ADVANCED SKILLS
Clinical Judgment – Assessment
Learning Objective-
§ Describe the role of the nurse in ensuring continuity of care between and among patient care settings.
§ Discuss considerations for establishing an effective nurse - patient relationship when admitting a patient to a healthcare setting.
§ Discuss transfer of patients within and among healthcare setting.
§ Describe the components of discharge planning in providing continuity of care.
§ Demonstrate knowledge and ability to admit/discharge a patient.
§ Identify the purposes of a clinical (focused) assessment.
§ Describe the techniques used during an assessment.
o Identifying normal and abnormal heart, breath and bowel sounds.
o Obtaining a pulse.
· Apical
· Femoral
· Popliteal
· Posterior tibial
· Dorsalis pedis
· Carotid
· Brachial
· Radial
· Temporal
o Assessing for Pulse Deficits
o Use of a Doppler
· Fetal Heart Rate
· Pulse Identification
§ Conduct a head to toe assessment in a systematic manner, identifying normal and abnormal findings.
§ Document significant findings in a concise, descriptive manner.
§ Identify the functions and signs of dysfunction of the 12 cranial nerves.
§ Demonstrate methods for assessing motor system function.
§ Identify the major reflexes and describe normal and abnormal responses.
§ Discuss the use of the Glasgow Coma Scale as an assessment tool for neurological status.
§ Differentiate levels of consciousness for alert, lethargic, obtunded, and comatose.
§ Describe the procedure for performing a finger stick for blood glucose monitoring.
§ State the limits for blood glucose which require treatment for hypoglycemia and hyperglycemia.
§ Describe the procedure necessary to collect the following specimens for specific tests and the nursing care required before during and after collection.
· wound
· blood
· cerebrospinal fluid
· throat
· sputum
· urine
· stool
A. Shift / Head to Toe Assessment
Required Text and Resources:
Yoost & Crawford (2016). Fundamentals of Nursing, Chapters 6 and 20
McKinney (2013). Maternal & Child Nursing (4th ed.) Chapter 33
Lewis (2014). Medical-Surgical Nursing (9thed.) Chapter 3, Applicable Chapters
Jarvis (2016). Pocket companion for Physical Examination & Health Assessment (7th ed.). Applicable Chapters
Mosby video series. Nursing Concepts Online. Advanced Skills – Clinical Judgement, Assessments
View on BlackBoard:
CD-ROM #4075 – The 10 Minute Assessment of the Adult – Inpatient Assessment
Practicum:
Practice a clinical (focused) assessment on a peer.
Have an instructor individually evaluate your ability to perform a clinical assessment.
Document your findings in the EHR (Electronic Health Record).
B. Heart & Breath Sounds
Required Text and Resources:
Yoost & Crawford (2016). Fundamentals of Nursing, Chapters 6 and 20
McKinney (2013). Maternal & Child Nursing (4th ed.) Chapter 33
Lewis (2014). Medical-Surgical Nursing (9th ed.) Chapters 26, 32
Jarvis (2016). Pocket companion for Physical Examination & Health Assessment (7th ed.). Chapters 11 & 12
Mosby video series. Nursing Concepts Online. Advanced Skills – Clinical Judgement, Assessing the Head and Thorax
Practicum:
Practice listening to heart, breath and bowel sounds, utilizing the lung/heart sound simulator in the Skills Lab.
Practice listening to heart, breath and bowel sounds on a peer and on family members.
C. Locating Pulses/Apical Pulse
Required Text and Resources:
Yoost & Crawford (2016). Fundamentals of Nursing, Chapters 6 and 20 Jarvis (2016). Pocket companion for Physical Examination & Health Assessment (7th ed.). Chapter 13
McKinney (2013). Maternal & Child Nursing (4thed.) Chapter 33
Lewis (2014). Medical-Surgical Nursing (9thed.) Chapter 32
Mosby Video Series. Nursing Concepts Online – Clinical Judgement, Assessing the Head and Thorax
Mosby video series. Nursing Concepts Online. Advanced Skills – Clinical Judgement Assessing the Peripheral Vascular System
Practicum:
Have two peers review your ability to assess apical pulse and palpate pulse sites.
Have a peer review your understanding of assessing pulse deficits.
Have an instructor individually evaluate your ability to assess apical pulse and palpate pulse sites.
D. Fetal Heart Tone/Doppler Assessment
Required Text and Resources:
Yoost & Crawford (2016). Fundamentals of Nursing, Chapter 20
McKinney (2013). Maternal & Child Nursing (4thed.) Chapter 18
Lewis (2014). Medical-Surgical Nursing (9th ed.), Chapter 38
Jarvis (2016). Pocket companion for Physical Examination & Health Assessment (7th ed.). Chapter 13
Practicum:
Have a peer review your ability to count FHR (fetal heart rate) using audiotapes in library.
Have a peer review your ability to use the Doppler following instructions from the manufacturer.
E. Pain Assessment
Required Text and Resources:
Yoost & Crawford (2016) Fundamentals of Nursing, Chapters 19 and 36
McKinney (2013). Maternal & Child Nursing (4thed.) Chapter 39
Mosby video series. Nursing Concepts Online. Advanced Skills – Assessing Pain
Practicum:
Review the Wong Baker Faces Pain Assessment Tool and the 0-10 Pain Assessment Scale.
F. Admission & Discharge
Required Text and Resources:
Yoost & Crawford (2016) Fundamentals of Nursing, Chapters 6 and 20
Practicum:
Complete an admission and discharge on a peer.
Document your findings in the EHR for evaluation by an instructor.
G. Functional Ability Assessment
Required Text and Resources:
Yoost & Crawford (2016) Fundamentals of Nursing, Chapters 20, 27 and 31
Lewis (2014) Medical –Surgical Nursing (9th ed.), Chapter 56
Jarvis (2016). Pocket companion for Physical Examination & Health Assessment (7th ed.). Chapter 16
Katz Index of Independence in Activities of Daily Living (ADL) http://consultgerirn.org/uploads/File/trythis/try_this_2.pdf
The Lawton Instrumental Activities of Daily Living (IADL) Scale http://consultgerirn.org/uploads/File/trythis/try_this_23.pdf
Practicum:
Review with a peer the 12 cranial nerves set up in the skills lab.
Have a peer review your ability to assess cranial nerves, motor function, reflexes, and sensory perception.
Discuss with a peer the use of the Glasgow Coma Scale as an assessment tool for neurological status.
Discuss with a peer the Katz Index of Independence in Activities of Daily Living (ADL).
Discuss with a peer the Lawton Instrumental Activities of Daily Living (IADL) Scale.
H. Diagnostic Testing/Specimen Collection
1. Specimen collection
2. Glucose monitoring
Required Text and Resources:
Yoost & Crawford (2016). Fundamentals of Nursing, Chapter 34
Mosby video series. Nursing Concepts Online. Advanced Skills – Clinical Judgement, Specimen collection
Practicum:
Practice using glucometers located in skills lab to perform control testing. DO NOT perform a finger stick on your peer.
Have a peer review your skill in monitoring for blood glucose.
Inspect various specimen collection supplies and demonstrate understanding of proper collection, control and testing procedures for point of care specimens.
Inspect various specimen collection supplies and demonstrate understanding of proper collection, labeling and transportation techniques for specimens to be tested in the laboratory.
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