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Nurses' Handbook of Health Assessment
Analyzing Data to Make Informed Clinical Judgments
Table of Contents
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About
Analyzing Data to Make Informed Clinical Judgments
Assessing Male Genitalia, Anus, and Rectum
Assessing Peripheral Vascular System
Box - Sample Application of Coldspa: Exploring the Symptoms of Back Pain
Box - The Alcohol Use Disorders Identification Test (Audit): Interview Version
Calculator - APGAR Score
Calculator - GDS-5/15 Geriatric Depression Scale
Dietary Assessment
Figure - Mobile Monitoring System
Figure - The Middle-Aged Adult is Able to Mentor Young Adults in the Workplace Because They Have Increased Problem-Solving Abilities and Life Experience
Functional Health Pattern Framework
Growth and Development Overview
Introduction-Validating, Analyzing, Documenting, and Communicating Data
Nursing Assessment-Assessing Breasts and Lymphatic System
Nursing Assessment-Assessing Heart and Neck Vessels
Nursing Assessment-Assessing Pain
Nursing Assessment-Assessing Peripheral Vascular System
Obtaining a Nursing Health History: Guidelines and Frameworks
Performing The Physical Assessment: Skills and Techniques
Structure and Function Overview-Assessing Ears
Structure and Function Overview-Assessing General Health Status and Vital Signs
Structure and Function Overview-Assessing Neurologic System
Structure and Function Overview-Assessing Nutritional Status
Table - Comparing Subjective and Objective Data
Table - Sounds (Tones) Elicited by Percussion
Teaching Tips for Selected Client Concerns
Teaching Tips for Selected Client Concerns
Teaching Tips for Selected Client Concerns
Teaching Tips for Selected Client Concerns and Collaborative Problems
Unit 1. Nursing Data Collection, Documentation, and Analysis
1: Obtaining a Nursing Health History: Guidelines and Frameworks
B - 1-1 Sample Application of Coldspa: Exploring the Symptoms of Back Pain
B - 1-2 Example of Observations and Questions to Ask a Client from Another Culture
B - 1-3 Generic Nursing History Format Summary
B - 1-4 Subjective And Objective Assessment Focus For Functional Health Patterns
Frameworks for Collecting Client Data
Functional Health Pattern Framework
Guidelines for Obtaining a Nursing Health History
Introduction
References
2: Performing The Physical Assessment: Skills and Techniques
Basic Guidelines for Physical Assessment
Physical Assessment Skills
T - 2-1 Comparing Subjective and Objective Data
T - 2-2 Sensitivity of Parts of the Hand
T - 2-3 Types of Palpation
T - 2-4 Types of Percussion
T - 2-5 Sounds (Tones) Elicited by Percussion
T - 2-6 Uses for Diaphragm and Bell of Stethoscope
3: Validating, Analyzing, Documenting, and Communicating Data
Analyzing Data to Make Informed Clinical Judgments
B - 3-1 SBAR (Situation, Background, Assessment, and Recommendation)
Documenting Data
Introduction
References
T - 3-1 Steps to Make a Clinical Judgment from Assessment Data
T - 3-2 Comparison of Opportunity to Improve Health, Risk for Client Concerns, and Actual Client Concerns
T - 3-3 Comparison of Client Concerns and Collaborative Problems
T - 3-4 Examples of Client Concerns, Collaborative Problems, and Medical Diagnoses
T - 3-5 Examples of Vague Versus Clear and Concise Documentation of Data
Validating Data
Unit 2. Integrative Holistic Nursing Assessment
4: Assessing Psychosocial, Cognitive, and Moral Development
F - 4-2. This Young Couple Has Reached Erikson's Stage of Intimacy
F - 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
F - 4-4. Older Adulthood Can be a Rich and Rewarding Time to Review Life Events
F - 4-5. The Middle-Aged Adult is Able to Mentor Young Adults in the Workplace Because They Have Increased Problem-Solving Abilities and Life Experience
F - 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
Growth and Development Overview
Nursing Assessment
References
T - 4-1 Erik Erikson's Stages of Psychosocial Development
T - 4-2 Jean Piaget's Stages of Cognitive Development
T - 4-3 Lawrence Kohlberg's Stages of Moral Development
Teaching Tips for Selected Client Concerns
5: Assessing Mental Status and Substance Abuse
B - 5-1 The Alcohol Use Disorders Identification Test (Audit): Interview Version
B - 5-2 Clinical Institute Withdrawal Assessment Scale
B - 5-3 Glasgow Coma Scale -P
B - 5-4 Slums Mental Status Examination
B - 5-5 Primary Care Ptsd Screen for Dsm-5 (Pc-Ptsd-5)
B - 5-6 Quick Inventory of Depressive Symptomatology (Self-Report)
B - 5-7 Sad Persons Suicide Risk Assessment Tool
B - 5-8 The 10 Signs and Symptoms of Alzheimer Disease
Conceptual Foundations
Nursing Assessment
References
T - 5-1 Identifying the Cause of Confusion: Dementia, Delirium, or Depression
Teaching Tips for Selected Client Concerns
6: Assessing General Health Status and Vital Signs
F - 6-1. Mobile Monitoring System
F - 6-2. Taking a Tympanic Temperature
F - 6-3. Taking the Radial Pulse Rate
F - 6-4. Auscultating Apical Pulse Rate
F - 6-5. (A) Auscultating Apical Pulse Rate in Child <2 Years. (B) Measuring Radial Pulse in Child Older Than 2 Years
F - 6-6. Measuring the Circumference of an Infant's Head
Nursing Assessment
References
Structure and Function Overview
T - 6-1 Choosing the Correct Route to Measure Body Temperature
T - 6-2 Types of Respirations
T - 6-3 Changes in Blood Pressure Classification
Teaching Tips for Selected Client Concerns and Collaborative Problems
7: Assessing Pain
B - 7-1 Numeric Rating Scale (NRS)
B - 7-2 Behavioral Pain Scale (Bps)
B - 7-3 Faces Pain Rating Scale
B - 7-4 Mccaffery Initial Pain Assessment Tool
Conceptual Foundations
F - 7-1. Transduction, Transmission, Perception, and Modulation of Pain
F - 7-2. Areas of Referred Pain
Nursing Assessment
References
Teaching Tips for Selected Client Concerns
8: Assessing for Violence
B - 8-1 Abuse Assessment Screen
B - 8-2 Self-Assessment: Danger Assessment
B - 8-3 Assessing A Safety Plan
Conceptual Foundations
F - 8-1. The Nurse Allows the Woman to Talk Freely about Her Experience
F - 8-2. Examples of Physical Child Abuse. Physical Injuries May Have Distinctive Outlines That Indicate the Instrument of Abuse
Nursing Assessment
References
Teaching Tips for Selected Client Concerns
9: Assessing Nutritional Status
Anthropometric Measurements
B - 9-1 Client's 24-Hour Diet Recall
B - 9-2 Determine Your Nutritional Health Nutritional Risk Assessment
B - 9-3 Edinburgh Feeding Evaluation in Dementia Questionnaire (Edfed-Q)
Dietary Assessment
F - 9-1. Measuring Mid-Arm Circumference
F - 9-2. Measuring Triceps Skinfold Thickness
F - 9-3. Myplate/Mywins
General Inspection
Nursing Assessment
References
Structure and Function Overview
T - 9-1 Body Mass Index (BMI) and Corresponding Body Weight Categories for Children and Adults
T - 9-2 Disease Risk for Type 2 Diabetes, Hypertension, and Cardiovascular Diseases Relative to Body Mass Index (BMI) and Waist Circumference
T - 9-3 Mid-Arm Circumference (MAC) Standard Reference
T - 9-4 Triceps Skinfold Thickness (TSF) Standard Reference
T - 9-5 Mid-Arm Muscle Circumference (MAMC) Standard Reference
T - 9-6 Estimated Calorie Needs Per Day, by Age, Sex, and Physical Activity Level
Teaching Tips for Selected Client Concerns
Unit 3. Nursing Assessment of Physical Systems
10: Assessing Skin, Hair, and Nails
B - 10-1 Push Tool to Measure Pressure Injury Healing
B - 10-2 Braden Scale for Predicting Pressure Sore Risk
B - 10-3 Common Variations: Skin Variations
B - 10-4 Self-Assessment: How to Examine Your Own Skin
F - 10-1. Skin and Hair Follicles
F - 10-2. The Nail and Related Structures
F - 10-3. Tattoos and Piercings
F - 10-4. Normal Angle
F - 10-5. Normal Creases
F - 10-6. Simian Creases Seen in Down Syndrome
F - 10-7. Senile Lentigines are Common on Aging Skin
Nursing Assessment
References
Structure and Function Overview
T - 10-1 Six Skin Types
Teaching Tips for Selected Client Concerns
11: Assessing Head and Neck
B - 11-1 Types And Characteristics of Headaches
B - 11-2 Signs And Symptoms of Altered Thyroid Function
B - 11-3 Abnormalities of the Head and Neck
B - 11-4 Recognizing Symptoms of Stroke
F - 11-1. Bones and Sutures of the Skull (Face and Cranium)
F - 11-2. Structures of the Neck
F - 11-3. Neck Muscles and Landmarks
F - 11-4. Palpating the Temporal Artery
F - 11-5. Palpating
F - 11-6. Palpating the Thyroid
F - 11-7. Auscultating for Bruits over the Thyroid Gland
F - 11-8. Lymph Node
Nursing Assessment
References
Structure and Function Overview
Teaching Tips for Selected Client Concerns
12: Assessing Eyes
F - 12-1. External Structures of the Eye
F - 12-10. Inspecting the Conjunctiva
F - 12-11. Observe the Pupils with a Penlight or Similar Device, Test Pupillary Reaction to Light
F - 12-12. Checking Accommodation of Pupils
F - 12-13. Palpating the Lacrimal Apparatus
F - 12-14. Inspecting the Red Reflex
F - 12-15. Normal Ocular Fundus (also Called the Optic Disc)
F - 12-16. Outer Canthus is in Alignment with the Tip of the Pinna
F - 12-2. The Lacrimal Apparatus Consists of Tear (Lacrimal) Glands and Ducts
F - 12-3. Extraocular Muscles Control the Direction of Eye Movement
F - 12-4. Anatomy of the Eye
F - 12-5. Normal Ocular Fundus
F - 12-6. Checking Distance Vision
F - 12-7. Checking Peripheral Vision
F - 12-8. Performing the Cover/Uncover Test
F - 12-9. Checking Extraocular Movements
Nursing Assessment
References
Structure and Function Overview
T - 12-1 Recommended Frequency of Comprehensive Medical Eye Examinations
T - 12-2 Recommended Eye Examination Frequency for the Pediatric Patient
Teaching Tips for Selected Client Concerns
13: Assessing Ears
B - 13-1 Ten Ways to Recognize Hearing Loss
F - 13-1. Structures in the Outer, Middle, and Inner Divisions
F - 13-2. Right Tympanic Membrane
F - 13-3. Inspecting the External Ear
F - 13-4. Using a Tuning Fork to Assess Auditory Function
F - 13-5. Placement and Alignment of Pinna in Children
F - 13-6. Infant Being Restrained in the Upright Position
Nursing Assessment
References
Structure and Function Overview
Teaching Tips for Selected Client Concerns
14: Assessing Mouth, Throat, Nose, and Sinuses
F - 14-1. Structures of the Mouth
F - 14-10. Torus Palatinus
F - 14-11. Inspecting Oropharynx
F - 14-12. Inspecting the Internal Nose
F - 14-13. Nose
F - 14-14. Nasal Polyp
F - 14-15. (A) Palpating Frontal Sinuses. (B) Palpating Maxillary Sinuses
F - 14-16. Timetable for Eruption of Deciduous Teeth
F - 14-2. Teeth
F - 14-3. Salivary Glands
F - 14-4. Nasal Cavity and Throat Structures
F - 14-5. Inspecting the Open Mouth
F - 14-6. Palpating the Lips
F - 14-7. Inspecting the Buccal Mucosa
F - 14-8. Normal Tongue Variations. (A) Fissured Tongue. (B) Fordyce Granules
F - 14-9. Inspecting Sides of Tongue
Nursing Assessment
References
Structure and Function Overview
Teaching Tips for Selected Client Concerns and Collaborative Problems
15: Assessing Thorax and Lungs
F - 15-1. Anterior Thoracic Cage
F - 15-10. Percussing Bilaterally for Diaphragmatic Excursions
F - 15-2. Posterior Thoracic Cage
F - 15-3. Vertical Lines
F - 15-4. (A) Anterior View of Lung Position. (B) Posterior View of Lung Position. (C) Lateral View of Left Lung Position. (D) Lateral View of Right Lung Position
F - 15-5. Major Structures of the Respiratory System
F - 15-6. Cross Section of Thorax
F - 15-7. Cross Section of Barrel-Shaped Thorax
F - 15-8. Palpation of Thoracic Expansion. (A) Posterior. (B) Anterior
F - 15-9. Intercostal Landmarks for Percussion and Auscultation of Thorax
Nursing Assessment
References
Structure and Function Overview
T - 15-1 Respiratory Rates in Children
Teaching Tips for Selected Client Concerns
16: Assessing Breasts and Lymphatic System
B - 16-1 Breast Self-Examination
F - 16-1. Anatomic Breast Landmarks and Their Position in the Thorax
F - 16-2. Breast Quadrants
F - 16-3. Internal Anatomy of the Breast
F - 16-4. The Lymph Nodes Drain Impurities from the Breasts (Arrows Show Direction)
F - 16-5. Arms
F - 16-6. Patterns for Breast Palpation
F - 16-7. Palpating Nipples for Masses and Discharge
F - 16-8. Gynecomastia
Nursing Assessment
References
Structure and Function
Teaching Tips for Selected Client Concerns
17: Assessing Heart and Neck Vessels
F - 17-1. The Heart and Major Blood Vessels Lie Centrally in the Chest Behind the Protective Sternum
F - 17-10. Areas to Palpate and Auscultate on the Chest
F - 17-11. Locate the Apical Impulse with the Palmar Surface (A) and Then Palpate the Apical Pulse with the Finger Pad (B)
F - 17-12. Palpating the Carotid Pulse While Auscultating S1
F - 17-13. Auscultating S2
F - 17-14. S3 Heart Sound
F - 17-15. S4 Heart Sound
F - 17-16. Location of Apex of Heart in (A) Infant, (B) Child, and (C) Adult
F - 17-2. Heart Chambers, Valves, and Direction of Circulatory Flow
F - 17-3. The Cardiac Cycle Consists of Filling and Ejection
F - 17-4. Common Sites of Anterior Chest Wall Pain Because of Chest Wall Structures or Referred Pain
F - 17-5. Pain Patterns with Myocardial Ischemia
F - 17-6. Assessing Jugular Venous Pressure
F - 17-7. Auscultating the Carotid Arteries
F - 17-8. Palpating the Carotid Arteries
F - 17-9. Landmarks of the Chest
Nursing Assessment
References
Structure and Function Overview
T - 17-1 Description of Various Types of Cardiovascular Pain
T - 17-2 Gradations of Systolic Murmurs
T - 17-3 Average Heart Rate of Infants and Children at Rest
Teaching Tips for Selected Client Concerns
18: Assessing Peripheral Vascular System
B - 18-1 Assessing Pulse Strength
F - 18-1. Major Arteries of the Arms and Legs
F - 18-10. Characteristic Ulcer of Arterial Insufficiency
F - 18-11. Pitting Edema
F - 18-12. Palpating the Femoral Pulse
F - 18-13. Auscultating the Femoral Pulse to Detect Bruits
F - 18-15. Palpating the Dorsalis Pedis Pulse
F - 18-16. Palpating the Posterior Tibial Pulse
F - 18-17. Testing for Arterial Insufficiency by (A) Elevating the Legs and Then (B) Having the Client Dangle the Legs
F - 18-18. Performing Manual Compression to Assess Competence of Venous Valves in Clients with Varicose Veins
F - 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
F - 18-3. Major Veins of the Legs
F - 18-4. Lymphatic Drainage
F - 18-5. Superficial Lymph Nodes of the Arms and Legs
F - 18-6. Palpating the Radial Pulse
F - 18-7. Palpating the Ulnar Pulse
F - 18-8. Palpating the Epitrochlear Lymph Nodes by Flexing the Client's Left Elbow about 90 Degrees
F - 18-9. Allen Test
Nursing Assessment
References
Structure and Function Overview
T - 18-1 Stages of Lymphedema
T - 18-2 Comparison of Arterial and Venous Insufficiency
T - 18-3 Characteristics of Arterial and Venous Insufficiency and Resulting Ulcers
Teaching Tips for Selected Client Concerns and Collaborative Problems
19: Assessing Abdomen
B - 19-1 Locating Abdominal Structures by Quadrants
B - 19-2 Abdominal Signs
F - 19-1. Abdominal Quadrants
F - 19-10. Performing Blunt Percussion over the Kidney
F - 19-11. Performing Fluid Wave Test
F - 19-12. Percussing for Level of Dullness with (A) Client Supine and (B) Client Lying on Side
F - 19-13. Assessing for Rovsing Sign: (A) Palpating Deeply. (B) Releasing Pressure Rapidly
F - 19-14. Test for Psoas Sign
F - 19-15. Test for Obturator Sign
F - 19-2. Abdominal Wall Muscles
F - 19-3. Abdominal Viscera
F - 19-4. Abdominal and Vascular Structures (Aorta and Iliac Artery and Vein)
F - 19-5. View Abdominal Contour from the Client's Side
F - 19-6. Vascular Sounds and Friction Rubs Can Best be Heard over These Areas
F - 19-7. Abdominal Percussion Sequences May Proceed Clockwise or Up and Down over the Abdomen
F - 19-8. Normal Liver Span
F - 19-9. The Scratch Test
References
Structure and Function Overview
Teaching Tips for Selected Client Concerns
20: Assessing Musculoskeletal System
B - 20-1 Ottawa Ankle Rules for X-Ray Referral
F - 20-1. Major Bones of the Skeleton
F - 20-10. Normal Range of Motion of the Elbow
F - 20-11. Squeeze Test (Hand)
F - 20-12. Anatomic Snuffbox
F - 20-13. Range of Motion of the Wrists
F - 20-14. Tests for Carpal Tunnel Syndrome. (A) Phalen Test. (B) Tinel Test
F - 20-15. Median Nerves Entrapped in the Carpal Tunnel Results in Pain, Numbness, and Impaired Function of the Hand and Fingers
F - 20-16. Normal Range of Motion of the Fingers
F - 20-17. Normal Range of Hip Motion
F - 20-18. Normal Range of Motion of Knee
F - 20-19. Squeeze Test (Foot)
F - 20-2. Muscles of the Body
F - 20-20. Normal Range of Motion of the Feet and Ankles
F - 20-21. Genu Varum
F - 20-22. Maneuver
F - 20-23. Assessing Spinal Curvature for Scoliosis
F - 20-3. Components of Synovial Joints (Right Hip Joint)
F - 20-4. Normal Spinal Curves
F - 20-5. Palpating the Temporomandibular Joint
F - 20-6. Normal Range of Motion of Cervical Spine
F - 20-7. Range of Motion of Trunk
F - 20-8. Measuring True Leg Length
F - 20-9. Normal Range of Motion of the Shoulder
Nursing Assessment
References
Structure and Function Overview
T - 20-1 Scale for Muscle Strength
T - 20-2 Normal Range of Motion for Joints of the Upper Extremities
T - 20-3 Normal Range of Motion for Joints of the Lower Extremities
Teaching Tips for Selected Client Concerns
21: Assessing Neurologic System
F - 21-1. Structure and Lobes of the Brain
F - 21-10. Testing Cranial Nerves IX and X: Checking Uvula Rise and Gag Reflex
F - 21-11. Testing Cranial Nerve XI: Assessing Strength of Trapezius Muscle
F - 21-12. Testing Cranial Nerve XI: Assessing Strength of Sternocleidomastoid Muscle
F - 21-13. Testing Balance: Tandem Walking (Heel to Toe)
F - 21-14. Hop on One Foot and Then on the other Foot
F - 21-15. Testing Coordination: Finger-to-Nose Test
F - 21-16. Testing Rapid Alternating Movements of Turning Palms Up and Then Down
F - 21-17. Performing Heel-to-Shin Test
F - 21-18. Decorticate Posture
F - 21-19. Decerebrate Posture
F - 21-2. Spinal Cord
F - 21-20. Testing Position Sense (Kinesthesia)
F - 21-21. Two-Point Discrimination
F - 21-22. Eliciting Biceps Reflex
F - 21-23. Eliciting Brachioradialis Reflex
F - 21-24. Eliciting Triceps Reflex
F - 21-25. (A) Eliciting Patellar Reflex. (B) Eliciting Patellar Reflex (Supine Position)
F - 21-26. (A) Eliciting Achilles Reflex. (B) Eliciting Achilles Reflex (Supine Position)
F - 21-27. Testing for Ankle Clonus
F - 21-28. (A) Eliciting Normal Plantar Reflex. (B) Eliciting Abnormal Positive Babinski
F - 21-29. Abdominal Reflex
F - 21-3. Sensory (Ascending) Neural Pathways
F - 21-30. Abdominal and Cremasteric Reflexes
F - 21-4. Motor (Descending) Neural Pathways
F - 21-5. Anterior and Posterior Dermatomes (Areas of the Skin Innervated by Spinal Nerves)
F - 21-6. Testing Cranial Nerve I
F - 21-7. Testing Sensory Function of Cranial Nerve V: Dull Stimulus Using a Paper Clip
F - 21-8. Testing Corneal Reflex with Wisp of Cotton
F - 21-9. Testing Motor Function of Cranial Nerve V
Nursing Assessment
References
Structure and Function Overview
T - 21-1 Lobes of the Cerebral Hemispheres and Their Function
T - 21-2 Cranial Nerves: Type and Function
T - 21-3 Two-Point Discrimination Findings
Teaching Tips for Selected Client Concerns
22: Assessing Male Genitalia, Anus, and Rectum
B - 22-1 Self-Assessment: Testicular Self-Examination
F - 22-1. External and Internal Male Genitalia
F - 22-10. Palpating the Prostate Gland
F - 22-2. Inguinal Area
F - 22-3. Anal and Rectal Structures
F - 22-4. Palpating for Urethral Discharge
F - 22-5. Palpating the Scrotal Contents
F - 22-6. Palpating for an Inguinal Hernia
F - 22-7. Selected Positions for Anorectal Examination
F - 22-8. Inspecting the Perianal Area
F - 22-9. Palpating the Anus
Health Assessment
References
Structure and Function Overview
T - 22-1 Tanner Sexual Maturity Rating: Male Genitalia Development and Pubic Hair Growth
Teaching Tips for Selected Client Concerns and Collaborative Problems
23: Assessing Female Genitalia, Anus, and Rectum
F - 23-1. External Female Genitalia
F - 23-10. Hands Positioned for Rectovaginal Examination
F - 23-2. Internal Female Reproductive System and Relationship to other Pelvic Structures Including the Rectum and Anus
F - 23-3. Some of the Equipment Needed for Female Genitalia Examination
F - 23-4. Inspecting the Labia Minora, Clitoris, Urethral Meatus, and Vaginal Opening
F - 23-5. Technique for Palpating Bartholin Gland
F - 23-6. Speculum Insertion for Inspection of Cervix
F - 23-7. Palpating the Vaginal Walls
F - 23-8. Palpating the Uterus
F - 23-9. Palpating the Ovaries
Nursing Assessment
References
Structure and Function Overview
T - 23-1 Tanner Sexual Maturity Rating: Female Pubic Hair Growth and Breast Development
Teaching Tips for Selected Client Concerns and Collaborative Problems
Unit 4. Nursing Assessment of Special Groups
24: Assessing Childbearing Women
B - 24-1 Gravida/Para Status
F - 24-1. Distribution of Weight Gain during Pregnancy
F - 24-10. Measurement of the Descent of the Fundus
F - 24-2. Pregnancy Pigmentation: Abdominal Midline (Linea Nigra) and Striae Gravidarum
F - 24-3. Marked Chloasma of Pregnancy
F - 24-4. Breast Changes during Pregnancy
F - 24-5. Measuring the Fundal Height
F - 24-6. Approximate Height of Fundus at Various Weeks of Gestation
F - 24-7. Assessment of Fetal Position and Station
F - 24-8. Measuring Station of the Fetal Head While it is Descending
F - 24-9. Involution of the Uterus
Intrapartum Maternal and Fetal Assessment
Introduction
Postpartum Maternal Assessment
Prenatal Maternal and Fetal Assessment
References
Teaching Tips for Selected Client Concerns
Teaching Tips for Selected Client Concerns
Teaching Tips for Selected Client Concerns
25: Assessing Newborns and Infants
B - 25-1 Newborn Reflexes: Differentiating Normal and Abnormal Findings
F - 25-1. Weighing the Newborn
F - 25-10. The Infant Head
F - 25-11. Caput Succedaneum
F - 25-12. Umbilical Hernia
F - 25-13. The Spine is Rounded in Infants Less Than 3 Months
F - 25-2. New Ballard Scale
F - 25-3. New Ballard Scale
F - 25-4. Square Window Sign
F - 25-5. Scarf Sign
F - 25-6. Classification of Infant for Gestational Age
F - 25-7. Mongolian Spots
F - 25-8. Stork Bites
F - 25-9. Palpating the Anterior Fontanelle
Introduction
Nursing Assessment of the Newborn and Infant
References
T - 25-1 APGAR Scoring System
Teaching Tips for Selected Client Concerns
26: Assessing Older Adults
B - 26-1 Assessment of Pain In Older Adult Clients With Or Without Cognitive Impairment
B - 26-2 Katz Activities of Daily Living
B - 26-3 Lawton Scale for Instrumental Activities of Daily Living (Iadl)
B - 26-4 Age-Related Abnormalities of the Eye
B - 26-5 Understanding Urinary Incontinence: Assessment and Intervention
B - 26-6 Timed Up and Go (Tug) Test
F - 26-1. Solar Lentigines are Very Common on Aging Skin
F - 26-2. Observe Facial Expression
F - 26-3. Degenerative Joint Disease
Introduction
Older Adult Nursing Assessment
References
Appendices
1. Nursing Assessment Form Based On Functional Health Patterns
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. Collaborative Problems‡
7. Spanish Translation for Nursing Health History and Physical Examination
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