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 Contents

Veins 314 Documentation and critical thinking 399

Lymphatics 315 Abnormal findings 400
Subjective data 318 Chapter 17 Lower airways 404
Objective data 320 Introduction 405
Inspect and palpate the arms 320 Structure and function 405
Inspect and palpate the legs 322 Position and surface landmarks 405
Further subjective and objective assessment The thoracic cavity 407
for advanced practice 328 Mechanics of ventilation and respiration 409
Inspect and palpate the arms 328 Subjective data 411
Summary checklist: peripheral vascular Objective data 415
examination 330
Inspect the posterior chest 415
Documentation and critical thinking 332
Palpate the posterior chest 416
Abnormal findings 333
Auscultate the posterior chest 416
Abnormal findings for advanced practice 334
Inspect the anterior chest 419
Chapter 15 Cardiac function 339 Palpate the anterior chest 420
Introduction 340 Auscultate the anterior chest 420
Structure and function 340 Common diagnostic tests 424
Position and surface landmarks 340 Further objective assessment for advanced practice 425
Heart wall, chambers and valves 341 Summary checklist: lower airways examination 429
Direction of blood flow 341 Documentation and critical thinking 430
Cardiac cycle 342 Abnormal findings 431
Heart sounds 344 Abnormal findings for advanced practice 435
Conduction 345
Pumping ability 346
UNIT 6 Assessing musculoskeletal
function 444
The neck vessels 346
Subjective data 351 Chapter 18 Musculoskeletal function 444
Objective data 355 Introduction 445
The neck vessels 355 Structure and function 445
The praecordium 356 Components of the musculoskeletal system 445
Further objective assessment for advanced practice 359 Joint anatomy 446
The adult over 65 years 368 Subjective data 454
Summary checklist: heart and neck vessels General principles 454
examination 368 Objective data 459
Documentation and critical thinking 369 GALS screening assessment 459
Abnormal findings 370 Other measurements 461
Abnormal findings for advanced practice 372 Further objective assessment for advanced practice 461
Summary checklist: musculoskeletal
UNIT 5 Assessing respiratory function 384 examination 488
Documentation and critical thinking 490
Chapter 16 Upper airways 384
Abnormal findings for advanced practice 491
Introduction 385
Structure and function 385 UNIT 7 Assessing nutrition and
Nose 385 metabolic function 502
Throat 387
Chapter 19 Nutritional and metabolic
Lymphatics 387 assessment 502
Subjective data 388 Introduction 503
Objective data 390 Structure and function 503
Inspect and palpate the nose 391 The mouth 503
Inspect the mouth 391 The thyroid gland 505
Inspect the throat 392 The pancreas 505
Further objective assessment for advanced practice 394 Defining nutritional status 505
Inspection and palpation 394 Purposes and components of nutritional
Summary checklist: upper airways examination 397 assessment 509

vii
Contents

Subjective data 511 Abnormal findings 618

Objective data 516 Abnormal findings for advanced practice 621
Anthropometric measures 517 Chapter 22 Urinary function 627
Inspect the mouth 518 Introduction 628
Inspect the throat 521 Structure and function 628
Blood glucose monitoring 522 Kidneys 628
Other measurements 523 Ureters 629
Serial assessment 526 Bladder 629
Further objective assessment for advanced practice 526 Urethra 629
Summary checklist: nutritional and metabolic Subjective data 631
examination 529
Objective data 637
Documentation and critical thinking 530
Vital signs 638
Abnormal findings 530
Abdominal examination 638
Abnormal findings for advanced practice 534
Summary checklist: urinary tract examination 640
Chapter 20 Skin, hair and nails 544 Documentation and critical thinking 641
Introduction 545 Abnormal findings 642
Structure and function 545 Chapter 23 Bowel function 644
Skin 545 Introduction 645
Epidermal appendages 546 Structure and function 645
Function of the skin 546 Anus and rectum 645
Subjective data 548 Regional structures 646
Objective data 553 Subjective data 647
Inspect and palpate the skin 553 Objective data 650
Inspect and palpate the hair and scalp 558 Inspect the perianal area 651
Inspect and palpate the nails 559 Inspection of stool 651
Promoting health and self-care 561 Further objective assessment for advanced practice 652
Summary checklist: skin, hair and nails Palpate the anus and rectum 652
examination 569
Summary checklist: anus and rectum
Documentation and critical thinking 570 examination 653
Abnormal findings 571 Documentation and critical thinking 654
Abnormal findings for advanced practice 579 Abnormal findings 655

UNIT 8 Urinary and bowel function 591 UNIT 9 Assessing sexuality and
Chapter 21 Abdominal assessment 591 reproductive function 659
Introduction 592 Chapter 24 Female sexual and reproductive
Structure and function 592 function 659
Surface landmarks 592 Introduction 660
Internal anatomy 592 Structure and function 660
Subjective data 596 External genitalia 660
Objective data 598 Pelvic floor muscles and perineum 660
General inspection 599 Internal genitalia 661
Inspect the abdomen 599 Subjective data 664
Auscultate bowel sounds 601 Objective data 670
Percuss general tympany 602 Position 670
Palpation 603 Approach or communication 670
Further objective assessment for advanced practice 607 External genitalia 670
Auscultate vascular sounds 608 Further objective assessment for advanced practice 673
Percuss general tympany, liver span and Position 673
splenic dullness 608 Internal genitalia 675
Palpate deeper areas 611 Summary checklist: female genital examination 685
Summary checklist: abdomen examination 616 Documentation and critical thinking 686
Documentation and critical thinking 617 Abnormal findings for advanced practice 686

viii
 Contents

Chapter 25 Male sexual and reproductive Inspection and palpation of skin, mouth,
function 695 neck, breasts 770
Introduction 696 Peripheral vascular assessment (hands, feet, legs) 771
Structure and function 696 Auscultation of heart and lungs 771
The male reproductive system 696 Abdominal examination 772
Pelvic floor muscles and perineum 697 Auscultation of the fetal heart 776
Subjective data 700 Pelvic examination 777
Objective data 705 Maternal and fetal health screening 783
Inspect the penis 706 Summary checklist: the pregnant woman 784
Inspect the scrotum 706 Documentation and critical thinking 785
Further objective assessment for advanced practice 708 Abnormal findings for advanced practice 786
Palpate the penis 708
Palpate the scrotum 709 UNIT 10 Utilising health assessment
Inspect and palpate for hernia 710 in practice 791
Palpate inguinal lymph nodes 710 Chapter 28 Risk and safety: screening for
Palpate the prostate gland via the rectum 711 family violence and abuse 791
Summary checklist: male sexual and Introduction 792
reproductive examination 714 Terminology and key concepts 792
Documentation and critical thinking 715 Health effects of family violence 794
Abnormal findings for advanced practice 715 Assessing for family violence 796
Chapter 26 Breast assessment 724 Assessing for intimate partner violence 797
Introduction 725 Assessing for child abuse and neglect 798
Structure and function 725 Assessing for elder and vulnerable person
Surface anatomy 725 abuse and neglect 799
Internal anatomy 725 Physical examination 800
Lymphatics 726 Documentation 801
The male breast 729 Chapter 29 Risk and safety: screening for
Subjective data 730 substance abuse 805
Objective data 735 Introduction 806
Inspect the breasts 735 Alcohol use and abuse 806
Palpate the breasts 738 Illicit drug use 807
The male breast 740 Diagnosing substance use disorder 807
Further assessment for advanced practice: lymph Assessment approaches 809
node assessment 742 Conclusion 809
Palpate axilla and nodes 742
Chapter 30 Focused assessment 812
Summary checklist: Breast examination 743
Introduction 813
Documentation and critical thinking 744
Clinical decision making and focused assessment 813
Abnormal findings 744
What is focused assessment? 813
Abnormal findings for advanced practice 747
When should focused assessment be performed? 813
Chapter 27 The pregnant woman 751 Case study 815
Introduction 752
Chapter 31 The complete health assessment:
Structure and function 752
putting it all together 821
Pregnancy and the placenta 752
Introduction 822
Changes during normal pregnancy 753
Approaches to comprehensive health assessment 822
Subjective data 757
Putting it all together 823
Objective data 769
General survey 769 Illustration credits 827
Blood pressure measurement 769 Index 834

ix
Text features
Assessing mental health, Unit
neurological and sensory
function
3 Colour-coded stucture
Chapter Nine
Mental health assessment
Written by Carolyn Jarvis
Adapted by Rebecca Corbett
Introduction
STRUCTURE AND FUNCTION
Defining mental status
SUBJECTIVE DATA
Components of the mental status examination
OBJECTIVE DATA
Appearance and behaviour
Mood and affect
Speech
Thought processes and content
Perception
Cognitive functions
Orientation
Mini-Mental State Examination
Supplemental mental status examination
Summary checklist: mental health examination
DOCUMENTATION AND CRITICAL THINKING
ABNORMAL FINDINGS
ABNORMAL FINDINGS FOR ADVANCED PRACTICE
http://evolve.elsevier.com/AU/Forbes/assessment
• Quick assessments for 20 common conditions
• Multiple review questions
• Appendices
• Weblinks
or schizophrenia). Mental status assessment documents a
dysfunction and determines how that dysfunction affects self-
care and engagement in everyday life. As with any assessment,
it is always important to determine the previous level of
functioning and the length of time the disruption has been
experienced. All diagnostic parameters for mental disorders
require a length of time during which the cluster of symptoms
has been experienced (APA, 2013).
Most aspects of mental status cannot be scrutinised directly
like the characteristics of skin or heart sounds. Its functioning
is inferred through assessment of an individual’s behaviours:
Evolve resources
Consciousness: being aware of one’s own existence, feelings
and thoughts and aware of the environment. It also describes
the level of wakefulness in the individual. This is the most
elementary of mental status functions which can be objectively
assessed using the Glasgow Coma Scale (see Ch 10).
Language: using the voice to communicate one’s thoughts and
feelings. This is a basic tool of humans and its loss has a heavy
social impact on the individual. Language is the direct medium
Student resources are listed at
through which thoughts are expressed and thereby assessed.
Language formation is also a highly complex cognitive function
and its impairment is a key early indicator of many neurological
as well as psychiatric conditions.
Mood and affect: both of these elements deal with the prevailing
the beginning of each chapter feelings; affect is a temporary expression of feelings—it is visible
to the assessor in the form of facial expressions and expressed
emotions—and mood is pervasive over time—how the person
feels internally—and is not always visible to the assessor.
Orientation: the awareness of the objective world in relation
to the self, specifically time, place and person.
Attention: the power of concentration, the ability to focus
on one specific thing without being distracted by many
environmental or internal stimuli.
Memory: the ability to lay down and store experiences and
perceptions for later recall. Recent memory evokes day-to-day
events; remote memory brings up years worth of experiences.
Abstract reasoning: pondering a deeper meaning beyond the
concrete and literal. Abstract reasoning ability will give some
cues to level of intelligence.
Thought process: the way a person thinks; the formation,
sequence, relatedness, speed, availability and logic of thoughts.
Thought content: what the person thinks—specific ideas,
beliefs, fears, preoccupations and the use of words.
Clinical Case Studies Perceptions: what the person perceives in the environment
through the senses and through their body as a whole.
Q DEVELOPMENTAL CONSIDERATIONS
Infants and children
The maturation of emotional and cognitive functioning is
Highlight health assessment described in detail in Chapter 2. It is difficult to separate and
trace the development of just one aspect of mental status.
All aspects are interdependent. For example, consciousness
is rudimentary at birth because the cerebral cortex is not yet
developed; the infant cannot distinguish the self from the
techniques across a range of
mother’s body. Consciousness gradually develops along with
language, so that by 18 to 24 months the child learns that it
is separate from objects in the environment and has words to
clinical situations
Documentation and critical thinking
FOCUSED ASSESSMENT: CLINICAL CASE STUDY
to lap. Speech is a bit slow but articula
Context
Lola Peters is a 79-year-old married woman, with a recent with word choice.
hospitalisation for evaluation of increasing memory loss, Mood and affect: Appears distracted a
confusion and socially inappropriate behaviour. During interview.
this hospitalisation, Mrs Peters has undergone a series Thought processes and content: Expe
of medical tests, including a negative lumbar puncture in train of thought, needs prompting to
test, normal electroencephalogram (EEG) and a benign questions. Thought content is logical. A
head computed tomography (CT) scan. Her physician and suspicion towards family members
now suggests a diagnosis of senile dementia of the ideation, no delusions evident.
Alzheimer’s type (SDAT).
Cognitive functions: Oriented to perso
Can state the season, but not the day
Subjective the year. Is not able to repeat the corre
She has been irritable with friends and has left a
complex directions involving lifting and
supermarket with items she did not pay for. Her family
of water to the other hand. Scores a on
reports that Mrs Peter’s hygiene and grooming standards
the Four Unrelated Words Test. Canno
have decreased; she eats very little and has lost weight,
how she would plan a grocery shoppin
does not sleep through the night, has angry emotional
Mini Mental State Examination score
tb t th t lik h f d dd
x
STRUCTURE AND FUNCTION
9 Mental health assessment
express this. We can also trace language development: from the
differentiated crying at 4 weeks, the cooing at 6 weeks, through
one-word sentences at 1 year to multi-word sentences at 2 years.
Yet the concept of language as a social tool of communication
occurs around 4 to 5 years of age, coincident with the child’s
readiness to play cooperatively with other children.
Attention gradually increases in span through preschool
years so that, by school age, most children are able to sit
and concentrate on their work for a period of time. Some
children are late in developing concentration. School readiness
coincides with the development of the thought process; around
age 7, thinking becomes more logical and systematic, and the
child is able to reason and understand. Abstract thinking, the
ability to consider a hypothetical situation, usually develops
between ages 12 and 15, although a few adolescents never
achieve it. Healthy physical, psychological, emotional and
social development is all dependent on the formation of
trusting attachments with parents or caregivers (Goldberg,
Muir, Kerr, 2009). Where there has been trauma, physical or
sexual abuse or neglect in the child’s environment there will
be a disruption to development. Prolonged physical illness
can also affect a child’s mental health. This may present itself
in many ways in the healthcare setting; possibly in regressed,
sexualised or angry behaviour, developmental delay, excessive
fear, passivity or clinginess. Should you observe any unusual
behaviours while assessing children and young people, a further
enquiry is warranted. Childhood trauma is a strong precursor
to the development of mental disorders. Perinatal issues such
as illness, mental illness, birth trauma and stress can also affect
the mental health and psychological development of a child.
It is pertinent to ask some basic screening questions of parents
about pregnancy, childbirth and maternal and paternal mental
health after birth when assessing a child. This information can
be documented in the clinical history and will be very helpful
should further psychiatric assessment be required.
Family history of mental illness and the nature and dis-
position of the child are important factors to assess for and
document. Shy, sensitive, easily distressed children are more
likely to develop depression and anxiety. Most childhood
mental illness will first manifest as anxiety. Mood and anxiety
disorders also commonly occur with other health and medi-
cal conditions, including asthma, insulin resistance and other
chronic medical conditions and might affect treatment adher-
ence for these conditions (Centers for Disease Control and
Prevention, 2011).
Late adulthood (65+ years)
The ageing process leaves the parameters of mental status
mostly intact. There is no decrease in general knowledge and
little or no loss in vocabulary. Response time is slower than in
youth; it takes a bit longer for the brain to process information
and react to it. Thus performance on timed intelligence tests
may be lower for the ageing person—not because intelligence
has declined, but because it takes longer to respond to the
questions. The slower response time affects new learning; if a
new presentation is rapidly paced, the older person does not
have time to respond to it (Sadock, Sadock, Ruiz, 2009).
Recent memory, which requires some processing (e.g.
medication instructions, 24-hour diet recall, names of new
acquaintances), is somewhat decreased with ageing. Remote
memory is not affected.
135
All health assessment Chapters
(9–27) provide a clearly identified
colour-coded structure to define
the five major sections of health
assessment
Easy navigation tabs
Highlight the section within
each chapter
STRUCTURE AND FUNCTION
9 Mental health assessment
or schizophrenia). Mental status assessment documents a express this. We can also trace language development: from the
dysfunction and determines how that dysfunction affects self- differentiated crying at 4 weeks, the cooing at 6 weeks, through
care and engagement in everyday life. As with any assessment, one-word sentences at 1 year to multi-word sentences at 2 years.
it is always important to determine the previous level of Yet the concept of language as a social tool of communication
functioning and the length of time the disruption has been occurs around 4 to 5 years of age, coincident with the child’s
experienced. All diagnostic parameters for mental disorders readiness to play cooperatively with other children.
require a length of time during which the cluster of symptoms Attention gradually increases in span through preschool
has been experienced (APA, 2013). years so that, by school age, most children are able to sit
Most aspects of mental status cannot be scrutinised directly and concentrate on their work for a period of time. Some
like the characteristics of skin or heart sounds. Its functioning children are late in developing concentration. School readiness
is inferred through assessment of an individual’s behaviours: coincides with the development of the thought process; around
Consciousness: being aware of one’s own existence, feelings age 7, thinking becomes more logical and systematic, and the
and thoughts and aware of the environment. It also describes child is able to reason and understand. Abstract thinking, the
ability to consider a hypothetical situation, usually develops
the level of wakefulness in the individual. This is the most
between ages 12 and 15, although a few adolescents never
elementary of mental status functions which can be objectively
assessed using the Glasgow Coma Scale (see Ch 10). achieve it. Healthy physical, psychological, emotional and
social development is all dependent on the formation of
Language: using the voice to communicate one’s thoughts and
trusting attachments with parents or caregivers (Goldberg,
feelings. This is a basic tool of humans and its loss has a heavy
Muir, Kerr, 2009). Where there has been trauma, physical or
social impact on the individual. Language is the direct medium
sexual abuse or neglect in the child’s environment there will
through which thoughts are expressed and thereby assessed.
be a disruption to development. Prolonged physical illness
Language formation is also a highly complex cognitive function
can also affect a child’s mental health. This may present itself
and its impairment is a key early indicator of many neurological
in many ways in the healthcare setting; possibly in regressed,
as well as psychiatric conditions.
sexualised or angry behaviour, developmental delay, excessive
Mood and affect: both of these elements deal with the prevailing fear, passivity or clinginess. Should you observe any unusual
feelings; affect is a temporary expression of feelings—it is visible behaviours while assessing children and young people, a further
to the assessor in the form of facial expressions and expressed enquiry is warranted. Childhood trauma is a strong precursor
emotions—and mood is pervasive over time—how the person to the development of mental disorders. Perinatal issues such
feels internally—and is not always visible to the assessor. as illness, mental illness, birth trauma and stress can also affect
Orientation: the awareness of the objective world in relation the mental health and psychological development of a child.
to the self, specifically time, place and person. It is pertinent to ask some basic screening questions of parents
Attention: the power of concentration, the ability to focus about pregnancy, childbirth and maternal and paternal mental
health after birth when assessing a child. This information can
on one specific thing without being distracted by many
environmental or internal stimuli. be documented in the clinical history and will be very helpful
Memory: the ability to lay down and store experiences and
perceptions for later recall. Recent memory evokes day-to-day
events; remote memory brings up years worth of experiences.
should further psychiatric assessment be required.
Family history of mental illness and the nature and dis-
position of the child are important factors to assess for and
document. Shy, sensitive, easily distressed children are more
Abstract reasoning: pondering a deeper meaning beyond the
likely to develop depression and anxiety. Most childhood
concrete and literal. Abstract reasoning ability will give some mental illness will first manifest as anxiety. Mood and anxiety
cues to level of intelligence. disorders also commonly occur with other health and medi-
Th h h h k h f l d l d h l d h
Clear headings
User-friendly design
makes the text easy to use
p p j
THE NECK VESSELS
Cardiovascular assessment includes the survey of vascular
structures in the neck—the carotid artery and the jugular
veins (Fig 15.10). These vessels reflect the efficiency of cardiac
function.
The carotid artery pulse
The pulse can be described as a pressure wave generated by
each systole pumping blood into the aorta. The carotid artery
is a central artery—that is, it is close to the heart. Its timing
closely coincides with ventricular systole. (Assessment of the
peripheral pulses is found in Chapter 14, and blood pressure
assessment is found in Chapter 8.)
The carotid artery is located in the groove between the
trachea and the sternocleidomastoid muscle, medial to and
alongside that muscle. Note the characteristics of its waveform
(Fig 15.11): a smooth rapid upstroke, a summit that is rounded
and smooth and a downstroke that is more gradual and that has
a dicrotic notch caused by closure of the aortic valve (marked
D in the figure).
Jugular venous pulse and pressure
The jugular veins empty deoxygenated blood directly into
the superior vena cava. Because no cardiac valve exists to
separate the superior vena cava from the right atrium, the
jugular veins give information about activity on the right
side of the heart. Specifically, they reflect filling pressure and
volume changes. Because volume and pressure increase when
 STRUCTURE AND FUNCTION
Unit 4 Assessing cardiovascular function

Highly illustrated 12 Eye function

Aorta (arch)

Cut edge of pericardium

Full colour illustrations TABLE 12.6 Red eye—vascular disorders continued

Primary angle-closure
os
sure glaucoma
Superior vena cava
Pulmonary veins

show detailed anatomy and Angle-closure glaucoma shows a circumcorneal redness around Pulmonary artery
a shows
uppil. Pupil is oval, dilated; cornea looks
the iris, with a dilated pupil.
ham
closure glaucoma occurss with
mber is shallow. Primary angle-
‘steamy’; and anterior chamber
with sudden increase in intraocular
Pulmonary veins
Left atrium

physiology, and demonstrate

ntterior chamber outflow. The person
pressure from blocked anterior
eccrease in vision, sudden eye pain
experiences a sudden decrease Aortic valve
Pulmonic valve
and halos around lights. Itt iss often accompanied by nausea
and vomiting. This requiresre
es emergency
emergency treatment to avoid
Right atrium Mitral (AV) valve
permanent vision loss.

examination techniques and Chordae tendineae

Left ventricle

abnormal findings Tricuspid (AV) valve

Inferior vena cava

Papillary muscle

Right ventricle Endocardium

TABLE 12.7 Abnormalities on the cornea, iris and anterior chamber Myocardium

Cultural and social Figure 15.4

From RA, venous blood travels through tricuspid valve to

right ventricle (RV)
© Pat Thomas, 2006

to head
and neck

considerations 2. From RV, venous blood flows through pulmonic valve to

pulmonary artery
Pulmonary artery delivers deoxygenated blood to lungs
3. Lungs oxygenate blood
Pulmonary veins return oxygenated blood to LA to arms to arms
4. From LA, arterial blood travels through mitral valve to LV 5
Pterygium Corneal abrasion
A triangular opaque wing of bulbar conjunctiva overgrows This is the most common n result 5. LVbut
result of a blunt eye injury, ejects blood through aortic valve into aorta 3
towards the centre of the cornea. It looks membranous, irregular ridges usually vis
visible 6. Aorta
sible only when fluorescein staindelivers oxygenated blood to body. 2
translucent and yellow to white, usually invades from nasal side rad
reveals yellow-green abradedded area. Top layer of corneal
and it may obstruct vision as it covers pupil. Occurs usually from epithelium damaged, from m scratches
om Remember
scratches or poorly fitting or that the circulation is a continuous loop. The
1
chronic exposure to hot, dry, sandy climate, which stimulates the overworn contact lenses. s. Because blood
Because the area is rich is kept moving along by continually shifting pressure
in nerve 4
growth of a pinguecula (see above) into a pterygium. endings, the person feelss intense
in
ntense pain, a foreigngradients.
body sensation
The blood flows from an area of higher pressure to
and lacrimation, redness saand
nd photophobia.
one of lower pressure.

Normal CARDIAC CYCLE

The rhythmic movement of blood through the heart is the cardiac
cycle. It has two phases, diastole and systole. In diastole, the
Q CULTURAL AND SOCIAL CONSIDERATIONS ventricles relax and fill with blood. This takes up two-thirds of the
cardiac cycle. The heart’s contraction is systole. During systole,
blood is pumped from the ventricles and fills the pulmonary and
systemic arteries. This is one-third of the cardiac cycle.

There is a significant correlation with the development of mental Diastole. In diastole, the ventricles are relaxed, and the
AV valves (i.e. the tricuspid and mitral) are open (Fig 15.6).
(Opening of the normal valve is acoustically silent.) The to abdomen
health issues with specific cultural groups and social circumstances pressure in the atria is higher than that in the ventricles, so and lower
extemities

ABNO
ABNORMAL
blood pours rapidly into the ventricles. This first passive filling
within the Australian and New Zealand communities. Refer to

ADVANCED
AD
Normal anterior chamber (for contrast)

DVA
ORM
A light directed across the eye from the temporal side Hyphaema
Chapter 4 for in-depth discussion of these issues. In particular, illuminates the entire iris evenly because the normal iris is flat
and creates no shadow.
Blood in anterior chamber is i a serious
i result
lt off blunt
bl t trauma
t
(a fist or a tennis ball) or spontaneous haemorrhage. Suspect
scleral rupture or major intraocular trauma. Note that gravity

FINDINGS
Indigenous Australians are in a very high risk group for settles blood.

PRACTI
continues
suicide, and are often over-represented in the health system
in general due to multiple overlapping vulnerabilities. Careful
consideration of cultural issues must be incorporated into
assessment of Indigenous people. It is relevant for all healthcare
providers to train in cultural sensitivity and competence, as this
skill set applies across healthcare settings and can help guide the
nurse in how to ask sensitive and difficult questions (Victorian
Summary checklist
Transcultural Psychiatry Unit, 2011). Provides quick review of examination
People who have arrived in Australia or New Zealand as steps to reinforce learning
either asylum seekers (awaiting refugee status) or refugees
(confirmed status) will have endured significant hardship and
suffering throughout the various stages of their journey. This
may include exposure to torture, violence (either at a personal,
Summary Checklist
family or community level), sexual assault, persecution, extreme
EYE EXAMINATION
1. Inspect external eye structures 2. Inspect anterior eyeball 3. Test visi
• General structures • Visual
• Eyebrows • Cornea and lens • Visual
• Iris and pupil

Promoting a healthy lifestyle box • Eyelids and lashes

• Eyeballs
• Conjunctiva and sclera
• Size, shape and equality
• Pupillary light reflex

Provides examples of Health Promotion and

encouraging self care
PROMOTING A HEALTHY LIFESTYLE

AGE-RELATED MACULAR DEGENERATION

Age related macular degeneration (AMD) is the of AMD or unexplained
most common cause of visual impairment in people social history including
over the age of 50 years in the developed world, alcohol intake, assessm
and contributes 50% of all blindness in Australia 2. Visual acuity testing

Developmental considerations (Coleman, Chan, Ferris et al 2008; Deloitte Access

Economics, 2011). AMD impairs central vision by
progressive destruction of the macula, and impacts
3.
4.
5.
Near visual acuity test
Visual field testing
Central visual field test
significantly on a person’s quality of life and
Highlight the needs of specific age groups independence. This includes affecting their ability
to read, recognise faces, drive a car and watch TV.
6. Examination of the fun
macula
As this is often a bilateral condition, people with The person at risk of AM
AMD often fear complete blindness. They require
OBJECTIVE DATA

AMD needs information a

Q DEVELOPMENTAL CONSIDERATIONS
Infants and children
The maturation of emotional and cognitive functioning is
described in detail in Chapter 2. It is difficult to separate and
trace the development of just one aspect of mental status.
All aspects are interdependent. For example, consciousness
is rudimentary at birth because the cerebral cortex is not yet
developed; the infant cannot distinguish the self from the
mother’s body. Consciousness gradually develops along with
language, so that by 18 to 24 months the child learns that it
i t f bj t i th i t dh
reassurance that peripheral vision is unaffected, the onset or progression
meaning that ‘navigational’ vision is preserved. include:
The disease can be classified into early (not visually • Information on how to
impairing) and late (visually impairing) stages. Late referral to support serv
AMD can be further divided into ‘wet’ (neovascular • Advice on controlling w
changes) and ‘dry’ (atrophic changes) forms. Non- regularly
modifiable risk factors that increase the speed of • Advice on eating a wel
progression of the disease include age, genetic
ƒ Eat fish two to three
factors and ethnicity (Caucasian). Cigarette
smoking is the major lifestyle risk factor predicting
leafy vegetables and
handful of nuts a wee
the presence and development of AMD. Dietary
ƒ Choose low glycaem
antioxidants also play a role in the occurrence,
prevention and treatment of the disease. carbohydrates instea
possible.
Recent developments in the treatment of wet • Considering a suitable
AMD have resulted in some success in slowing consultation with an ey
the progression of vision loss, and in some cases (several supplements a
achieving an improvement in vision. There is currently
no effective treatment for dry AMD (Coleman et al,
formulated specifically
risk of AMD or who hav
2008; Deloitte Access Economics, 2011). Prevention the disease)
is the first approach to reducing vision loss in
persons affected by AMD. These measures focus
• Using the Amsler grid d
symptoms of AMD, for
on modifiable risk factors. By controlling such risk
factors as smoking, alcohol, high body mass index
lines or missing areas (s
• Providing adequate pro
d t (BMI) and inadequate diet the onset of AMD may be

xi
About the Australian adapting editors
Helen Forbes
RN, BAppSc (Adv Nurs) (La Trobe University), MEdStudies (Monash University), PhD (University of Sydney)
Elizabeth Watt
RN, RM, DipN (College of Nursing Australia), BAppSc (Adv Nurs) (Lincoln Institute of Health Sciences), MNS (La Trobe
University), Cert Prom Cont, FACN
Helen Forbes
Helen has a background in general adult acute care nursing
as well as a focus on care of patients following head and
neck surgery. She has extensive higher education experience
and has held various teaching and leadership roles at both
undergraduate and postgraduate levels over the past 30 years.
Her current role is Associate Head of School (Teaching &
Learning) at the School of Nursing & Midwifery, Deakin
University, Melbourne. She has vast experience in curriculum
design and development in nursing education.
Helen’s current teaching interests include clinical education,
health assessment and adult acute care nursing. She has taught
health assessment at undergraduate and postgraduate level for
many years locally and internationally.
About the US author
Carolyn Jarvis received her BSN cum laude from the
University of Iowa, her MSN from Loyola University (Chicago)
and her PhD from the University of Illinois at Chicago, with
a research interest in the physiological effect of alcohol on
the cardiovascular system. She has taught physical assessment
and critical care nursing at Rush University (Chicago), the
University of Missouri (Columbia) and the University of
Illinois (Urbana), and she has taught physical assessment,
pharmacology and pathophysiology at Illinois Wesleyan
University (Bloomington).
Dr Jarvis is a recipient of the University of Missouri’s
Superior Teaching Award; has taught physical assessment to
thousands of baccalaureate students, graduate students and
nursing professionals; has held 150 continuing education
xii
Elizabeth Watt
Liz has a background in adult acute care nursing and has also
practised in both hospital and community-based midwifery.
Her main clinical focus is in urological and continence nursing.
She has over 30 years experience in higher education, teaching
in undergraduate and postgraduate nursing programs. She is
currently Year 3 Coordinator and Course Coordinator Master
of Nursing (Urological & Continence) Course, La Trobe
University/Austin Health Clinical School of Nursing, School of
Nursing & Midwifery (Melbourne Campus). She has significant
experience in curriculum development and implementation.
Liz’s current teaching interests include urological and
continence nursing, health assessment, adult acute care nursing
and clinical education. She has taught health assessment at
undergraduate and postgraduate level for many years.
seminars; and is the author of numerous articles and textbook
contributions.
Dr Jarvis has maintained a clinical practice in advanced
practice roles—first as a cardiovascular clinical specialist in
various critical care settings and as a certified family nurse
practitioner in primary care. She is currently a Professor at Illinois
Wesleyan University; is a nurse practitioner in Bloomington,
Illinois; and is licensed as an advanced practice nurse in the
state of Illinois. During the last 8 years, her enthusiasm has
focused on using Spanish language skills to provide healthcare
in rural Guatemala and at the Community Health Care Clinic
in Bloomington. Dr Jarvis has been instrumental in developing
a synchronous teaching program for Illinois Wesleyan students
both in Barcelona, Spain and at the home campus.
Australian and New Zealand contributors
Josh Allen
GradDip Nurs Prac (CritCare), BNurs(Hons), BNurs
Lecturer in Nursing, School of Nursing and Midwifery
Deakin University, Victoria, Australia
Mari Botti
RN, BA, PhD, MRCNA
Alfred Deakin Professor, School of Nursing and Midwifery
Deakin University, Victoria, Australia
Rhonda Brown
PhD, RN, RPN, MSocSci, GradDip Comm Health, GradDip
Family Therapy, GradCert Higher Ed
Senior Lecturer, School of Nursing and Midwifery
Deakin University, Victoria, Australia
Tracey K Bucknall
RN, ICU Cert, BN, GradDip Adv Nurs, PhD
Professor of Nursing and Associate Head of School (Research)
School of Nursing and Midwifery, Faculty of Health, Deakin
University
Foundational Chair in Nursing, Alfred Health, Victoria,
Australia
Trish Burton
DipAppSc, BSc, BAppSc, MEd, PhD, FCNA
Senior Lecturer, Nursing, College of Health and Biomedicine
Victoria University, Victoria, Australia
Rebecca Corbett
RPN, MANP
Psychiatric Nurse Consultant
Mental Health, Drugs and Alcohol Education Team
Barwon Health, Victoria, Australia
Leonie Cox
RN, BA(Hons 1), PhD
Senior Lecturer, School of Nursing
Queensland University of Technology, Brisbane, Queensland,
Australia
Jessica Guinane
RN, CCRN, MN
PhD candidate, Deakin University, Burwood
Emergency Nurse, Cabrini Hospital, Malvern, Victoria,
Australia
Nicky A Hewitt
MN, GradDip Arts (Applied Nurs), BSc (Physiology), DipHE
(Critical Care), RN
Research Fellow, School of Nursing and Midwifery
Deakin University and Deakin Alfred Health Nursing
Research Centre, Alfred Health, Victoria, Australia
Clinical Nurse Specialist, Department of Critical Care Medicine,
St Vincent’s Hospital, Melbourne, Victoria, Australia
Amy NB Johnston
BSc(Hons), BN, GradDip Ad Ed, MEd, PhD, RN
Senior Lecturer, Menzies Health Institute
Griffith University, Queensland, Australia
Research Fellow, Emergency Department
Gold Coast University Hospital, Queensland, Australia
Jennifer Lillibridge
RN, MSN, PhD, CNE
Professor Emeritus, School of Nursing
California State University, Chico, California, USA
Maria Murphy
RN, PhD, GradDip (Crit Care), GradCert (TT+L), BN,
DipAppSci (Nurs)
Lecturer, Clinical School of Nursing, Austin Health
College of Science, Health and Engineering, La Trobe
University, Melbourne
Clinical Nurse Specialist, Austin Health, Melbourne, Victoria,
Australia
Elizabeth Pascoe
RN, MSc
Stream Coordinator, Postgraduate Cancer Courses, School of
Nursing and Midwifery
La Trobe University, Victoria, Australia
Fran Pearce
RN, MSc Ortho, MPE (Deakin University)
Education Coordinator, Continuing Care, Austin Health,
Melbourne, Victoria, Australia
Diane Phillips
DEd, MEd, BAppSci, RN, RM, FACN, MACM
Associate Professor
Deakin University, Faculty of Health, School of Nursing and
Midwifery, Victoria, Australia
Andrew Scanlon
DNP, MNS, NP (Australia), Adult Health NP (USA), FACN,
FACNP
Nurse Practitioner, Austin Health, Victoria
Lecturer, La Trobe University, Victoria, Australia
Sue Sharrad
RN, BEd, GradDip Intensive Care, MNurs
Lecturer, School of Nursing
The University of Adelaide, South Australia, Australia
Chris Taua
RN, BN, PGCert HSc (MH), CAdT, MN, FNZCMHN
Associate Director, Pumahara Partners, Christchurch,
New Zealand
PhD candidate, The University of Queensland, Brisbane,
Australia
xiii
Australian and New Zealand xontributors
Rebecca Thornton
MNSc, GradDip Adv Nurs (Paediatrics), DipEd, BNSc, RN
Lecturer in Nursing, School of Nursing and Midwifery
Deakin University, Victoria, Australia
Amanda Wylie
RN, MN, GCert Nursing (Clinical Education), GCert
Ophthalmic Nursing
Contributors to US edition
Chapter 1, Evidence-based assessment
Ann Eckhardt, PhD, RN
Carolyn Jarvis, PhD, APN, CNP
Chapter 2, Cultural competence
Susan Caplan, PhD, MSN, APRN-BC
Carolyn Jarvis, PhD, APN, CNP
Chapter 5, The interview
Ann Eckhardt, PhD, RN
Carolyn Jarvis, PhD, APN, CNP
Chapter 7, Domestic and family violence assessment
(cultural content)
Susan Caplan, PhD, MSN, APRN-BC
Kelsey Merl, MSN MPH, PNP-C
Shawna S Mudd, DNP, PNP-BC, CPNP-AC
Daniel J Sheridan, PhD, RN, FAAN
Chapter 9, General survey, measurement, vital signs
Ann Eckhardt, PhD, RN
Carolyn Jarvis, PhD, APN, CNP
xiv
EVOLVE CONTRIBUTORS
Trish Burton
DipAppSc, BSc, BAppSc, MEd, PhD, FCNA
Senior Lecturer, Nursing, College of Health and Biomedicine
Victoria University, Victoria, Australia
Nicole Reinke
BSc(Hons), PhD, GCert Ed, MEd
Lecturer in Physiology and Pathophysiology
University of the Sunshine Coast, Queensland, Australia
Chapter 10, Pain assessment
Sarah Jarvis, BSN, RN, DNPc
Carolyn Jarvis, PhD, APN, CNP
Chapter 11, Nutritional assessment
Joyce K Keithley, DNSc, RN, FAAN
Chapter 29, Bedside assessment and electronic health
recording (electronic health recording content)
Ann Eckhardt, PhD, RN
Carolyn Jarvis, PhD, APN, CNP
Chapter 30, Functional assessment of the older adult
Carla Graf, PhD, RN, CNS-BC
Promoting a Healthy Lifestyle feature boxes
Martha Driessnack, PhD, PNP-BC
Australian and New Zealand reviewers

Cathleen Aspinall Andrea Miller

MSc, RN, PG Cert Academic Practice BN(Hons), MCN, MEd
Professional Teaching Fellow, School of Nursing Lecturer, School of Health Sciences
University of Auckland, New Zealand University of Tasmania, Tasmania, Australia

Elspeth Hillman Jane Truscott

RN, BN, MN, GCertTert Teaching PhD, MBA, MS
Lecturer, Nursing, Midwifery & Nutrition, College of Nurse Practitioner, Aspen Medical, Australia
Healthcare Sciences, Division of Tropical Health and Medicine Senior Lecturer, Charles Darwin University, NT, Australia
James Cook University, Townsville, Queensland, Australia Senior Lecturer, CQUniversity, Queensland, Australia

Nancy McNamara Karen Wotton

MHSc, BN, RComPN, CATE RN, BN, MEd, PhD
Senior Academic Staff Member Education Consultant
Wintec, New Zealand Adelaide, South Australia, Australia

xv
Preface
Health assessment is central to nursing practice. By practising
and developing the knowledge and skills of health assessment
you will develop confidence and competence in understanding
and responding to each person’s situation. You need to listen
to the cues from the person as these will guide and direct your
questioning and physical examination. Whether you are an
undergraduate nursing student, a newly qualified registered
nurse or an experienced nurse seeking to advance your practice,
this book holds the content you need to develop and refine
your health assessment skills.
As a learner you should use this text in conjunction with
other resources such as videos, practice in skills in laboratory and
clinical settings, personal reflection on learning and progress,
and feedback which you actively seek from teachers and
clinicians. The second edition of this text is contextualised to
suit the Australian and New Zealand healthcare environments.
We hope this text will become an invaluable part of your
professional library and we look forward to ongoing feedback
from you, our readers.
NEW TO THE SECOND AUSTRALIAN
AND NEW ZEALAND EDITION
The second ANZ edition of Jarvis’s Physical Examination
& Health Assessment has been fully revised and updated for
the Australian and New Zealand contexts and structured to
enhance learning for undergraduate and postgraduate students
and clinicians.
Each chapter begins with an overview highlighting the
importance and relevance of the given topics to nursing
practice. The introductory chapter describes the purpose of
health assessment in nursing practice and how it contributes to
a multidisciplinary health assessment. All spelling, terminology,
measurements, cultural and social considerations, clinical
procedures and best practice reflect the Australian and New
Zealand contexts. In addition you will find:
• Updated contents to assist the reader to understand the
relevance of the health assessment areas to the functional
status of the person
• The addition of common laboratory studies (including normal
values) in objective data tables where relevant
• A new chapter on focused assessment integrating clinical
decision making and clinical reasoning using a real clinical
case study of a person with deteriorating health status
• A new chapter on substance abuse assessment
• A new chapter on the complete health assessment, outlining
the application of various frameworks for health assessment
(head-to-toe, body systems, functional). Clinical case
studies are provided to challenge the reader to apply
knowledge of health assessment techniques and clinical
reasoning in the planning and conduct of focused health
assessments
xvi
• Clearly identified health assessment skills in each chapter for
beginning and advanced nursing practice
• Revised clinical case studies in each chapter which illustrate
documentation and critical thinking related to the chapter
focus.
DUAL FOCUS AS TEXT AND
REFERENCE
Jarvis’s Physical Examination & Health Assessment is a text for
beginning students of health assessment as well as a text and
reference for advanced practitioners. The chapter progression
and format permit this scope without sacrificing one use for
the other.
Chapters 1 to 4 focus on approaches and contexts of
health assessment in nursing, including critical thinking,
developmental tasks and health promotion for all age groups,
and cultural safety.
Chapters 5 to 8 focus on health assessment tools and
techniques, including the health interview and health history,
physical assessment techniques, general survey, measurement
and vital signs.
Chapters 9 to 27 focus on the key areas for health
assessment which are organised around functional areas
relevant to nursing practice. Each of these chapters has five
major sections: Structure and Function, Subjective Data
(history), Objective Data (procedures and normal findings/
abnormal findings and clinical alerts), Documentation and
Critical Thinking, and Abnormal Findings. The beginning
nurse can review anatomy and physiology and learn the skills,
normal findings and common variations for generally healthy
people and selected abnormal findings in the Objective
Data sections. They will also be prompted to report and
refer clinically significant abnormal findings. The advanced
practice nurse will be able to review anatomy and physiology
and fundamental health assessment skills, while focusing on
the more complex knowledge and skills required for specialty
nursing practice. Students can also study the extensive
pathology illustrations and detailed text in the Abnormal
Findings sections.
Chapters 28 to 31 focus on utilising health assessment in
practice. Chapter 28 describes risk and safety: screening for
family violence and abuse. Chapter 29 describes risk and safety:
screening for substance abuse. Chapter 30 describes focused
assessment of the deteriorating patient. Chapter 31 outlines the
application of various frameworks for health assessment (head-
to-toe, body systems, functional).
CONCEPTUAL APPROACH
Jarvis’s Physical Examination & Health Assessment reflects a
commitment to:

• Person-centred care, in the focus on the person as a whole,
both in wellness needs and illness needs, as well as their
perceptions of their health and the impact of health issues
on their quality of life
• Health promotion and disease prevention, in the
health history questions that elicit health and lifestyle
management, the age-specific charts for periodic health
examinations, the Promoting a Healthy Lifestyle boxes, and
the self-examination teaching presented for skin, breast and
testicles
• Interacting with the person as an active participant in
healthcare, by encouraging discussion of what the person
currently is doing to promote health and by engaging the
person to participate in self-care
• Cultural and social considerations that take into account
the global society in which culturally diverse people seek
healthcare and the social determinants of health and illness
• The individual across the life span, supported by the
belief that a person’s state of health must be considered
in light of developmental stage. Chapter 3 presents a
baseline of developmental tasks and topics expected for
each age grouping, and subsequent chapters integrate
relevant developmental content. Developmental anatomy,
modifications of history taking and examination technique,
and expected findings are given for infants and children,
adolescents, pregnant women and older adults.
APPROACH TO LEARNING HEALTH
ASSESSMENT
This text has been designed to reflect clinical practice in the
Australian and New Zealand context. There has been much
debate in the nursing literature about the extent of health
assessment skills required by registered nurses and therefore
which skills need to be taught in undergraduate nursing
curricula. Research by Birks et al (2013)1 found that Australian
registered nurses are not utilising many of the physical
assessment skills being taught in undergraduate nursing
programs, nor does their role require these skills. Undergraduate
health assessment subjects are often crowded with content
that students are never likely to practise in the clinical setting.
This textbook has been designed to separate those skills that
all registered nurses require from those required by nurses in
specialty areas of practice.
FEATURES FROM THE FIRST EDITION
Jarvis’s Physical Examination & Health Assessment is built on
the strengths of the previous edition and is designed to engage
students and enhance learning:
• The two-column format begins in the Subjective Data
section, where the running column provides assessment
guidelines and clinical significance and clinical alerts. In
the Objective Data section, the running column highlights
procedures and normal findings and abnormal findings and
clinical alerts
1 Birks M, Cant R, James A et al: The use of physical assessment skills by
registered nurses in Australia: issues for nursing education, Collegian,
20(1):27–33, 2013.
Preface
• Health history (Subjective Data) is detailed in each
chapter, including history questions that elicit the person’s
perception of their health and the impact of health
problems on their quality of life. In addition, health and
life-style maintenance activities are highlighted
• Techniques and sequence of physical examination
(Objective Data section) is clear, orderly and easy to follow.
Hundreds of examination illustrations are linked directly
with the text to demonstrate the techniques in a step-by-
step format
• Abnormal Findings tables organise and expand on material
in the Objective Data section. The atlas format of these
extensive collections of pathology and original illustrations
helps students recognise, sort and describe abnormal findings
• Developmental approach in each chapter is focused on
the adult, then age-specific content for the infant, child,
adolescent, pregnant woman and older adult so that
students can learn common variations and approaches for
all age groups
• Stunning full-colour art shows detailed human anatomy,
physiology, examination techniques and abnormal findings
• Summary checklists towards the end of each chapter
provide a quick review of examination steps to help develop
a mental checklist
• Focused assessment/clinical case studies of frequently
encountered situations show the application of assessment
techniques and critical thinking to people of different ages
and in differing clinical situations
• User-friendly design and use of colour makes the book
easy to use. Frequent subheadings and instructional
headings assist in easy retrieval of material.
SUPPLEMENTS
• The EVOLVE Website (located at http://evolve.elsevier.
com/AU/Forbes/assessment) provides lecturers with
PowerPoints and Test Banks for each of the 31 chapters,
an Image Collection, a Laboratory Manual Answer Key
and a comparative table of contents. Students have access
to Appendices, Multiple Choice Review Questions, Quick
Assessments for 20 Common Conditions and WebLinks—
in effect, a comprehensive online resource that takes
advantage of the dynamic nature of electronic content and
online delivery.
• The Jarvis’s Pocket Companion for Physical Examination &
Health Assessment is a handy and current clinical reference
that provides pertinent material in full colour and includes
illustrations from the textbook.
• The Laboratory Manual is a workbook that includes a
student study guide for each chapter, glossary of key terms,
clinical objectives, regional write-up forms and review
questions.
ACKNOWLEDGMENTS
We would like to acknowledge the people who made the second
Australian and New Zealand edition of this text possible:
• Melinda McEvoy (Senior Content Strategist) for her
support and persistence in keeping us on track
xvii
Preface
• Martina Vascotto (Content Development Specialist) for her
support and keeping us organised and informed about the
publishing process
• Sybil Kesteven (Editor) for her outstanding attention to
detail and for helping us to be better writers
• Rochelle Deighton (Senior Project Manager) for her efforts
in transforming the manuscript into a textbook.
We would also like to thank our families for allowing us
to take over our respective dining room tables, computer and
study over the past two and a half years. We thank them for their
support and encouragement and for the endless cups of tea.
We would like to dedicate this edition to the nursing
students and registered nurses who will use this text to develop
xviii
their clinical skills. We encourage you to continually strive to
develop and refine your health assessment skills. Your efforts
will contribute to improving the person’s experience and the
overall quality and safety of nursing care.
To the nursing lecturers, we thank you for your continuing
motivation and encouragement of student learning in this
critical area of nursing practice.
The publisher and editors would also like to thank each of
the chapter authors and reviewers who ensured the relevance,
accuracy and strong clinical application of the content.
In this new edition we would also like to acknowledge past
contributors and reviewers who provided a strong foundation
on which we could build.
Companion resources

NEW EDITION

anion
Pocket Comp

Pocket Companion
A quick reference, health assessment resource for students on
clinical placement.

• Directly aligned to Jarvis’s Physical Examination & Health

Assessment, ANZ edition, 2e
• Content based on the most up-to-date data, clinical practice
and policies
• New chapter: Risk and Safety: Screening for Substance Abuse
• Extensive diagrams, tables and photos of examination techniques
• Highlights helpful techniques for interviewing, health history-
taking and assessment

NEW EDITION

Manual
Laboratory

Laboratory Manual
The ideal clinical preparation tool for laboratory practice.

• Directly aligned to Jarvis’s Physical Examination & Health

Assessment, ANZ edition, 2e and Jarvis’s Physical Examination
& Health Assessment Pocket Companion, ANZ edition, 2e
• New chapter: Risk and Safety: Screening for Substance Abuse
• Reading assignments for each chapter
• Critical thinking questions to test your understanding
Contents
UNIT 1 Approaches and contexts of health assessment in nursing 1
Chapter 1 The context of health assessment in nursing practice 1
Chapter 2 Critical thinking in health assessment 5
Chapter 3 Developmental tasks and health promotion across the life span 14
Chapter 4 Cultural safety: cultural considerations 38

UNIT 2 Health assessment tools and techniques 60

Chapter 5 The health assessment interview 60
Chapter 6 The health history 79
Chapter 7 Physical assessment techniques 89
Chapter 8 General survey, measurement and vital signs 101

UNIT 3 Assessing mental health, neurological and sensory function 133

Chapter 9 Mental health assessment 133
Chapter 10 Neurological function 158
Chapter 11 Pain assessment 224
Chapter 12 Eye function 241
Chapter 13 Ear function 286

UNIT 4 Assessing cardiovascular function 312

Chapter 14 Peripheral vascular assessment 312
Chapter 15 Cardiac function 339

UNIT 5 Assessing respiratory function 384

Chapter 16 Upper airways 384
Chapter 17 Lower airways 404

UNIT 6 Assessing musculoskeletal function 444

Chapter 18 Musculoskeletal function 444

UNIT 7 Assessing nutrition and metabolic function 502

Chapter 19 Nutritional and metabolic assessment 502
Chapter 20 Skin, hair and nails 544

UNIT 8 Urinary and bowel function 591

Chapter 21 Abdominal assessment 591
Chapter 22 Urinary function 627
Chapter 23 Bowel function 644

UNIT 9 Assessing sexuality and reproductive function 659

Chapter 24 Female sexual and reproductive function 659
Chapter 25 Male sexual and reproductive function 695
Chapter 26 Breast assessment 724
Chapter 27 The pregnant woman 751

UNIT 10 Utilising health assessment in practice 791

Chapter 28 Risk and safety: screening for family violence and abuse 791
Chapter 29 Risk and safety: screening for substance abuse 805
Chapter 30 Focused assessment 812
Chapter 31 The complete health assessment: putting it all together 821
Approaches and contexts of Unit
health assessment in nursing 1
Chapter One
The context of health
assessment in nursing practice
Adapted by Helen Forbes and Elizabeth Watt

Introduction
What is health?
What is nursing?

http://evolve.elsevier.com/AU/Forbes/assessment
• Test Bank
• Weblinks
• PowerPoints
• Multiple choice review questions
• Lab Manual answer key
Unit 1 Approaches and contexts of health assessment in nursing
INTRODUCTION
Assessment is the collection of data about an individual’s
health state. Throughout this text, you will be studying the
techniques of collecting and analysing subjective data (i.e.
what the person says about themself during history taking) and
objective data (i.e. what you as the health professional observe
by inspecting, percussing, palpating and auscultating during
the physical examination). Together with the patient’s record
and laboratory studies, these elements form the database of the
assessment of the person’s health.
From the database, you make a clinical judgment or diagnosis
about the individual’s health state or response to actual or risk
for health issues. Thus, the purpose of a health assessment
is to make a judgment or diagnosis. Because all healthcare
treatments and decisions are based on the data gathered during
assessment, it is paramount that the assessment be factual
and complete, providing the foundation for clinical decision
making. Chapter 2 provides more detail about the process of
clinical decision making that requires critical thinking and
health assessment.
WHAT IS HEALTH?
Assessment is the collection of data about an individual’s health
state. Therefore, a clear idea of health is important because
this determines which assessment data should be collected. In
general, the list of data that must be collected has lengthened
as our concept of health has broadened. The World Health
Organization (WHO) (2003) defines health as ‘a state of
complete physical, mental, and social well-being and not
merely the absence of disease or infirmity’. While this is a broad
definition it is important to recognise that health is an emerging
state and is not merely the absence of disease. In order to achieve
an adequate quality of life in later years, actively promoting good
health is vital throughout life. Further descriptions of health
from a cultural perspective can be found in Chapter 4.
The situations in which people are born, grow, live and
play have an important role in determining health. WHO
(2008) states: ‘The social determinants of health are the
conditions in which people are born, grow, live, work and age,
including the health system. These circumstances are shaped
by the distribution of money, power and resources at global,
national and local levels, which are themselves influenced by
policy choices. The social determinants of health are mostly
responsible for health inequities—the unfair and avoidable
differences in health status seen within and between countries.’
Therefore, conducting health assessment on a person
requires acknowledgment of both the social and the environ-
mental context in which they live. For example, consider the
discharge needs of a homeless young male patient following
a motor cycle accident. How could his wound care and
nutritional needs be managed in the community context if he
has no fixed address?
Models of health
The social model of health acknowledges the effect of social,
economic, cultural and political factors and conditions on a
person’s state of health and wellbeing. Use of the model aims
to improve health outcomes, prevent and reduce illness and
address the inequalities and disadvantage that exist within
the community. Community healthcare, as a part of primary
healthcare, is informed by the values and principles supported
2
in the Alma-Ata Declaration on Primary Health Care (WHO,
1978) and the Ottawa Charter for Health Promotion
(WHO, 1986).
The social model of health recognises:
• The social, economic and environmental determinants of
health and illness
• The importance of health promotion and disease prevention
• The importance of community participation in decision
making
• The importance of working with sectors outside the health
sector
• That equity is an important outcome of health service
intervention.
The biomedical model of western tradition views health
as the absence of disease. Health and disease are opposites,
extremes on a linear continuum. Disease is caused by specific
agents or pathogens. Thus, the biomedical focus is the diagnosis
and treatment of those pathogens and the curing of disease.
Assessment factors are a list of biophysical symptoms and signs.
The person is certified as healthy when these symptoms and
signs have been eliminated. When disease does exist, medical
diagnosis is worded to identify and explain the cause of disease.
The accurate diagnosis and treatment of illness is an
important part of healthcare but the medical model has limiting
boundaries. The public’s concept of health has expanded since
the 1950s. Now we view health in a wider context. We have
an increasing interest in lifestyle, personal habits, exercise and
nutrition, and the social and natural environment. Wellness
is a dynamic process, a move towards optimal functioning.
Different levels of wellness exist, with optimal health described
as ‘high-level wellness’. Wellness is a direction of progress.
Healthcare providers serve to maximise the person’s potential,
to assist the person to grow towards high-level wellness.
Consideration of the whole person is the essence of
holistic health. Holistic health views the mind, body and
spirit as interdependent and functioning as a whole within
the environment. Health depends on all these factors working
together. The basis of disease is multifaceted, originating both
from within the person and from the external environment.
Thus, the treatment of disease requires the services of numerous
providers.
A natural progression to health promotion and disease
prevention now rounds out our concept of health. Australian
Bureau of Statistics (2012) and the New Zealand Public Health
Advisory Committee (2006) assert that the majority of deaths
among Australians and New Zealanders under age 65 are
preventable. Prevention can be achieved through counselling by
primary care providers, which is designed to change people’s
unhealthy behaviours related to smoking, alcohol and other
drug use, lack of exercise, poor nutrition, injuries and sexually
transmitted infections. Health promotion is a much broader
concept than disease prevention. Health promotion was defined
in the Ottawa Charter for Health Promotion (WHO) (1986)
and includes building public health policy, creating supportive
environments for healthy living, strengthening community
action, developing personal knowledge and skills and reorienting
the healthcare system (Talbot and Verinder, 2013). There is
further discussion of varying cultural conceptualisations of
health in Chapter 4.

WHAT IS NURSING?
The International Council of Nurses (ICN) states that nursing
includes ‘autonomous and collaborative care of individuals of
all ages, families, groups and communities, sick or well and
in all settings. Nursing includes the promotion of health,
prevention of illness, and the care of ill, disabled and dying
people. Advocacy, promotion of a safe environment, research,
participation in shaping health policy and in patient and health
systems management, and education are also key nursing
roles’ (ICN, 2014). This implies that the nursing approach to
healthcare is holistic in nature and therefore health assessment
should reflect that philosophy with its focus on the whole
person and their context.
There is a range of clinical contexts in which you may work
as a nurse. These include community health settings, mental
healthcare, acute and critical care contexts, remote and rural
settings, rehabilitation or residential aged care. The nature
of the context will usually determine the type and focus of
health assessment required. In the community you may focus
on assessing an individual, a family or a community and be
interested in gathering information about wellness as opposed
to illness. In an acute setting, whether it is in critical care or
more general ward areas, your focus will be a little different.
Patient problems may vary across the treatment trajectory,
which means that you will time and focus your health
assessment accordingly.
In the provision of care, nurses and midwives are ethically
responsible and accountable to the recipient of care (ICN,
2012). From an ethical point of view it is expected that nurses
and midwives will respect, promote, protect and uphold the
rights of people either receiving care or providing healthcare.
The nursing and midwifery codes of ethics outline minimum
national standards of conduct that members of the professions
are expected to uphold. These codes inform the community
of the standards of professional conduct it can expect
nurses and midwives to uphold and provide the consumer,
regulatory, employing and professional bodies with a basis
for evaluating their professional conduct. The Nursing and
Midwifery Board of Australia and Nursing Council of New
Zealand codes of professional conduct provide guidelines
about expected behaviour of nurses and midwives. Nurses
and midwives are expected to conduct their practice using
exemplary standards of behaviour. In summary, it is expected
that each professional will be safe and competent and practise
in accordance with the standards of nursing and the broader
health system. Nurses must conduct their practice according to
laws relevant to nursing. Nurses and midwives are also legally
responsible for their practice and answerable to the relevant
professional registering body: the Nursing and Midwifery
Board of Australia or the Nursing Council of New Zealand.
All nurses and midwives in Australia and New Zealand must
demonstrate competence in a range of domains, one of which
relates to the conduct of comprehensive and systematic
nursing health assessment (Nursing and Midwifery Board
of Australia, 2006a,b; Nursing Council of New Zealand,
2012a–c). Advanced practice nurses, for example nurse
practitioners, also have legal requirements for competence
in their specialist area related to advanced health assessment
(Nursing and Midwifery Board of Australia, 2014; Nursing
Council of New Zealand, 2012). See the bibliography for
references to the relevant codes of ethics and professional
1 The context of health assessment in nursing practice
conduct for nurses and midwives and competency standards
in Australia and New Zealand.
Quality and safety
Once a person accesses the healthcare system for treatment
of illness, a number of factors pose potential risk for harm.
Examples include increasing age, comorbidity and the
increasing use of complex technology, the use of numerous and
complex interventions during an episode of illness, movement
between community and hospital health sectors giving rise to
possible duplication of, or gaps in, care and/or communication
breakdown. The Australian Charter of Healthcare Rights
and the New Zealand Code of Rights describes the rights of
patients and other people using the Australian or New Zealand
health systems. One of the principles of these Charters is the
recognition that every person has the right to the highest
standard of care (Australian Commission on Quality and
Safety in Health Care (ACQSHC), 2008; New Zealand Health
and Disability Commissioner, 2009). While the solutions to
decreasing risk to the person are complex, improving the use,
availability and communication of health information is critical
to the provision of high quality and safe care (ACQSHC, 2011;
Health Quality and Safety Commission New Zealand, 2013).
Quality and safe care of people requires that nurses assess
in order to determine care needs. Assessment is conducted in
collaboration with the patient and the multidisciplinary
healthcare team to achieve positive goals and health outcomes
for the recipient of care.
Life span considerations
It is important to consider health assessment from a life cycle
approach, no matter what clinical context you are working
in. First, you must be familiar with the usual and expected
developmental tasks for each age group (Ch 3). This alerts you
to which physical, psychosocial, cognitive and behavioural tasks
are important for each person. For example, if you are assessing
a 6-year-old child with asthma, your approach will need to
take into account the developmental tasks for that child’s age
group which include mastering skills that will be needed later
as an adult, building self-esteem and a positive self-concept,
adopting moral standards and taking a place in a peer group.
This knowledge will guide how you approach the collection
of subjective and objective data. The data from the physical
examination is more accurate when you consider age-specific
information about anatomy, method of examination, normal
findings and abnormal findings. For example, an average
normal respiratory rate for a 6-year-old child is 21–26 breaths
per minute.
Q CULTURAL AND SOCIAL CONSIDERATIONS
The population of Australia is in excess of 23 million; New
Zealand in excess of 4 million. The Australian community
now includes people from about 200 countries (Department
of Foreign Affairs & Trade, 2012). Similarly, the New Zealand
population includes people from over 145 countries (Statistics
New Zealand, 2010). As mentioned above, cultural and social
considerations are critical to health assessment: there is an
introduction to these concepts in Chapter 4 and the concepts
are threaded throughout the text as they relate to specific
chapters.
3
Unit 1 Approaches and contexts of health assessment in nursing
BIBLIOGRAPHY
Australian Bureau of Statistics: Causes of death, Australia, 2012.
2012. www.abs.gov.au/ausstats/abs@.nsf/Lookup/by%20Subject/
3303.0~2012~Main%20Features~Leading%20Causes%20of
%20Death~10001
Australian Commission on Quality and Safety in Health Care
(ACQSHC): Windows into Safety and Quality in Health Care
2011. Sydney, 2011, ACSQHC. www.safetyandquality.gov.au/
wp-content/uploads/2011/11/Windows-into-Safety-and-Quality-
in-Health-Care-2011.pdf
—: Australian Charter of Healthcare Rights. 2008. www.
safetyandquality.gov.au/national-priorities/charter-of-healthcare-
rights/
Department of Foreign Affairs and Trade: The land and its people.
nd. www.dfat.gov.au/about-australia/land-its-people/Pages/
population.aspx
Haig KM, Sutton S, Whittington J: SBAR: A shared mental
model for improving communication between clinicians, Joint
Commission Journal on Quality and Patient Safety, 32(3):167–175,
2006.
Health Practitioner Regulation National Law Act 2012. New Zealand.
www.ahpra.gov.au/documents/default.aspx?record=WD10/
1563&dbid=AP&chksum=b1YsKvtKyhHdnDKio5ERFA==
International Council of Nurses: The ICN definition of nursing. 2014.
www.icn.ch/about-icn/icn-definition-of-nursing/
—: The ICN code of ethics for nurses. Geneva, 2012, ICN. www.icn.
ch/images/stories/documents/about/icncode_english.pdf
Irwin A, Scali E: Action on the social determinants of health: learning
from previous experiences. Social determinants of health discussion
paper 1 (debates). 2010, WHO. http://apps.who.int/iris/bitstre
am/10665/44488/1/9789241500876_eng.pdf
Ministry of Health, New Zealand: Māori health. 2014a. www.
maorihealth.govt.nz/moh.nsf/menuma/About+Maori+Health
—: New Zealand burden of diseases, injuries and risk factors study,
2006–2016. 2014b. www.health.govt.nz/nz-health-statistics/
health-statistics-and-data-sets/new-zealand-burden-diseases-
injuries-and-risk-factors-study-2006-2016
National Health and Hospitals Reform Commission: A healthier
future for all Australians—final report of the National Health and
Hospitals Reform Commission—June 2009. Canberra, 2009,
Commonwealth of Australia. www.health.gov.au/internet/nhhrc/
publishing.nsf/Content/nhhrc-report
New Zealand College of Midwives: Code of ethics, nd. www.midwife.
org.nz/index.cfm/1,179,530,0,html/Code-of-Ethics
New Zealand Health and Disability Commissioner: Statement
of intent 2013–2016. 2013. www.hqsc.govt.nz/about-the-
commission/
—: Code of health & disability services: Consumers’ rights. 2009. www.
hdc.org.nz/media/24833/leaflet%20code%20of%20rights.pdf
Nursing and Midwifery Board of Australia: Nurse Practitioner
standards for practice. 2014. www.nursingmidwiferyboard.gov.au/
Codes-Guidelines-Statements/Codes-Guidelines.aspx
—: Code of ethics for nurses in Australia. 2008a. www.
nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/
Codes-Guidelines.aspx#codesofethics
4
—: Code of professional conduct for nurses in Australia. 2008b. www.
nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/
Codes-Guidelines.aspx#codesofethics
—: National competency standards for the midwife. 2006a. www.
nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/
Codes-Guidelines.aspx
—: National competency standards for the registered nurse. 2006b.
www.nursingmidwiferyboard.gov.au/Codes-Guidelines-
Statements/Codes-Guidelines.aspx
Nursing Council of New Zealand: Code of conduct for nurses. 2012a.
www.nursingcouncil.org.nz/Nurses/Code-of-Conduct
—: The competencies for registered nurses. 2012b. www.
nursingcouncil.org.nz/Nurses/Continuing-competence
—: The competencies for the nurse practitioner scope of practice. 2012c.
www.nursingcouncil.org.nz/Nurses/Continuing-competence
Public Health Advisory Committee: Health is everyone’s business:
Working together for health and wellbeing, Wellington, New
Zealand, 2006, Public Health Advisory Committee. http://
nhc.health.govt.nz/archived-publications/phac-publications-
pre-2011/health-everyones-business-working-together-
healthworking-together-health
Statistics New Zealand: National population estimates: December 2009
quarter. 2010. www.stats.govt.nz/browse_for_stats/population/
estimates_and_projections/NationalPopulationEstimates_
HOTPDec09qtr.aspx
Talbot L, Verinder G: Promoting health: A primary health care
approach, 5th edn. Chatswood, NSW, 2013, Churchill
Livingstone Elsevier.
World Health Organization (WHO): Towards health-equitable
globalisation: rights, regulation and redistribution. Final report
to the Commission on Social Determinants of Health. 2007.
www.who.int/social_determinants/resources/gkn_final_
report_042008.pdf?ua=1
—: Definition of health. 2003. www.who.int/about/definition/en/
print.html
—: Men, ageing and health. Geneva, 2001, WHO. http://
whqlibdoc.who.int/hq/2001/who_nmh_nph_01.2.pdf
—: Ottawa Charter for Health Promotion. 1986. www.who.int/
healthpromotion/conferences/previous/ottawa/en/
—: Declaration of Alma-Ata, 1978. www.who.int/hpr/NPH/docs/
declaration_almaata.pdf
—: Preamble to the Constitution of the World Health Organization as
adopted by the International Health Conference, New York, 19–22
June, 1946.
Websites
Australian Commission on Quality and Safety in Health Care.
www.safetyandquality.gov.au/
Australian Health Practitioner Regulation Agency. www.ahpra.gov.
au/index.php
Health Quality and Safety Commission New Zealand. www.hqsc.
govt.nz/
Another random document with
no related content on Scribd:
The Project Gutenberg eBook of Kansankapina
Ahvenanmaalla v. 1808
This ebook is for the use of anyone anywhere in the United States
and most other parts of the world at no cost and with almost no
restrictions whatsoever. You may copy it, give it away or re-use it
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Title: Kansankapina Ahvenanmaalla v. 1808

Author: J. Säilä

Release date: September 11, 2023 [eBook #71613]

Language: Finnish

Original publication: Tampere: Uusi Kirjapaino, 1896

Credits: Tuula Temonen

*** START OF THE PROJECT GUTENBERG EBOOK

KANSANKAPINA AHVENANMAALLA V. 1808 ***
KANSANKAPINA AHVENANMAALLA V. 1808

Sommitteli

J. J. [J. Säilä]

Tampereella, Uuden Kirjapaino-yhtiön Kirjapainossa, 1896.

Tuo meren aaltojen huuhtelema Ahvenan saaristo, ollen Suomen

ja Ruotsin välillä, on usein ollut sodan jaloissa niiden useiden sotain
aikana, joita Venäjä kävi Ruotsia vastaan Suomen omistuksesta.

Niin tapahtui sotavuosinakin 1808-1809.

Kun sotatorvet alkoivat soida Suomen saloilla, niin pian kajahteli

niiden räikeä ääni Ahvenanmaan kallioistakin.

Venäjän ylipäällikkö Buxhoewden oli maaliskuun 25 p. v. 1808

ottanut Turun pääkortteerikseen ja jo huhtikuun 2 p. näkivät
ahvenanmaalaiset kauhukseen noita, kansan kesken hirmutunteella,
mainitulta kasakoita vanhan raunioiksi riutuneen Kastelholman
linnan edustalla. Kuitenkaan ei ollut tämä peljätyn vihollisen
äkkinäinen ilmestys muuta kuin uhkaus, pieni pilven hattara
Ahvenanmaan vielä kirkkaalla taivaalla. Yhtä pian kuin viholliset
ilmestyivät yhtä pian he taas katosivatkin. Tarkoitus heidän
käynneillään ei ollutkaan muu, kuin viedä Kastelholman
kruununmakasiinista viljavaroja pääarmeijalle Suomessa.

Mutta kohta oli idän rohkea kotka levittävä siipensä lentoon yli
meren ja ulapoiden iskeäkeeen kyntensä lännen monista taisteluista
uupuneesen jalopeuraan.

Katselkaamme hetkisen tuota sota näytelmää, missä esiripun

noustua on ihailtavanamme kaksi urosta, joiden ympärillä
sotatapaukset tuolla rauhallisella saaristolla kietoutuvat, jossa ei
isoon aikaan oltu nähty muuta taistelua, kuin minkä meren lakkapäät
laineet taistelevat sen riuttasia rantoja vastaan.

*****

Kevät ihanine toiveineen oli tullut. Elettiin toivossa, että tuo

jääsilta, jota pitkin vihollinen niin helposti pääsi Ahvenanmaalle, oli
pian särkyvä ja sulava. Myös oli toivoa meren auetessa, suojaa ja
turvaa Ruotsin laivastosta.

Toisin oli kuitenkin käyvä.

Kauhistuneina herättiin näistä suloisista unelmista, kun jo

huhtikuun puolivälissä kaksi venäläistä vihollisosastoa esiintyi
saaristossa. Ne olivat sekä kasakoita että jääkäreitä. 120 miehinen
joukkio jääkäreitä, majuri von Nejdbardtin johdolla, valloitti Ahvenan
mantereen ja ylipäällikkö eversti Kritsch asettui 500 miehen kanssa
Kumlingen pitäjään. Sitäpaitsi sijoitettiin kasakoita vartijoiksi eri
paikkoihin, aina Ruotsin puoleisesta läheisemmästä paikasta,
Signildskäristä, Brändösen saakka, mikä on Ahvenan saariston
äärimmäinen paikka Suomen puolella.

Nuo kauhistuttavat muistot entisistä sota-ajoista, mitkä polvesta

polveen olivat kulkeneet kansan suussa, tulivat nyt mielikuvituksen
tenhovoimalla ilmieläviksi. Isonvihan hirmuisten aikojen, jolloin
kansan täytyi jättää kotonsa kylmille ja paeta Ruotsiin, luultiin nyt
uudelleen koittavan. Mutta tässä erehdyttiin. Paljon olivat muuttuneet
sadan vuoden kuluessa. Venäjän istuimella istui nyt ruhtinas, joka,
ollen lempeä ja jalomielinen luonteeltaan, harrasti kansansa parasta
ja tahtoi muodostaa sotilaittensakin tapoja ihmismäisiksi.

Mutta sota on sotaa! Se tuo mukanaan rasituksia, jopa raskaitakin.

Sitä saivat saaristolaisetkin kokea.

Niin esim, käyttivät venäläiset heidän vetojuhtiaan yöt päivät ilman

maksutta, kuormainsa kuljetukseen. Se jo enensi tuon
luonnonomaisen vastenmielisyyden vihollista vastaan vielä
suuremmaksi.

Mutta mielet vasta silloin kuohahtivat kuohuksiin kun venäläisten

päällikkö antoi ahvenalaisille erään luonnottoman käskyn, jota oli
mahdoton täyttää. Ja sepä se yllättikin vapauttaan rakastavan
kansan julkiseen vastarintaan niin että se tarttui aseisiin
karkoittaakseen vihollisen maasta taikka kunnialla kuollakseen sen
edestä.

Majuri Nejdhardt antoi nimittäin venäläisen päällystön nimessä,

toukokuun 3 p:nä, seuraavan käskyn Ahvenanmaan silloiselle
kruununvoudille:
 1) Että kaikki alukset, 8 laidan suuruuteen saakka, olivat
siirrettävät sellaisiin valkamiin, joista niillä oli helpoin päästä merille.

2) Että kaikki aseet, olkoot millaiset hyvänsä, olivat annettavat

ruunun miesten haltuun paitsi säätyläisten omistamat.

3) Että kaikki laivat olivat neljänkolmatta tunnin kuluessa pantavat

purjehduskuntoon ja jää valkamissa rikottava niin pitkältä, että samat
laivat, mitä pikemmin saattoivat purjehtia.

Se olikin tämän määräyksen kolmas kohta, mikä sittemmin tuotti

turmion venäläisille.

Tuo lyhyt aika, jolloin määräys oli täsmälleen täytettävä, osoitti

suurinta järjettömyyttä. Ja tätä järjettömyyttä lisäsi vielä nuo
hirvittävät uhkaukset hengen ja omaisuuden menettämisestä, ellei
käskyä määrätyn ajan kuluessa täytettäisi. Vieläpä uhattiin leikata
vastahakaisilta korvat ja nenäkin sekä lähettää heidät Siperiaan.

Tarkoitus tällä määräyksellä oli arvattavasti se, että venäläiset,

ollen etäällä pääarmeijastaan ja lähellä Ruotsia, olisivat vaaran
hetkenä tilaisuudessa päästä pikemmin pakosalle.

Hämmästystä ja kauhistusta levitti tuo määräys uhkauksineen

saaristolaisissa. Huhu levisi, että venäläisten varsinainen aikomus,
laivain panemiselle purjehduskuntoon, olikin kuljettaa niillä
asekuntoinen saaristokansa Venäjälle. Ja tämä se partailleen panikin
mielet kuohumaan. Kuitenkaan ei ole syytä luulla tuota huhua
todenperäiseksi.

Mutta määräys oli toteltava. Silloinen kruununvouti Taxell lähetti

kiireimmittäin käskyn kaikille piirinsä nimismiehille tuon määräyksen
pikaisesta täyttämisestä. Mahdotonta oli se kuitenkin täyttää. Tosin
noudatti kansa kussakin nimismiespiirissä käskyä ja miehissä
ponnistettiin voimat uuvuksiin asti; mutta määräys jäi kuin jäikin
toteuttamatta luonnon esteitten vuoksi.

Mikä nyt neuvoksi? kyseltiin toinen toisiltaan. Oltiin aivan

tyhmistyneet, ei tietty mitä tehdä. Vihollisen uhkaukset kasvoivat
hirviöiksi kansan mielikuvituksessa. Synkkänä ja uhkamielisenä
kokoontui kansa kussakin paikkakunnassa neuvottelemaan. Aika oli
jo kulunut 6 p:vään toukokuuta.

Mutta missä vaara on suurin, siinä on apukin lähinnä. Tuona

Ahvenanmaan aikakirjoissa niin merkillisenä päivänä saapui
muutamia kansan miehiä Finströmin pitäjän nimismiehen, Erik
Arén’in luo neuvottelemaan. Kansa luotti häneen ja sentähden tultiin
nyt neuvoa häneltä saamaan.

Turhaan ei häneltä kysyttykään neuvoa. Rohkea ajatus leimahti

silloin tuon uljaan nimismiehen sielussa. Siitä, näet riippui
Ahvenanmaan pelastus tai kukistus.

Uljaasti sanoi hän nyt miehilie, ettei ollut muuta neuvoa enään
jäljellä kuin yksimielisesti karkoittaa vihollinen pois ja vapauttaa maa
raskaasta rasituksesta. Sentähden oli yleinen kansan kapina vielä
saman päiwän ehtoona klo 8 pantava toimeen. Kaikki alukset olivat
poistettavat rannoilta loitommaksi, ettei venäläiset pääsisi
pakenemaan ja äkkiä yllätettävä heidän kimppuunsa sijoitus
asemissaan. Ensin aikoi hän itse tehdä ylläkön vihollisten päällikön
pääkortteeriin. Strömsvikin kartanoon, missä Nejdhardt 10 kasakan
kanssa majaili ruununvouti Taxell'in luona.
 Päätös oli tehty. Salaman tavoin olivat Arén’in uljaat sanat
sytyttäneet miesten mielet. Tuo synkkyys, mikä äsken kuvastui
heidän kasvoissaan, oli nyt kadonnut ja uljuus loisti nyt silmistä.

*****

Mutta tutustukaamme ensin erääseen toiseen urheamieliseen

mieheen, joka
Arén’in kanssa jakaa kunnian Ahvenanmaan pelastuksesta.

Hengen miekkaa on hän tottunut käyttämään tähän asti, mutta me

tulemme näkemään hänen yhtä taitavasti osaavan käyttää
teräsmiekkaakin.

Tuolla istuu hän huoneessaan ajatellen arvatenkin maansa

tukalaa tilaa.
Apulaispappi on hän Finströmin pitäjässä; nimensä on Henrik
Juhana
Gummerrus. Sana saapuu hänelle Arénilta kiiruhtamaan hänen
luokseen.
Pian onkin hän valmis lähtemään ja suoralla, rohkealla suomalaisella
luonteellaan hyväksyy hän paikalla Arén'in tuumat.

Muistettava on tuo hetki, jolloin nuo molemmat isänmaalliset

miehet
Arén’in asunnossa keskustelivat Ahvenanmaan tulevaisuudesta.

Yhdessä he sitten koko tämän omituisen kansan sodan aikana

johtivat kansaa taistelussa vihollista vastaan.

Varustukseensa ei Gummerus tuhlannut kallista aikaa. Arén’ilta sai

hän vanhan miekan, vyökseen sitaisi hän punaisen sukkanauhan ja
niin oli hän maallisesti varustettu.

Kokoontuneille talonpojille piti hän lyhyen puheen. Suoraan

tunnusti hän yritystä vaikeaksi, mutta kuitenkaan ei ollut mitään
pelättävää, kun oli kysymyksessä velvollisuuden täyttäminen, johon
rakkaus kuninkaasen, isänmaahan ja vapauteen velvoitti heitä.

Valtava oli puheen vaikutus. Talonpojat riensivät kukin

kotiseudulleen ilmoittamaan tapauksesta. Helppoa olikin saattaa
sanoma ylt'ympäri, kun talonpojat kukin kotiseudullaan olivat
kokoontuneet määräpaikkoihin jään rikkomista vartan.

Salaman nopeudella lensi nyt, yöllä vasten lauvantaita, toukokuun

7 päivää, kehotus taisteluun Ahvenanmaan rauhallisissa seuduissa
herättäen kansaa synkkämielisyydestään.

Ihmeellinen muutos tapahtui nyt kansassa. Tuo muutoin iloinen,

kohtelias ja rauhallinen saaristolainen muuttui yhdellä haavaa
uhkamieliseksi. Hänen vihansa kääntyi yhtä paljon venäläisiä
vastaan kuin maan säätyläisiäkin vastaan, joita hän samoin piti
vihollisina kuin edellisiäkin, koska säätyläiset ei ollenkaan edistäneet
tätä yritystä, vaan koettivatpa vielä estelläkin sitä.

Kuitenkaan ei tapahtunut yhtään murhaa koko tämän kansan

sodan aikana ja siihen oli syynä etupäässä päälliköiden järjestyksen
pito sekä tuo hyvä luontoisuus, mikä on ahvenalaisen luonteen
pohjana. Mutta yhteiskunnallinen järjestys rikkoutui kuitenkin ja
muutaman päivän kuluessa oli Ahvenanmaa sotaisen tasavallan
kaltainen, jossa ei noudatettu kenenkään muun käskyjä kuin Arén’in
ja Gummeruksen.
 Tosin ei puuttunut niitäkään, jotka kokivat rauhoittaa kansaa
kuvailemalla kuinka vaarallista olisi nousta vihollista vastaan, jolla jo
oli koko etelä-Suomi vallassaan, mutta he eivät voineet sen
enempää pidättää isänmaallisuudesta ja vapaudesta innostunutta
kansaa, kuin heikot takeet voivat estää paisuvaa kevätvirtaa
tulvailemasta.

*****

Kaunis oli keväinen ilta toukokuun 6 p:nä, kun klo 9 j.pp. nähtiin
erityinen joukkio verkalleen liikkuvan koilliseen suuntaan Finströmin
pitäjän Bambölen kylästä, missä Arén'in asunto oli. Siinä oli sankarit
Arén ja Gummerus ratsain ja heitä seuraa 100 Finströmin
talonpoikaa jalkaisin, enimmät varustettuina terävillä seipäillä, syystä
että ennenmainitun venäläisten käskyn johdosta ampuma-aseet
olivat riistetyt pois. Harvalla ainoastaan oli tuo tunnettu, mainio
hyljeslinkku. Arénin vanhemman veljen, Malmbergin johdolla
lähetettiin Hammarlandiin 30 miestä estämään vihollisen pakoa,
mutta itse pääjoukko marssi Strömsvikiin vihollispäällikön
pääkortteeriin siten yhdellä iskulla masentaaksean vihollisen.

Mutta sinne saapuneina huomasivat ahvenalaiset harmikseen

Nejdhardtin joukkoineen paenneen. Arvattavasti oli hän saanut vihiä
ahvenalaisten aikeista ja rientänyt isäntänsä, tuon epäiltävän
kruununvouti Taxell’in kanssa pakoon.

Hetkeksi lamautti tämä ahvenalaisten intoa. Mutta hetkeksi vain!

Sillä tuossa tuokiossa päättivät Arén ia Gummerus

rientomarssissa kiiruhtaa Färjsundin salmelle, mikä syvään
pistävänä Ahvenan mantereesen jakaa sen kahtia ja on
luonnollisena rajana itäisen ja läntisen Ahvenan välillä. Täten
aikoivat he ajoissa estää vihollisen yhtymistä suuremmaksi voimaksi
ja valloittamalla Färjsundin katkaista Nejdhardt’ilta tilaisuuden koota
joukkojaan, jotka, kuten ennen on mainittu, olivat sijoitetut eri
haaroille Ahvenan mannerta.

Tuo luonnon ihana Färjsund oli nyt ensimmäinen näyttämö, missä

ahvenalaisten miehuus tuli näkyviin. Kohta sinne saavuttuaan otettiin
neljä vihollista vangiksi.

Mutta pian lähestyy yön juhlallisessa hiljaisuudessa tuon leveän

salmen rasvatyyntä vedenpintaa myöten lautta täynnä jääkäriä ja
kasakoita, joiden aikomus on tietysti joutua Nejdhardtin avuksi,
Lautan tultua Finströmin puoliselle rannalle hyökkäävät rohkeat
talonpojat hämmästynyttä vihollista vastaan, jonka he vangitsevat.
Tässä taistelussa ottivat Arén ja Gummerus kumpikin
kasakkahevosen ja miekan ja nyt olivat he mielestään
"kelposotilaan" näköisiä.

Mutta vihollisia oli vielä toisella eli Saltvikin puolisella rannalla ja

aavistaen vaaraa rupesivat he kiivaasti ampumaan, mutta
tähdätessään liian korkealle eivät he osunneet kehenkään.
Ahvenalaiset vastasivat manioilla hyljepyssyillään, joilla
saaristolainen 500— 600 sylen päästä takaa maaliin.

Omituisen juhlallista oli yön hämärässä nähdä tuliluikkujen

säkenöivää leimahtelemista kuulla luotien vinkunaa ja pauketta
kallioihin hälveten taistelevien huutoon ja meluun. Vihdoin kuitenkin
oli venäläisten pakeneminen hakattuansa ensin lauttatouvin poikki,
estääkseen siten talonpoikien pääsyä Saltvikin eli Färjsundin itäiselle
rannalle. Mainitaan, että vähäinen joukko ahvenalaisia olisi
huomaamatta mennyt salmen yli ja kiertänyt viholliset, jonka vuoksi
heidän oli pakoon painuminen.
 Näin päättyi taistelu Färjsund’illa ahvenalaisten voitoksi.
Mahtavasti elähytti se kansan toiveita ja innostutti sitä uusiin
ponnistuksiin.

Paljon oli kuitenkin vielä tehtävää ennenkuin voitiin vapaasti

hengittää. Kaikkialla oli kansa tarttunut aseisiin ja kaikkialla, missä
vain vihollisia löytyi, häädettiin ne pois.

Aikaa ei ollut lepoon eikä liian iloisiin pitoihin.

Samana yönä, jolloin Färjsund'issa taisteltiin, tekivät

Hammarlannin miehet sukkelan tempun vihollisille.

Lähellä Marsundia, mikä eroittaa Hammarlannin Ekkeröstä,

vietettiin par’aikaa häitä eräässä talossa. Kun tieto levisi tänne
Arén’in ja Gummerruksen rohkeasta ylläköstä, niin jäi häiden vietto
sikseen. Ei kuulunut enään hääsoittelua, eikä haluttanut
hyppelykään ketään. Vakavuus ja totisuus kuvautui äsken niin
iloisilla kasvoilla. Miehenpuoli hääväestä, jopa sulhokin, jättäen
morsiamensa, joutuu intoihinsa ja lähtee siltavouti Vadmanin
johtamana vihollista hätyyttämään, mikä retki päättyikin niin
onnellisesti, että viholliset, joita oli 7 miestä eräässä talossa,
joutuivat tuota pikaa lyhyen taistelun perästä hääväen vangiksi.
Mutta Ekkerön puolelta rientää kasakkaparvi auttamaan tovereitaan.
Talonpojat rientävät vastaan huutaen heille, että antautuisivat ja
kasakat nähdessään vastustuksen turhaksi antautuvatkin. Heitä oli
14 kasakkaa.

Edellä on mainittu, että Arén’in veli, Malmberg määrättiin retkelle

Trömsvik’iin 30 miehen kanssa rientämään Hammarlantiin Emkarbyn
kestikievariin. Mutta ennenkuin hän sinne ehti, olivat hollimiehet
vanginneet mainitussa kestikievarissa maijailevat 6 venäläistä ja
sulkeneet erääsen kamariin. Näitä läksi Malmberg, kun Hammarland
nyt oli vapaa venäläisistä, viemään Godbybyn, mikä on lähellä
Färjsund’ia. Tiellä sinne tapasivat ahvenalaiset Neijdhardtin
adjutantin luutnantti Schröder’in, joka kovuudestaan, jolla hän pakotti
talonpoikia täyttämään Nejdhardt’in ennen mainittua luonnotonta
käskyä, oli tehnyt itsensä erittäin vihatuksi. Huolettomana ratsasti
Schröder eteenpäin, mutta huomattuaan vangitut venäläiset,
talonpoikien keskellä, kannusti hän hevosensa pakoon. Samassa
kuului laukaus ja luoti lävisti Schröderin hatun riipaisten hänen
päästänsä aivojen kohdalta. Tajutona putosi hän hevosensa seljästä
ja pistettiin toisten vankien joukkoon. Samalla kun Malmberg, tuli
myös äsken mainittu hääjoukkokin vangittujen vihollisten kanssa
Godbyhyn.

*****

Jo alkoi päivä koittaa toukokuun 7 p:nä. Luonto heräsi yön

syleilystä linnut virittivät aamusäveleitään puiden latvoissa. Mutta ei
näkynyt maanmies nythankkivan rauhallisiin töihin. Ei kuulut kuten
tavallisesti, iloisia lauluja mailta eikä vesiltä — taisteluintoisen
kansan ääniä vain.

Färjsund’in syvään veteen, tuossa kun se jyrkkien kallioitten

kupehessa tyynenä vielä uinahteli, rupesi aurinko sirottelemaan
kultiaan, kun kookas, roteva mies ratsun seljässä 20 miehen
seuraamana ratsastaa ylöspäin mäenrinnettä Finströmin puolella. Se
on Gummerus, joka suomatta itselleen lepoa rientää Jomalan pitäjän
taistelutantereelle. Arén’in jätti hän Färjsundia vartioimaan.

Tarkastellessa Ahvenanmaan saaristoinaan kansaa, huomaa sen

olevan, vaikka onkin ylt’yleensä ruotsalainen eri pitäjissä erilaisen.
Esim. Kumlingen talonpoika on kookas ja laihanlainen, jota vastoin
Kökarin luotolainen on lyhyt ja kokoonpuristunut varreltaan,
Kumpikaan heistä ei ole taas mannerahvenalaisen kaltainen. Kielikin
eroittaa heidät suuresti toisistaan, Mutta mantereellakin huomataan
nä’össä niinkuin luonteessakin eroavaisuutta kansalle. Jomalan
pitäjäläiset eroavat toisista mannermaalaisista rotevan kasvunsa,
levottoman luonteensa ja rohkeutensa puolesta. Missä ikinä he
sotavuonna 1808 näyttäytyivät, siellä vapisivat maan vihatut
säätyläiset, joiden luultiin pitävän yhtä vihollisten kanssa.

Ei missään pitäjässä leimahtanut sodan liekki uhkeampana kuin

Jomalassa. Koko seurakunta oli kuin tulta syöksevä vuori. Viholliset,
jotka olivat sijoitetut ylt’ympäri pitäjän, joutuivat pian tuon rohkean ja
pelottoman kansan edessä allekynteen. Erittäin ansaitsee kaksi
kansan miestä jälkimaailman muiston. Ne olivat Jansson Överbysta
ja Erik Henriksson Jomalan kylästä. Missä miehuutta kysyttiin ja
vaara oli suurin, siellä nähtiin hekin etumaisina rientävän taistelun
vimmaan, Vielä tänäänkin mainitsee Jomalan mies ylpeydellä heidän
nimiänsä.

Eipä siis ihmettä, että kun sanoma saapui Jomalaan yritettävästä

ylläköstä venäläisiä vastaan, kansanomainen kiihko tulistui
täydelliseksi raivoksi.

Niinpä Öfvernäsin kylässä vangittiin 20 venäläistä lyhyen taistelun

perästä. Samoin tapahtui Hambruddon yksinäisessä kylässä, jossa
toistakymmentä vihollista majaili. Mutta Godtbyn kylässä oli
sattumalta kaksi kasakkaa, joista toinen, oikea jättiläinen, vasta
kovan taistelun perästä voitettiin. Jomalan kirkon juurella riehui
niinikään ankara kahakka, kun Gummerus joukkoineen saapui
avuksi. Yksi upseeri ja 13 venäläistä jääkäriä otettiin siinä vangiksi.
 Mutta vaikka voitto oli jokapaikassa ahvenalaisten, niin ei ollut se
kuitenkaan vielä täydellinen niinkauvan kuin ylipäällikkö Nejdhardt oli
kateissa. Kaikin paikoin etsittiin häntä. Luulossa hänen piileksivät
Jomalan pappilassakin, riensivät pitäjäläiset häntä sieltä etsimään.

Iloista ei suinkaan ollut silloiselle kirkkoherralle Hambraeus’elle,

nähdä raivostuneitten seurakuntalaistensa ryntäävän, lauvantai
aamuna, toukokuun 7:nä p:nä, pappilaan. Puettuna yö nuttuun ja
patalakkiin astui tuo 60 vuotinen vanhus hillittömän joukon eteen,
vakuutellen Nejdhardtin ei olevan pappilassa.

Mutta Jomalalaiset eivät ottaneet sitä uskoaksensa, vaan etsivät

pakenijaa kaikkialta pappilan huoneista. Vihdoin nähtyään
hakemisensa turhaksi, läksivät he matkoihinsa, jättäen
Hammarlannin miesten vartioimaan pappilaa. Silloinpa vasta tulikin
kirkkoherran olo tukalaksi, sillä nuo vieraan pitäjän miehet
käyttäytyivät kerrassaan sopimattomasti. He tunkeutuivat kellariin,
joivat, metelöivät ja saartivat pappilan kokonaan kuten vihollisen
linnan ainakin. Kirkkoherra oli kun vanki omassa talossaan. Tämä
kohtalo vaikutti sen, että hän jälemmin siirtyi Jomalasta Ruotsiin.

Nejdhardt oli jo aikoja ennen pappilan hevoisilla, päässyt

pakenemaan. Mutta kuitenkin oli hänen, välttääkseen kansan
huomiota, jättäminen pian hevoset erään kylän lähelle sekä
harhaileminen kahden kasakan seurassa Grelsbyn latokartanon ja
Finströmin pappilan välillä. Gummerus määräsi kruununvouti Taxellin
nimismiesten avulla tarkasti häntä etsimään. Epätoivon ja nälän
rasittamana esiintyi hän sittemmin kohta vapaaehtoisesti Finströmin
pappilassa, missä hän antautui.

Arén ja Malmberg veivät hänen muutamaa päivää myöhemmin

Ruotsiin.
 Nejdhardt kuvaillaan sotilaaksi kiireestä kantapäähän asti,
kookkaaksi ruhtinasmoisella, esiintymisellä, miellyttävillä kasvoilla
sekä ylpeäksi ja pontevaksi luonteeltaan.

*****

Ei ollut vuorokausi kulunut kun vihollinen oli kukistettu länteisellä

elikkä isommalla osalla Ahvenaa. Mutta vielä oli vihollisia itäisellä
puoliskolla ja saarilla. Niitä kukistamaan oli nyt rientäminen.

Että ahvenalaisilla tässä omituisessa kansan sodassa oli niin

arvaamaton menestys riippui erittäinkin päälliköitten viisaista, hyvin
tehdyistä suunnitelmista ja siitä nopeudesta, millä nuo suunnitelmat
pantiin täytäntöön.

Gummerus ja Arén yhtyivät taas Godbyssä lähteäkseen vihollisia

ahdistamaan itäpuolelta Ahvenaa.

Lauvantaina, toukokuun 7 p:nä, astuivat nuo uljaat miehet

hevostensa selkään ja, johtaen joukkojaan, suunnittivat he nyt
kulkuaan Bomarsund’iin. Tällä matkalla liittyi heihin Saltvikin ja
Sundin pitäjistä lisäväkeä. Mutta saapuneina Bomarsund’iin ei ollut
venäläisiä enään sielläkään. Vasta Töftössä, Vårdön puolella,
huomattiin vihollisen eräällä niityllä ponnistelevan voimiaan
saadakseen muutama alus vesille. Lukuisa oli vihollisjoukko ja hyvin
varustettu. Sitävastoin oli ahvenalaisilla enimmäkseen vain noita
hätäkeihäitä (teroitettuja seipäitä), joita tosin vihollinen luuli
varsinaisiksi sotaaseiksi, vaan joista ei ollut apua täydellisillä sota-
aseilla varustettua vihollista vastaan. Kummako sitten, että
hetkellinen pelko valtasi talonpoikien mielet!
 Mutta muutama sana päälliköiltä Korkeamman voimasta ja
velvollisuudesta täyttämään mitä niin kunniallisesti oli aljettu, palautti
talonpoikain itseluottamuksen. Nyt valmistauttiin hyökkäykseen, 3
miestä kussakin rivissä, Arén ja Gummerus ratsastaen kummallakin
puolella. Juoksujalassa, hurraata huutaen, rynnättiin vihollista
vastaan. Hämmästyneet venäläiset luulivat näkevänsä varsinaista
ruotsalaista sotaväkeä, eivätkä ehtineet ampua tuskin laukausta,
kuin jo venäläiset upseerit komensivat miehiään antautumaan sekä
lähestyivät hattu kädessä, ahvenalaisia suostuttaaksensa heitä.
Silmänräypäykseasä riisuivat talonpojat nyt sotamiehiltä aseet ja
venäläiset, luvultaan 130 miestä ja 6 kasakkaa, olivat nyt vankina.
Arén ja Gummerus pitivät nyt tarkkaa huolta ett’ei vangitulta pahoin
kohdeltaisi. Ja ansaitsevatkin ahvenalaiset kiitokset vankeinsa
hyvästä kohtelusta. Nämäkin venäläiset vietiin entisten lisäksi
Godbyhyn.

*****

Mainittu on jo, että säätyläiset ja virkamiehet eivät ottaneet osaa

tähän kansan sotaan, vaan vieläpä kieltelivätkin kansaa. Tämän
vuoksi kääntyi kansan viha heitäkin vastaan. Heitä vangittiin, missä
vaan heitä tavattiin ja olivatpa he joskus hengen vaarassakin. Niin
vangittiin tuo jo ennen mainittu epäilyksen alainen kruununvouti
Taxell. Niinikään vangittiin henkikirjuri Vallin, tirehtööri Lignell,
kirkkoherran apulainen Andströmer, maanmittari Dahlén poikineen
sekä maanmittarit Fontell ja Granell. Nämä viimeksimainitut, jotka
olivat tunnetut innokkaiksi Backus’en suosijoiksi, istuivat eräänä
päivänä aivan levollisina eräässä talossa Saltvik’issä valmistetellen
karttoja venäläisille. Arvaamatta ilmestyi 8 Jomalan pitäjän miestä
etsimään heitä. Fontell pyysi silloin vähän "karvaanpuolta"
vahvistuakseen, mutta talonpojat vangitsivat kummankin ja veivät
heidät pois häkkirattaissa. Nimismiehet Bomansson ja Linqvist
vangittiin niinikään, vaikka jälkimmäinen sittemmin päästettiin irti.
Että virkamiehet olisivat olleet salakähmässä vihollisten kanssa ei
ole kuitenkaan todeksi näytetty.

*****

Jo nyt voi siis koko manner-Ahvena riemuita vapaudestaan. Mutta

kaikki vaarat eivät vielä siltä olleet hälvenneet; vielä vallitsi eversti
Vritsch päävoiman kanssa Kumlingessä. Ehkäpä olikin Ahvenen tila
nyt vaarallisempi kuin kansansodan alussa. Ainoastaan osa
vihollisista oli vasta kukistettu, suurin joukko oli vielä luodolla, joita
helposti voidaan puolustaa hyökkääjiä vastaan. Sitäpaitsi saattoivat
venäläiset koska hyvään jäiden lähdettyä, vihoissaan ja raivossaan
tulla manner-Ahvenaan ja verisesti kostaa ahvenalaisille. Ettei tämä
kuitenkaan tapahtunut siitä on ahvenalaisten kiittäminen pientä
ruotsalaista laivastoa luutnantti von Kapfelman'in johdolla, joka jo 6
p:nä toukokuuta saapui Kumlingen kohdalle.

Toukokuun 9 p:nä sai Gummerus tiedon laivaton tulosta

Kumlingeen ja luutnantti Kapfelman’ilta pyynnön saapumaan hänen
avukseen. Paikalla lähetti Gummerus sanansaattajille kehoituksen,
että miehen kustakin talosta oli valmistauminen retkelle Kumlingeen.

Kehoitusta noudatettiin mitä suurimmalla alttiudella ja jo saman

päivän ehtoolla läksi Gummerus 300 miehen joukon kanssa aluksilla,
meren ulapan yli, Kumlingeen. Laivaston osasto, jota Gummerus itse
johti, kulki Värdon eteläpuolitse ja viivähti pimeimmän osan yöstä
Bergön saaren kohdalla, jota vastoin toinen osasto purjehti
Märsshagan ja Sottungan välitse.