TESTuiBANK
EssentialuiHealthuiAssessment
Janice M Thompson
ui ui
1stuiEdition
,TableuiofuiContents
Chapterui01uiUnderstandinguiHealthuiAssessment 1
Chapterui02uiInterviewinguitheuiPatientuiforuitheuiHealthuiHistory 11
Chapterui03uiTakinguitheuiHealthuiHistory 40
Chapterui04uiAssessinguiNutritionuianduiAnthropometricuiMeasurements 61
Chapterui05uiAssessmentuiTechniques 88
Chapterui06uiGeneraluiSurveyuianduiAssessinguiVitaluiSigns 99
Chapterui07uiAssessinguiPain 128
Chapterui08uiAssessinguitheuiSkin,uiHair,uianduiNails 149
Chapterui09uiAssessinguitheuiHead,uiFace,uiMouth,uianduiNeck 188
Chapterui10uiAssessinguitheuiEars 229
Chapterui11uiAssessinguitheuiEyes 250
Chapterui12uiAssessinguitheuiRespiratoryuiSystem 281
Chapterui13uiAssessinguitheuiCardiovascularuiSystem 308
Chapterui14uiAssessinguitheuiAbdomen 335
Chapterui15uiAssessinguitheuiPeripheraluiVascularuiSystemuianduiRegionaluiLymphaticuiSystem 363
Chapterui16uiAssessinguitheuiMusculoskeletaluiSystem 391
Chapterui17uiAssessinguitheuiNeurologicaluiSystem 417
Chapterui18uiAssessinguitheuiFemaleuiBreasts,uiAxillae,uianduiReproductiveuiSystem 451
Chapterui19uiAssessinguitheuiMaleuiBreastsuianduiReproductiveuiSystem 477
Chapterui20uiAssessinguitheuiAnusuianduiRectum 501
Chapterui21uiAssessinguitheuiNewborn 517
Chapterui22uiAssessinguitheuiChilduianduiAdolescent 555
Chapterui23uiAssessinguitheuiPregnantuiWoman 583
Chapterui24uiAssessinguitheuiOlderuiAdult 612
, TestuiBankui-
uiEssentialuiHealthuiAssessment,ui1stuieditionui(Thompson,ui2018)
Chapterui1:uiUnderstandinguiHealthuiAssessment
1. TheuiWorlduiHealthuiOrganizationui(WHO)uiestablisheduiauiglobaluistrategyuicalledui“Healthuifo
ruiAll.”uiTheuigoaluiforuithisuistrategyuiis:
1. Alluiindividualsuitouigetuitheuisameuihealthuicareuithroughoutuitheiruilifeuispans.
2. Theuigovernmentuitouisupplyuimoneyuitouicareuiforuialluitheuipeopleuiinuitheuiworld.
3. Resourcesuiforuihealthuicareuitouibeuievenlyuidistributeduianduiaccessible.
4. Health-careuiprovidersuicanuineveruidenyuipatientsuihealthuicare.
2. Healthuiassessmentuiisuiauifoundationaluianduipriorityuinursinguiskill.uiThisuiessentialuiskilluir
equiresuiregistereduinursesui(RNs)uito:
1. Diagnoseuianduitreatuipatients.
2. Identifyuinormaluianduiabnormaluifindings.
3. Referuipatientsuiwithuiabnormaluifindings.
4. Counseluipatientsuiwithuipsychosocialuineeds.
3. Youuiareuiassessinguiauipatientuiwithuifiveuigunshotuiwoundsuionuiauitraumauiunit.uiThereuiisuiauip
oliceuipresenceuioutsideuihisuidooruibecauseuitheuipatientuiisuiauiknownuidruguidealeruiinuitheuicommun
ity.uiYouuiknowuithatuinursesuimustuitreatuialluipatientsuiasuipersons.uiThisuiisuicalled:
1. Caring.
2. Holisticuiprocess.
3. Person-centereduicareui(PCC).
4. Standardsuiofuicare.
4. Theuiscience-
baseduiframeworkuiupdateduieveryui10uiyearsuibyuitheuiU.S.uiDepartmentuiofuiHealthuianduiHuma
nuiServicesuithatuihasuisetuinationaluigoalsuianduiobjectivesuiforuihealthuipromotionuianduidisease
uipreventionuiis:
1. HealthyuiPeople.
2. HealthyuiPeopleui2020.
3. U.S.uiPreventiveuiTaskuiForce.
4. WorlduiHealthuiOrganization.
5. Aui38-year-olduimaleuihasuiauifamilyuihistoryuiofuicolonuicancer.uiHisuifatheruidieduiofuicolonuicanceruiatuiage
48.uiTheuidoctoruirecommendeduithatuithisuipatientuihaveuiauicolonoscopyuithisuiyear.uiThisuiisuianuiexampleuiof
:
1. Primaryuihealthuiprevention.
1ui|uiPuiauigui
e
, TestuiBankui-
uiEssentialuiHealthuiAssessment,ui1stuieditionui(Thompson,ui2018)
2. Secondaryuihealthuiprevention.
3. Tertiaryuihealthuiprevention.
6. Auipatientuiinuitheuihospitaluiputsuionuihisuicalluilightuianduitellsuitheuipersonuiansweringuithatuiheui“t
hinksuiheuiisuirunninguiauifeveruianduihasuistomachuidiscomfort.”uiYouuiareuitheuiregistereduinurseuiin
uicharge.uiWhatuishoulduiyouuido?
1. Askuitheuimedicaluiassistantuitouigouitouitheuipatient’suiroomuianduiassessuihisuicomplaints.
2. GouicheckuitouiseeuiifuitheuipatientuihasuianuiorderuiforuiTylenoluiforuiauifever.
3. Pageuitheuiresidentuionuicalluiimmediatelyuitouiassessuitheuipatient.
4. Gouitouitheuipatient’suiroomuianduiassessuiforuifeveruianduitheuiepigastricuidiscomfort.
7. Youuiareuileadinguianuiinterdisciplinaryuiteamuiconferenceuitouidiscussuihowuitouiprovideuibetteruic
areuiforuiauichallenginguipatientuiwhouihasuibehavioraluiproblems.uiThereuiareuiseveraluiareasuithatuin
eeduitouibeuiproblemuisolveduianduinewuiideasuiformulateduitouicreateuianuiimproveduiplanuiofuicare.ui
Whatuicognitiveuiskillsuiareuiyouuiusing?
1. Criticaluithinking
2. Clinicaluidecisionuimaking
3. Intuitiveuithinking
4. Clinicaluireasoning
8. Bestuipracticeuiassessmentuitechniquesuianduiinstrumentsuihaveuibeenuivalidateduiby:
1. AmericanuiNursesuiAssociation.
2. CodeuiofuiEthicsuiforuiNursesuiWithuiInterpretiveuiStatements.
3. Researchuianduievidence-baseduipractice.
4. PatientuiProtectionuianduiAffordableuiCareuiAct.
9. Healthuianduiillnessuiareuidetermineduibyuimanyuifactors.uiWhatuiareuitheuideterminantsuiofuihealthuii
dentifieduibyuitheuiCentersuiforuiDiseaseuiControluianduiPreventionui(CDC)?uiSelectuialluithatuiapply.
1. Geneticsuianduibiology
2. Genderuianduioccupation
3. Individualuibehavior
4. Socialuienvironment
5. Physicaluienvironment
6. Healthuiservices
2ui|uiPuiauigui
e
EssentialuiHealthuiAssessment
Janice M Thompson
ui ui
1stuiEdition
,TableuiofuiContents
Chapterui01uiUnderstandinguiHealthuiAssessment 1
Chapterui02uiInterviewinguitheuiPatientuiforuitheuiHealthuiHistory 11
Chapterui03uiTakinguitheuiHealthuiHistory 40
Chapterui04uiAssessinguiNutritionuianduiAnthropometricuiMeasurements 61
Chapterui05uiAssessmentuiTechniques 88
Chapterui06uiGeneraluiSurveyuianduiAssessinguiVitaluiSigns 99
Chapterui07uiAssessinguiPain 128
Chapterui08uiAssessinguitheuiSkin,uiHair,uianduiNails 149
Chapterui09uiAssessinguitheuiHead,uiFace,uiMouth,uianduiNeck 188
Chapterui10uiAssessinguitheuiEars 229
Chapterui11uiAssessinguitheuiEyes 250
Chapterui12uiAssessinguitheuiRespiratoryuiSystem 281
Chapterui13uiAssessinguitheuiCardiovascularuiSystem 308
Chapterui14uiAssessinguitheuiAbdomen 335
Chapterui15uiAssessinguitheuiPeripheraluiVascularuiSystemuianduiRegionaluiLymphaticuiSystem 363
Chapterui16uiAssessinguitheuiMusculoskeletaluiSystem 391
Chapterui17uiAssessinguitheuiNeurologicaluiSystem 417
Chapterui18uiAssessinguitheuiFemaleuiBreasts,uiAxillae,uianduiReproductiveuiSystem 451
Chapterui19uiAssessinguitheuiMaleuiBreastsuianduiReproductiveuiSystem 477
Chapterui20uiAssessinguitheuiAnusuianduiRectum 501
Chapterui21uiAssessinguitheuiNewborn 517
Chapterui22uiAssessinguitheuiChilduianduiAdolescent 555
Chapterui23uiAssessinguitheuiPregnantuiWoman 583
Chapterui24uiAssessinguitheuiOlderuiAdult 612
, TestuiBankui-
uiEssentialuiHealthuiAssessment,ui1stuieditionui(Thompson,ui2018)
Chapterui1:uiUnderstandinguiHealthuiAssessment
1. TheuiWorlduiHealthuiOrganizationui(WHO)uiestablisheduiauiglobaluistrategyuicalledui“Healthuifo
ruiAll.”uiTheuigoaluiforuithisuistrategyuiis:
1. Alluiindividualsuitouigetuitheuisameuihealthuicareuithroughoutuitheiruilifeuispans.
2. Theuigovernmentuitouisupplyuimoneyuitouicareuiforuialluitheuipeopleuiinuitheuiworld.
3. Resourcesuiforuihealthuicareuitouibeuievenlyuidistributeduianduiaccessible.
4. Health-careuiprovidersuicanuineveruidenyuipatientsuihealthuicare.
2. Healthuiassessmentuiisuiauifoundationaluianduipriorityuinursinguiskill.uiThisuiessentialuiskilluir
equiresuiregistereduinursesui(RNs)uito:
1. Diagnoseuianduitreatuipatients.
2. Identifyuinormaluianduiabnormaluifindings.
3. Referuipatientsuiwithuiabnormaluifindings.
4. Counseluipatientsuiwithuipsychosocialuineeds.
3. Youuiareuiassessinguiauipatientuiwithuifiveuigunshotuiwoundsuionuiauitraumauiunit.uiThereuiisuiauip
oliceuipresenceuioutsideuihisuidooruibecauseuitheuipatientuiisuiauiknownuidruguidealeruiinuitheuicommun
ity.uiYouuiknowuithatuinursesuimustuitreatuialluipatientsuiasuipersons.uiThisuiisuicalled:
1. Caring.
2. Holisticuiprocess.
3. Person-centereduicareui(PCC).
4. Standardsuiofuicare.
4. Theuiscience-
baseduiframeworkuiupdateduieveryui10uiyearsuibyuitheuiU.S.uiDepartmentuiofuiHealthuianduiHuma
nuiServicesuithatuihasuisetuinationaluigoalsuianduiobjectivesuiforuihealthuipromotionuianduidisease
uipreventionuiis:
1. HealthyuiPeople.
2. HealthyuiPeopleui2020.
3. U.S.uiPreventiveuiTaskuiForce.
4. WorlduiHealthuiOrganization.
5. Aui38-year-olduimaleuihasuiauifamilyuihistoryuiofuicolonuicancer.uiHisuifatheruidieduiofuicolonuicanceruiatuiage
48.uiTheuidoctoruirecommendeduithatuithisuipatientuihaveuiauicolonoscopyuithisuiyear.uiThisuiisuianuiexampleuiof
:
1. Primaryuihealthuiprevention.
1ui|uiPuiauigui
e
, TestuiBankui-
uiEssentialuiHealthuiAssessment,ui1stuieditionui(Thompson,ui2018)
2. Secondaryuihealthuiprevention.
3. Tertiaryuihealthuiprevention.
6. Auipatientuiinuitheuihospitaluiputsuionuihisuicalluilightuianduitellsuitheuipersonuiansweringuithatuiheui“t
hinksuiheuiisuirunninguiauifeveruianduihasuistomachuidiscomfort.”uiYouuiareuitheuiregistereduinurseuiin
uicharge.uiWhatuishoulduiyouuido?
1. Askuitheuimedicaluiassistantuitouigouitouitheuipatient’suiroomuianduiassessuihisuicomplaints.
2. GouicheckuitouiseeuiifuitheuipatientuihasuianuiorderuiforuiTylenoluiforuiauifever.
3. Pageuitheuiresidentuionuicalluiimmediatelyuitouiassessuitheuipatient.
4. Gouitouitheuipatient’suiroomuianduiassessuiforuifeveruianduitheuiepigastricuidiscomfort.
7. Youuiareuileadinguianuiinterdisciplinaryuiteamuiconferenceuitouidiscussuihowuitouiprovideuibetteruic
areuiforuiauichallenginguipatientuiwhouihasuibehavioraluiproblems.uiThereuiareuiseveraluiareasuithatuin
eeduitouibeuiproblemuisolveduianduinewuiideasuiformulateduitouicreateuianuiimproveduiplanuiofuicare.ui
Whatuicognitiveuiskillsuiareuiyouuiusing?
1. Criticaluithinking
2. Clinicaluidecisionuimaking
3. Intuitiveuithinking
4. Clinicaluireasoning
8. Bestuipracticeuiassessmentuitechniquesuianduiinstrumentsuihaveuibeenuivalidateduiby:
1. AmericanuiNursesuiAssociation.
2. CodeuiofuiEthicsuiforuiNursesuiWithuiInterpretiveuiStatements.
3. Researchuianduievidence-baseduipractice.
4. PatientuiProtectionuianduiAffordableuiCareuiAct.
9. Healthuianduiillnessuiareuidetermineduibyuimanyuifactors.uiWhatuiareuitheuideterminantsuiofuihealthuii
dentifieduibyuitheuiCentersuiforuiDiseaseuiControluianduiPreventionui(CDC)?uiSelectuialluithatuiapply.
1. Geneticsuianduibiology
2. Genderuianduioccupation
3. Individualuibehavior
4. Socialuienvironment
5. Physicaluienvironment
6. Healthuiservices
2ui|uiPuiauigui
e
