El Camino College

Associate Degree

Nursing Program

Nursing 155

Health Assessment

1.0 unit

Fall 2007/SPRING 2008

PRINTED EXCLUSIVELY FOR THE EL CAMINO COLLEGE BOOKSTORE

N 155 HEALTH ASSESSMENT

N 155 COURSE DESCRIPTION

Students will develop and utilize health assessment skills necessary to care for clients. The focus will be on describing normal findings and common abnormalities observed in physical assessments of clients. Students will perform physical assessments, explain the pathophysiology of common abnormalities, and document assessment findings.

N 155 ENTRY COMPETENCIES

Students should enter N155 with knowledge of the normal pathophysiology of cardiac, respiratory, musculoskeletal, and peripheral vascular systems. Students should be familiar with the physical assessment and physical assessment techniques taught in N150.

N 155 STUDENT LEARNING OUTCOMES

At the end of N155 the student will be able to complete a physical assessment of a client identifying normal and common abnormal findings. The student will be able to document their findings in a concise and accurate format.

N 155 COURSE OBJECTIVES

  1. Gather data for a health history from an adult client.
  2. Perform a physical assessment on an adult client incorporating the cardiac, respiratory, peripheral vascular, abdominal, musculoskeletal, lymphatic, head, eyes, ears, nose, and throat (HEENT), and neurological systems.
  3. Identify normal body landmarks that correspond to underlying structures on the anterior and posterior chest wall of a client.
  4. Identify common abnormal assessment findings.
  5. Compare and contrast the pathophysiology of normal and abnormal assessment findings.
  6. Evaluate the impact of abnormal assessment findings on a client.
  7. Document assessment findings utilizing a problem-based format.
  8. Formulate a priority nursing diagnosis based upon assessment findings.
  9. Complete a comprehensive health history (in the clinical setting).

N 155 UNIT OBJECTIVES:

At the end of each Module the student will:

Module One

  1. Explain the purpose and components of the health history.
  2. Describe effective and ineffective interviewing techniques.
  3. Gather appropriate data for each health history component: biographic data, health and illness patterns, health promotion patterns, role and relationship patterns, and a summary of health history data.
  4. Describe modifications needed to accommodate the client’s structural variables and basic needs.
  5. Document a health history utilizing AIE format.
  6. Identify the steps in the nursing process and how they are used in collecting data for a history and physical.
  7. Explain how the subjective and objective data gathered during assessment relate to the nursing process.
  8. Identify methods of collecting and organizing nursing assessment data: interviewing and observation.
  9. Identify the steps of the Mini Mental State Exam

Module II

  1. Discuss the purpose and components of the physical assessment.
  2. Describe the equipment required to perform the physical assessment and demonstrate its use.
  3. Identify the purpose of the following physical exam techniques: inspection, auscultation, palpation, and percussion.
  4. Demonstrate the techniques of inspection, auscultation, palpation, and percussion.
  5. Describe how to perform a general survey on an adult client.
  6. Utilize an adult simulator to perform a health assessment.
  7. Identify the normal anatomy and physiology of the Integumentary system.

Module III

  1. Identify the normal anatomy and physiology of the head, eye, ears, nose and throat (HEENT).
  2. Identify common abnormal findings (TMJ).
  3. Document normal and abnormal findings of the HEENT exam using appropriate terminology.

Module IV

  1. Identify the anatomic structures and physiologic functions of the respiratory system.
  2. Describe the mechanics of respiration.
  3. Demonstrate how to inspect, auscultate, palpate, and percuss respiratory system structures.
  4. Describe the normal findings of the respiratory system detected by inspection, auscultation, palpation, and percussion.
  5. Describe the most common abnormal findings of the respiratory system (rales, rhonchi, wheezes, nasal flaring, clubbing, position for breathing, pursed-lip breathing, use of accessory muscles, sternal retractions) detected by inspection, auscultation, palpation, and percussion.
  6. Document normal and abnormal findings of the respiratory system using appropriate terminology.

Module V

  1. Identify the anatomic structures and physiologic function of the heart (chambers and valves).
  2. Trace the blood flow through the pulmonary and coronary and systemic circulation.
  3. Explain the events of the cardiac cycle (systole and diastole).
  4. Differentiate between normal and abnormal findings of the cardiovascular system during inspection and auscultation (lifts, heaves, pulsations, S1, S2, Split S2
  5. Demonstrate auscultation of the aortic, pulmonic, tricuspid and mitral areas and describe heart sounds normally auscultated at each site.
  6. Describe common abnormal findings on auscultation of the heart (murmurs)
  7. Document normal and abnormal findings of the CV system using appropriate terminology.
  8. Identify the anatomic location of all peripheral pulses.
  9. Review rate, rhythm, and strength of pulses.
  10. Assess for jugular venous distention (JVD).
  11. Describe common abnormal findings of the peripheral vascular system (bruits and JVD) detected by inspection, auscultation and palpation.

Module VI

  1. Demonstrate how to perform an abdominal assessment on an adult client.
  2. Identify and locate (by inspection, auscultation, palpation and percussion) the organs of the gastrointestinal system (liver).
  3. Differentiate between normal and abnormal findings detected on physical assessment of the GI system (contour, pulsations, Borborygmi, ascites, rebound tenderness, guarding, hypo/hyperactive sounds, and solid mass).
  4. Document normal and abnormal findings of the GI systems using appropriate terminology.
  5. Identify normal breast tissue.
  6. Perform a breast examination on a simulator
  7. Describe common abnormal findings (orange peel, dimpling) on inspection and palpation of breast tissue.
  8. Describe Testicular Self Exam

Module VII

  1. Describe the normal anatomy and physiology of the musculoskeletal system.
  2. Identify developmental musculoskeletal system variations (scoliosis, lordosis, kyphosis, and TMJ).
  3. Explain overall body symmetry, gait, posture, and muscle and joint functions.
  4. Describe systematic palpation of muscles, bones, joints, ROM, and muscle strength.
  5. Document normal and abnormal findings of the musculoskeletal system using appropriate terminology.
  6. Identify the major components of the central nervous system (CNS).
  7. Identify the function and assess the 12 cranial nerves.
  8. Explain the difference between a neurologic screening test, a complete neurologic assessment, and a neuro check.
  9. Describe how to assess a client’s level of consciousness.
  10. Compare and rate deep tendon reflexes (DTR’s) of the biceps, triceps, brachioradialis, patellar and Achilles.
  11. Document common findings on inspection, palpation, percussion and auscultation of the Musculoskeletal and Nervous Systems using appropriate terminology.

N 155 UNIT HOURS:

This is a one unit nursing course, consisting of lecture and lab.

N 155 PREREQUISITES:

Successful completion of N150, N151, and N152.

N 155 COURSE PLACEMENT:

This course is offered during the second eight weeks of the second semester of the nursing program.

N 155 REQUIRED TEXTS/EQUIPMENT

Jarvis, C. (2004). Physical examination and health assessment (4th ed.).

Philadelphia: W.B. Saunders Co.

A dual head or single head (cardiac) stethoscope is required for lab and pen light.

N 155 RECOMMENDED TEXTS

Any pocket edition for Physical Assessment is acceptable.

N 155 METHODS OF INSTRUCTION:

Case Studies

Lectures and demonstrations of a sequenced basic physical exam and a cognitive status exam

Discussion of typical findings in a basic adult assessment

Group projects focused on use of assessment skills

Handouts related to various aspects of course content

Hands on physical examination practice

N 155 LEARNING ACTIVITIES

Reading (Reading list will be provided).

Assigned or recommended content in texts and references related to normal and abnormal findings in basic physical assessment of the adult.

Documentation of history and physical findings on a sample client record

Demonstration of a timed, observed comprehensive basic physical examination

Observe, interpret and analyze client behavior

Demonstration of use of clinical assessment skills

Practice skills in the lab on student colleagues.

N 155 FACULTY RESPONSIBILITIES:

Faculty will be prepared and present to assist students in the learning lab.

Faculty will present weekly lectures. Faculty will be available to students during office hours.

N 155 STUDENT RESPONSIBILITIES:

Students will be responsible for arriving to lecture and lab on time, having completed reading assignments. Students will be responsible for reviewing previously learned material for class. Students will provide their own stethoscopes, penlight and wrist watch with second hand.

The student is responsible for demonstrating all behavioral objectives of the course. Clinical evaluation is based on demonstrated ability to achieve all course objectives by the last day of classes. Course expectations include attendance and experiential learning.

N 155 STUDENT-FACULTY COMMUNICATION:

Faculty office hours will be posted on faculty offices. Lab faculty should provide their availability to students.

For the didactic component of the course, students should communicate with the lecturer. For the lab component of the course, students should communicate with the lab instructor(s).

*All students and faculty have El Camino College e-mail addresses which will be utilized throughout this course. Students are required to check their El Camino College email address routinely in that course information and updates will be sent via email periodically throughout the semester. Students are responsible for all information sent to them via their El Camino account.

N 155 ATTENDANCE POLICY:

Course expectations include attendance and experiential learning. Students must successfully pass the final practical examination to complete the course.

N 155 GRADING POLICY:

The standard nursing criteria will be utilized in the calculation of all grades. The minimum grade points are as follows

92-100% A / 83-87% B / 77-78% C / 65-72% D
90-91% A- / 81-82% B- / 75-76% C- / 63-64% D-
88-89% B+ / 79-80% C+ / 73-74% D+ / 62% or less F

N 155 METHODS OF EVALUATION:

Quizzes

Four short 10 point quizzes will be given at the beginning of specified labs. The content of each quiz will relate to the readings assigned for that day. Students who arrive late will not be able to make up missed quizzes. Each quiz will be worth 10 points (10% of grade).

Lab activity documentation:

Complete and accurate documentation of assessment findings completed during clinical labs.There will be a total of 8 (eight) documentation assignments each worth 5 points for a total of 40 points (40% of grade).

Final Practicum (Pass/Fail): This consists of performing a head to toe exam within 15 minutes. Students must pass this in order to pass the class.

Grading:

Quizzes 440%

Health History20%

Weekly lab documentation 40%

Total 100%

N155 WRITTEN HOMEWORK: HEALTH HISTORY

Students are required to complete a health history on an adult client in their clinical setting (see paper format example on the course website). You will be given a Health History form for this assignment by one of the course lecturers. If you are not in a clinical setting during this semester, please notify your instructor.

Grading for the Health History: 20 Points

Subjective data gathered 10 Points

Identify 3 relationships between structural variables and basic needs

based on subjective data gathered with rationale and references6 Points

Identify 1 Actual and 1 ‘Risk for’ NANDA approved Nursing Diagnosis (must be written properly) 2 Points

APA Format/Grammar (see below)2 Points

Total 20 Points

NOTE: You must follow APA guidelines when writing this paper. This includes format, spelling, and grammar written at a college level. If you do not follow these guidelines and/or have an unacceptable number of grammatical/spelling errors, you will receive an automatic 50% (10 points) on this assignment. NO second chance will be granted after the due date.

Final Practicum

N155 Health Assessment

Outline Lecture 1

Kim Baily RN, MSN, PhD

  • Health Assessment
  • Purpose
  • Assessment
  • Nursing Assessment
  • Interviewing
  • What is an interview?
  • Factors affecting the interview
  • Internal factors
  • Liking others
  • Empathy
  • Active Listening
  • External Factors
  • Privacy
  • Interruptions
  • Physical environment
  • Dress
  • Note taking
  • Stages of the Interview
  • Orientation
  • Introductions
  • Purpose of interview
  • Length of interview
  • Developing therapeutic relationship
  • Working Phase
  • Termination
  • Working Phase
  • Gathering data
  • Open-ended questions
  • Close ended questions
  • Therapeutic Communication Techniques
  • Facilitation
  • Paraphrasing
  • Restating
  • Reflections
  • Focusing
  • Clarifying
  • Silence
  • Confrontation
  • Summarizations
  • One question at a time
  • Ten Traps of Interviewing
  • False reassurance
  • Giving unwanted advice
  • Using authority
  • Using avoidance language
  • Distance
  • Using medical jargon
  • Using leading or biased questions
  • Talking too much!
  • Interrupting
  • Asking “why”
  • Check your non/verbal body language
  • Yawning
  • Body turned away
  • Facial expression
  • Lack of eye contact
  • Gesticulations
  • Touching
  • Termination of Interview
  • Summarize important findings
  • Check with client if there is anything else they would like to discuss
  • Explain what the next step will be
  • Provide information
  • Cross Cultural Communication
  • Etiquette
  • Proxemics
  • Intimate space – within 6 inches
  • Personal space – 6 inches to 4 feet
  • Social space – 4 to 12 feet
  • Public space – more than 12 feet
  • Comfort zone
  • The Complete Health History
  • Biographical data
  • Reason for seeking care (Was called “Chief Complaint” but this has negative connotation)
  • Present health or history of present illness
  • Past history
  • Family history
  • Review of systems
  • Functional assessment or activities of daily living
  • Terminology Review
  • Symptom – Subjective sensation
  • Sign – Objective observations
  • Sources of Data
  • Primary
  • Secondary
  • Biographical Data
  • Reason for Seeking Care
  • Want the client to describe their problem in their own words
  • Do not interpret or rephrase complaint
  • Do not use “Chief Complaint”
  • Present Health or History of Present Illness
  • Chronological record of why pt seeking care
  • Characteristics of symptom:
  • Location
  • Character or quality
  • Quantity or severity
  • Timing
  • Setting
  • Aggravating or relieving factors
  • Associated factors
  • Patient’s perception
  • Analysis of Symptoms
  • PQRST Mnemonic
  • P: Provocative or palliative
  • Q: Quality or quantity
  • R: Region or radiation
  • S: Severity scale
  • T: Timing
  • U: Understand patient’s perception
  • Past Health
  • List of past problems,
  • Childhood illness
  • Chronic illness – dm 1, congenital heart dx,
  • Accidents and injuries
  • Hospitalizations and Operations:
  • Obstetric history
  • Immunizations
  • Last examination date
  • Allergies
  • Current medications
  • Family History
  • Genogram
  • Review of Systems (ROS)
  • Done to ensure no significant data was overlooked
  • Also asks about health promotion practices
  • Series of “yes” or “no” questions
  • Begins with general health (weight loss, fatigue, weakness, fever, chills present weight)
  • Remember, if your client has an acute problem, every other body system will be affected
  • If any positive findings from ROS, always do an analysis of the symptom (PQRSTU) on that finding
  • Functional Assessment
  • ADLs and self care ability;
  • Activity/exercise
  • Sleep/rest
  • Nutrition/elimination
  • Interpersonal relationships/resources
  • Coping and stress management
  • Personal habits
  • Alcohol
  • Street drugs
  • Environment/hazards
  • Occupational health
  • Perception of Health
  • How do you define health?
  • How do you view your situation now?
  • What do you think will happen in the future?
  • What are your health goals?
  • Self-esteem, self-concept
  • What are your concerns/goals?
  • What do you expect from your health care providers?
  • Mental Status Examination
  • Examination - ABCT
  • Appearance
  • Posture, body movement, dress, grooming and hygiene
  • Behavior
  • Level of consciousness
  • Alert- awake or easily aroused
  • Lethargic- not fully alert, drifts off when not stimulated
  • Obtunded- sleeps most times, difficult to arouse (loud noise, vigorous shaking or pain)
  • Stupor- need persistent loud noise or pain for arousal; responds to stimuli
  • Coma- no response
  • Acute confusional state (delirium)
  • Facial expression
  • Speech
  • Mood and affect
  • Cognition
  • Orientation (Person, time, place and purpose)
  • Attention span
  • Recent memory
  • Remote memory
  • New learning—the four unrelated words test
  • Judgment
  • Thought processes
  • Thought processes
  • Thought content
  • Perceptions
  • Screen for suicidal thoughts
  • Mini Mental State Exam
  • Orientation
  • Registration
  • Attention and calculation
  • Recall
  • Language
  • Glascow Coma Scale
  • Eye opening
  • Best Verbal responsiveness
  • Best Motor responsiveness
  • Reminders - Review
  • Cultural Assessment Page 48-49
  • Developmental Considerations for adult and older adult in Chapter 2.

Note: All remaining lecture outlines will be found at

Outlines should be printed out each week before lecture.

N155 WEEK 1 – LAB

1. INTERVIEW TO OBTAIN A HEALTH HISTORY (SEE HEALTH HISTORY FORM)

  • Work in groups of three
  • Student 1 – Interviewer
  • “Interview” patient. Remember interviewing techniques, therapeutic communication and body language”
  • Analyze any symptoms using PQRSTU mnemonic
  • Document interview findings on below:
  • Pick one problem and write a SOAP note on this form – hand into both documents to lab instructor
  • Student 2 – Interviewee (client)
  • Pretend to be a patient with a new medical condition and a chronic health problem (do not discuss with Student 1 or 3)
  • Student 3 Recorder
  • Silently observe “nurse” and ‘patient”. Make notes on interview technique, including types of questions asked and body language of both nurse and client. You will provide constructive feedback to the “nurse” regarding interview technique.
  • Each student should attempt each role and hand in Health Form and SOAP note.

DOCUMENTATION:

Summarize findings using SOAP note:

Subjective:

Objective:

Assessment:

Plan

Nursing Diagnosis

Based on the subjective data collected above, identify one applicable nursing diagnosis and/or collaborative problems. Write a complete nursing diagnosis using the PES format. If you need help writing a correct nursing diagnosis please ask lab faculty.

2. COMPLETE MINI-MENTAL STATE EXAM

  • Work in pairs to complete Mini-Mental State Exam

Name of Interviewer (Nurse): ______

Date: ______

EL CAMINO COLLEGE