating Scale - Box
7-1 Transduction, Transmission, Perception, and Modulation of Pain - Fig
7-2 Areas of Referred Pain - Fig
7-2 Mccaffery Initial Pain Assessment Tool - Box
7-3 Flacc Scale for Pediatric Pain Assessment - Box
7-3 Numeric Rating Scale (NRS) - Fig
Conceptual Foundations
Nursing Assessment
Teaching Tips for Selected Nursing Diagnoses
8: Assessing for Violence
8: Assessing for Violence
8-1 Abuse Assessment Screen - Box
8-2 Self-Assessment: Danger Assessment - Box
8-3 Assessing a Safety Plan - Box
Conceptual Foundations
Nursing Assessment
Teaching Tips for Selected Nursing Diagnoses
9: Assessing Nutritional Status
9: Assessing Nutritional Status
9-1 Adult Body Mass Index (BMI) Chart - Table
9-1 Measuring Mid-Arm Circumference - Fig
9-1 Speedy Checklist for Nutritional Health - Box
9-2 Disease Risk for Type 2 Diabetes, Hypertension, and Cardiovascular Diseases Relative to BMI and Waist Circumference - Table
9-2 Measuring Triceps Skinfold Thickness - Fig
9-2 Self-Assessment: Sample Form for a Nutrition History - Box
9-3 Edinburgh Feeding Evaluation in Dementia Questionnaire (Edfed-Q) - Box
9-3 Mid-Arm Circumference (MAC) Standard Reference - Table
9-3 Myplate/Mywins - Fig
9-4 Triceps Skinfold Thickness (TSF) Standard Reference - Table
9-5 Mid-Arm Muscle Circumference (MAMC) Standard Reference - Table
9-6 Estimated Calorie Needs Per Day by Age, Gender, and Physical Activity Level - Table
Anthropometric Measurements
Dietary Assessment
General Inspection
Nursing Assessment
Structure and Function Overview
Teaching Tips for Selected Nursing Diagnoses
Unit 2. Integrative Holistic Nursing Assessment
Unit 3. Nursing Assessment of Physical Systems
10: Assessing Skin, Hair, and Nails
10: Assessing Skin, Hair, and Nails
10-1 Braden Scale for Predicting Pressure Sore Risk - Box
10-1 Identification of Pressure Ulcer Stage - Assessment Tool(s)
10-1 Primary Skin Lesions - Abnormal Finding(s)
10-1 The Six Skin Types - Table
10-1 The Skin and Hair Follicles - Fig
10-2 Push Tool to Measure Pressure Ulcer Healing - Box
10-2 Secondary Skin Lesions (Changes in Primary Skin Lesions) - Abnormal Finding(s)
10-2 The Nail and Related Structures - Fig
10-3 Normal Angle - Fig
10-3 Self-Assessment: How to Examine Your Own Skin - Box
10-3 Vascular Lesions - Abnormal Finding(s)
10-4 Common Nail Disorders - Abnormal Finding(s)
10-4 Common Variations: Skin Variations - Box
10-4 Normal Creases - Fig
10-5 Simian Creases Seen in Down's Syndrome - Fig
10-6 Senile Lentigines are Common on Aging Skin - Fig
Nursing Assessment
Structure and Function Overview
Teaching Tips for Selected Nursing Diagnoses
11: Assessing Head and Neck
11: Assessing Head and Neck
11-1 Bones and Sutures of the Skull (Face and Cranium) - Fig
11-1 Types and Characteristics of Headaches - Box
11-2 Signs and Symptoms of Altered Thyroid Function - Box
11-2 Structures of the Neck - Fig
11-3 Abnormalities of the Head and Neck - Box
11-3 Neck Muscles and Landmarks - Fig
11-4 Palpating the Temporal Artery - Fig
11-5 Palpating the TMJ - Fig
11-6 Palpating the Thyroid - Fig
11-7 Auscultating for Bruits over the Thyroid Gland - Fig
11-8 Lymph Nodes - Fig
Nursing Assessment
Structure and Function Overview
Teaching Tips for Selected Nursing Diagnoses
12: Assessing Eyes
12: Assessing Eyes
12-1 Comprehensive Medical Eye Evaluation for Patients with Diabetes Mellitus or Risk Factors for Glaucoma - Table
12-1 External Structures of the Eye - Fig
12-1 Extraocular Muscle Function - Abnormal Finding(s)
12-1 Using the Ophthalmoscope - Assessment Tool(s)
12-10 Inspecting the Conjunctiva - Fig
12-11 Observe the Pupils with a Penlight or Similar Device, Test Pupillary Reaction to Light (Photo by B. Proud) - Fig
12-12 Checking Accommodation of Pupils - Fig
12-13 Palpating the Lacrimal Apparatus - Fig
12-14 Inspecting the Red Reflex - Fig
12-15 Normal Ocular Fundus (also Called the Optic Disc) - Fig
12-16 Outer Canthus is in Alignment with the Tip of the Pinna (Photo by B. Proud) - Fig
12-2 External Eye Examination: Deviations from Normal - Abnormal Finding(s)
12-2 The Lacrimal Apparatus Consists of Tear (Lacrimal) Glands and Ducts - Fig
12-3 Extraocular Muscles Control the Direction of Eye Movement - Fig
12-3 Pupil and Iris Abnormalities - Abnormal Finding(s)
12-4 Anatomy of the Eye - Fig
12-4 Ophthalmoscope Examination: Deviations From Normal - Abnormal Finding(s)
12-5 Normal Ocular Fundus - Fig
12-6 Checking Distance Vision - Fig
12-7 Checking Peripheral Vision - Fig
12-8 Performing the Cover/Uncover Test - Fig
12-9 Checking Extraocular Movements - Fig
Nursing Assessment
Structure and Function Overview
Teaching Tips for Selected Nursing Diagnoses
13: Assessing Ears
13: Assessing Ears
13-1 Abnormal External Ear Findings - Abnormal Finding(s)
13-1 Ten Ways to Recognize Hearing Loss - Box
13-1 The Ear - Fig
13-1 Using an Otoscope to Inspect the External Canal and the Tympanic Membrane - Assessment Tool(s)
13-2 Abnormal Tympanic Membrane Findings - Abnormal Finding(s)
13-2 Right Tympanic Membrane - Fig
13-3 Inspecting the External Ear - Fig
13-4 Using a Tuning Fork to Assess Auditory Function - Fig
13-5 Placement and Alignment of Pinna in Children - Fig
13-6 Infant Being Restrained in the Upright Position (Photo by B. Proud) - Fig
Nursing Assessment
Structure and Function Overview
Teaching Tips For Selected Nursing Diagnoses
14: Assessing Mouth, Throat, Nose, and Sinuses
14: Assessing Mouth, Throat, Nose, and Sinuses
14-1 Mouth and Throat Abnormalities - Abnormal Finding(s)
14-1 Structures of the Mouth - Fig
14-1 Using Otoscope with Wide-Tipped Attachment - Assessment Tool(s)
14-10 Torus Palatinus - Fig
14-11 Inspecting Oropharynx - Fig
14-12 Inspecting the Internal Nose - Fig
14-13 Nose - Fig
14-14 Nasal Polyp - Fig
14-15 Palpating Sinuses - Fig
14-16 Timetable for Eruption of Deciduous Teeth - Fig
14-2 Detecting and Grading Tonsillitis - Abnormal Finding(s)
14-2 Teeth - Fig
14-3 Salivary Glands - Fig
14-4 Nasal Cavity and Throat Structures - Fig
14-5 Inspecting the Open Mouth - Fig
14-6 Palpating the Lips - Fig
14-7 Inspecting the Buccal Mucosa - Fig
14-8 Fissured, Geographic Tongue - Fig
14-9 Inspecting Sides of Tongue - Fig
Nursing Assessment
Structure and Function Overview
Teaching Tips for Selected Nursing Diagnoses and Collaborative Problems
15: Assessing Thorax and Lungs
15: Assessing Thorax and Lungs
15-1 Altered Respiration Patterns - Abnormal Finding(s)
15-1 Anterior Thoracic Cage - Fig
15-1 Respiratory Rates in Children - Table
15-10 Percussing Bilaterally for Diaphragmatic Excursions - Fig
15-2 Adventitious Breath Sounds - Abnormal Finding(s)
15-2 Posterior Thoracic Cage - Fig
15-3 Vertical Lines, Imaginary Landmarks - Fig
15-4 View of Lung Position - Fig
15-5 Major Structures of the Respiratory System - Fig
15-6 Cross Section of Thorax - Fig
15-7 Cross Section of Barrel-Shaped Thorax - Fig
15-8 Palpation of Thoracic Expansion - Fig
15-9 Intercostal Landmarks for Percussion and Auscultation of Thorax - Fig
Nursing Assessment
Structure and Function Overview
Teaching Tips for Selected Nursing Diagnoses
16: Assessing Breasts and Lymphatic System
16: Assessing Breasts and Lymphatic System
16-1 Anatomic Breast Landmarks and Their Position in the Thorax - Fig
16-1 Breast Abnormalities Seen on Inspection - Abnormal Finding(s)
16-1 Self-Assessment: Breast Awareness and Self-Examination - Box
16-2 Abnormalities Noted on Palpation of the Breasts - Abnormal Finding(s)
16-2 Breast Quadrants - Fig
16-3 Internal Anatomy of the Breast - Fig
16-4 The Lymph Nodes Drain Impurities from the Breasts (Arrows Show Direction) - Fig
16-5 Arms - Fig
16-6 Patterns for Breast Palpation - Fig
16-7 Palpating Nipples for Masses and Discharge - Fig
16-8 Gynecomastia - Fig
Nursing Assessment
Structure and Function
Teaching Tips for Selected Nursing Diagnoses
17: Assessing Heart and Neck Vessels
17: Assessing Heart and Neck Vessels
17-1 Classification for Intensity, Pitch, and Quality of Murmurs - Table
17-1 The Heart and Major Blood Vessels Lie Centrally in the Chest Behind the Protective Sternum - Fig
17-11 Auscultating S1 and S2 - Fig
17-12 S3 Heart Sound - Fig
17-13 S4 Heart Sound - Fig
17-14 Location of Apex of Heart in (A) Infant, (B) Child, and (C) Adult - Fig
17-2 Average Heart Rate of Infants and Children at Rest - Table
17-2 Heart Chambers, Valves, and Direction of Circulatory Flow - Fig
17-3 The Cardiac Cycle Consists of Filling and Ejection - Fig
17-4 Assessing Jugular Venous Pressure - Fig
17-5 Auscultating the Carotid Arteries - Fig
17-6 Palpating the Carotid Arteries - Fig
17-7 Landmarks of the Chest - Fig
17-8 Areas to Palpate and Auscultate on the Chest - Fig
17-9 Locate the Apical Impulse with the Palmar Surface (A), and Then Palpate the Apical Pulse with the Fingerpad (B) - Fig
Nursing Assessment
Structure and Function Overview
Teaching Tips for Selected Nursing Diagnoses
18: Assessing Peripheral Vascular System
18: Assessing Peripheral Vascular System
18-1 Assessing Pulse Strength - Box
18-1 Comparison of Arterial and Venous Insufficiency - Table
18-1 Major Arteries of the Arms and Legs - Fig
18-10 Characteristic Ulcer - Fig
18-11 Pitting Edema - Fig
18-12 Palpating the Femoral Pulses - Fig
18-13 Auscultating the Femoral Pulse to Detect Bruits - Fig
18-14 Palpating the Popliteal Pulse with the Client (Top) Supine and (Bottom) Prone - Fig
18-15 Palpating the Dorsalis Pedis Pulse - Fig
18-16 Palpating the Posterior Tibial Pulse - Fig
18-17 Varicose Veins - Fig
18-18 Testing for Arterial Insufficiency by (Left) Elevating the Legs and Then (Right) Having the Client Dangle the Legs - Fig
18-19 Performing Manual Compression to Assess Competence of Venous Valves in Clients with Varicose Veins - Fig
18-2 Characteristics of Arterial and Venous Insufficiency - Table
18-2 Normal Capillary Circulation Ensures Removal of Excess Fluid (Edema) from the Interstitial Spaces as Well as Delivery of Oxygen and Nutrients and Removal of Carbon Dioxide - Fig
18-3 Major Veins of the Legs - Fig
18-4 Lymphatic Drainage - Fig
18-5 Superficial Lymph Nodes of the Arms and Legs - Fig
18-6 Palpating the Radial Pulse - Fig
18-7 Palpating the Ulnar Pulse - Fig
18-8 Palpating the Epitrochlear Lymph Nodes by Flexing the Client's Left Elbow about 90 Degrees - Fig
18-9 Allen Test - Fig
Nursing Assessment
Structure and Function Overview
Teaching Tips for Selected Nursing Diagnoses and Collaborative Problems
19: Assessing Abdomen
19: Assessing Abdomen
19-1 Abdominal Quadrants - Fig
19-1 Liver and Spleen Palpation - Assessment Tool(s)
19-1 Locating Abdominal Structures by Quadrants - Box
19-1 Mechanisms and Sources of Abdominal Pain - Abnormal Finding(s)
19-10 Performing Blunt Percussion over the Kidney - Fig
19-11 Performing Fluid Wave Test - Fig
19-12 Percussing for Level of Dullness with (A) Client Supine and (B) Client Lying on Side - Fig
19-13 Assessing for Rovsing's Sign - Fig
19-14 Test for Psoas Sign - Fig
19-15 Test for Obturator Sign - Fig
19-2 Abdominal Signs - Box
19-2 Abdominal Wall Muscles - Fig
19-2 Kidney Palpation - Assessment Tool(s)
19-3 Abdominal Viscera - Fig
19-4 Abdominal and Vascular Structures (Aorta and Iliac Artery and Vein) - Fig
19-5 View Abdominal Contour from the Client's Side - Fig
19-6 Vascular Sounds and Friction Rubs Can Best be Heard over These Areas - Fig
19-7 Abdominal Percussion Sequences May Proceed Clockwise or Up and Down over the Abdomen - Fig
19-8 Normal Liver Span - Fig
19-9 The Scratch Test - Fig
Structure and Function Overview
Teaching Tips for Selected Nursing Diagnoses
20: Assessing Musculoskeletal System
20: Assessing Musculoskeletal System
20-1 Abnormal Spinal Curves - Abnormal Finding(s)
20-1 Major Bones of the Skeleton - Fig
20-1 Ottawa Ankle Rules for X-Ray Referral - Box
20-1 Scale for Muscle Strength - Table
20-10 Normal Range of Motion of the Elbow - Fig
20-11 Squeeze Test (Hand) - Fig
20-12 Anatomic Snuffbox - Fig
20-13 Range of Motion of the Wrists - Fig
20-14 Tests for Carpal Tunnel Syndrome - Fig
20-15 Median Nerves Entrapped in the Carpal Tunnel Results in Pain, Numbness, and Impaired Function of the Hand and Fingers - Fig
20-16 Normal Range of Motion of the Fingers - Fig
20-17 Normal Range of Hip Motion - Fig
20-18 Normal Range of Motion of Knee - Fig
20-19 Squeeze Test (Foot) - Fig
20-2 Abnormal Upper and Lower Extremity Findings - Abnormal Finding(s)
20-2 Muscles of the Body - Fig
20-2 Normal Range of Motion for Joints of the Upper Extremities - Table
20-20 Normal Range of Motion of the Feet and Ankles - Fig
20-21 Genu Varum - Fig
20-22 Maneuver - Fig
20-23 Assessing Spinal Curvature for Scoliosis - Fig
20-3 Components of Synovial Joints (Right Hip Joint) - Fig
20-3 Normal Range of Motion for Joints of the Lower Extremities - Table
20-4 Normal Spinal Curves - Fig
20-5 Palpating the Temporomandibular Joint - Fig
20-6 Normal Range of Motion of Cervical Spine - Fig
20-7 Range of Motion of Trunk - Fig
20-8 Measuring True Leg Length - Fig
20-9 Normal Range of Motion of the Shoulder - Fig
Nursing Assessment
Structure and Function Overview
Teaching Tips for Selected Nursing Diagnoses
21: Assessing Neurologic System
21: Assessing Neurologic System
21-1 Eliciting Deep Tendon Reflexes - Assessment Tool(s)
21-1 Lobes of the Cerebral Hemispheres and Their Function - Table
21-1 Structure and Lobes of the Brain - Fig
21-10 Testing Cranial Nerves IX and X: Checking Uvula Rise and Gag Reflex - Fig
21-11 Testing Cranial Nerve XI: Assessing Strength of Trapezius Muscle - Fig
21-12 Testing Cranial Nerve XI: Assessing Strength of Sternocleidomastoid Muscle - Fig
21-13 Testing Balance: Tandem Walking - Fig
21-14 Hopping on One Foot - Fig
21-15 Testing Coordination: Finger-to-Nose Test - Fig
21-16 Testing Rapid Alternating Movements: Palms - Fig
21-17 Performing Heel-to-Shin Test - Fig
21-18 Decorticate Posture - Fig
21-19 Decerebrate Posture - Fig
21-2 Cranial Nerves: Type and Function - Table
21-2 Spinal Cord - Fig
21-20 Testing Position Sense (Kinesthesia) - Fig
21-21 Two-Point Discrimination - Fig
21-22 Eliciting Biceps Reflex - Fig
21-23 Eliciting Brachioradialis Reflex - Fig
21-24 Eliciting Triceps Reflex - Fig
21-25 Eliciting Patellar Reflex - Fig
21-26 Eliciting Achilles Reflex - Fig
21-27 Testing for Ankle Clonus - Fig
21-28 Eliciting Plantar Reflex - Fig
21-29 Abdominal Reflex - Fig
21-3 Sensory (Ascending) Neural Pathways - Fig
21-3 Two-Point Discrimination Findings - Table
21-30 Abdominal and Cremasteric Reflexes - Fig
21-4 Motor (Descending) Neural Pathways - Fig
21-5 Anterior and Posterior Dermatomes (Areas of the Skin Innervated by Spinal Nerves) - Fig
21-6 Testing Cranial Nerve I - Fig
21-7 Testing Sensory Function of Cranial Nerve V: Dull Stimulus Using a Paper Clip - Fig
21-8 Testing Corneal Reflex with Wisp of Cotton - Fig
21-9 Testing Motor Function of Cranial Nerve V - Fig
Nursing Assessment
Structure and Function Overview
Teaching Tips for Selected Nursing Diagnoses
22: Assessing Male Genitalia and Rectum
22: Assessing Male Genitalia and Rectum
22-1 Abnormalities of the Penis - Abnormal Finding(s)
22-1 External and Internal Male Genitalia - Fig
22-1 Self-Assessment: Testicular Self-Examination - Box
22-1 Tanner Sexual Maturity Rating: Male Genitalia Development and Pubic Hair Growth - Table
22-10 Palpating the Prostate Gland - Fig
22-2 Abnormalities of the Prostate Gland - Abnormal Finding(s)
22-2 Inguinal Area - Fig
22-3 Anal and Rectal Structures - Fig
22-4 Palpating for Urethral Discharge (Photo by B. Proud) - Fig
22-5 Palpating the Scrotal Contents (Photo by B. Proud) - Fig
22-6 Palpating for an Inguinal Hernia (Photo by B. Proud) - Fig
22-7 Selected Positions for Anorectal Examination - Fig
22-8 Inspecting the Perianal Area (Photo by B. Proud) - Fig
22-9 Palpating the Anus - Fig
Health Assessment
Structure and Function Overview
Teaching Tips for Selected Nursing Diagnoses and Collaborative Problems
23: Assessing Female Genitalia and Rectum
23: Assessing Female Genitalia and Rectum
23-1 Abnormalities of the External Genitalia and Vaginal Opening - Abnormal Finding(s)
23-1 External Female Genitalia - Fig
23-1 Tanner's Sexual Maturity Rating: Female Pubic Hair Growth and Breast Development - Table
23-1 Using a Speculum - Assessment Tool(s)
23-10 Hands Positioned for Rectovaginal Examination - Fig
23-2 Internal Female Reproductive System and Relationship to other Pelvic Structures Including the Rectum and Anus - Fig
23-2 Obtaining Tissue Specimens for Analysis - Assessment Tool(s)
23-3 Some of the Equipment Needed for Female Genitalia Examination - Fig
23-4 Inspecting the Labia Minora, Clitoris, Urethral Meatus, and Vaginal Opening - Fig
23-5 Technique for Palpating Bartholin Gland - Fig
23-6 Speculum Insertion for Inspection of Cervix - Fig
23-7 Palpating the Vaginal Walls - Fig
23-8 Palpating the Uterus - Fig
23-9 Palpating the Ovaries - Fig
Nursing Assessment
Structure and Function Overview
Teaching Tips for Selected Nursing Diagnoses and Collaborative Problems
Unit 3. Nursing Assessment of Physical Systems
Unit 4. Nursing Assessment of Special Groups
24: Assessing Childbearing Women
24: Assessing Childbearing Women
24-1 Distribution of Weight Gain during Pregnancy - Fig
24-1 Gravida/Para Status - Box
24-10 Measurement of the Descent of the Fundus - Fig
24-2 Pregnancy Pigmentation: Abdominal Midline (Lineanigra) and Striae Gravidarum - Fig
24-3 Marked Chloasma of Pregnancy - Fig
24-4 Breast Changes during Pregnancy - Fig
24-5 Measuring the Fundal Height - Fig
24-6 Approximate Height of Fundus at Various Weeks of Gestation - Fig
24-7 Assessment of Fetal Position and Station - Fig
24-8 Measuring Station of the Fetal Head While it is Descending - Fig
24-9 Involution of the Uterus - Fig
Intrapartum Maternal and Fetal Assessment
Introduction
Postpartum Maternal Assessment
Prenatal Maternal and Fetal Assessment
Teaching Tips for Selected Nursing Diagnoses
Teaching Tips for Selected Nursing Diagnoses
Teaching Tips for Selected Nursing Diagnoses
25: Assessing Newborns and Infants
25: Assessing Newborns and Infants
25-1 APGAR Score - Table
25-1 Newborn Reflexes: Differentiating Normal and Abnormal Findings - Box
25-1 Weighing the Newborn - Fig
25-10 The Infant Head - Fig
25-11 Caput Succedaneum - Fig
25-12 Umbilical Hernia - Fig
25-13 The Spine is Rounded in Infants Less Than the Age of 3 Months - Fig
25-2 New Ballard Scale - Fig
25-3 New Ballard Scale - Fig
25-4 Square Window Sign - Fig
25-5 Scarf Sign - Fig
25-6 Classification of Infant for Gestational Age - Fig
25-7 Mongolian Spots - Fig
25-8 Stork Bites - Fig
25-9 Palpating the Anterior Fontanelle - Fig
Introduction
Nursing Assessment of the Newborn and Infant
Teaching Tips for Selected Nursing Diagnoses
26: Assessing Older Adults
26: Assessing Older Adults
26-1 Assessment of Pain in Older Adult Clients with or Without Cognitive Impairment - Box
26-1 Solar Lentigines are Very Common on Aging Skin - Fig
26-2 Katz Activities of Daily Living - Box
26-2 Observe Facial Expression - Fig
26-3 Get Up and Go Test - Fig
26-3 Lawton Scale for Instrumental Activities of Daily Living (Iadl) - Box
26-4 Age-Related Abnormalities of the Eye - Box
26-4 Degenerative Joint Disease - Fig
26-5 Understanding Urinary Incontinence: Assessment and Intervention - Box
Introduction
Older Adult Nursing Assessment
Unit 4. Nursing Assessment of Special Groups
Appendices
1. Nursing Assessment Form Based on Functional Health Patterns
10. Collaborative Problems
11. Spanish Translation for Nursing Health History and Physical Examination
2. Physical Assessment Guide: Pulling It All Together
3. Sample Adult Nursing Health History And Physical Assessment
4. Assessment of Family Functional Health Patterns
5. Child Cognitive (Piaget) And Psychosocial (Erickson) Development (Birth To 18 Years)
6. Recommended Childhood and Adolescent Immunization Schedule
7. 2017 Recommended Immunizations for Adults: By Age
8. Height-Weight-Head Circumference Charts for Children
9. NANDA Approved Nursing Diagnoses 2015-2017
Appendices
References and Bibliography
References and Bibliography
Front Matter
Contributors
Preface
Reviewers
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