NUR 307 Syllabus Fall 2010 1 Stephen F. Austin State University DeWitt School of Nursing ASSESSMENT ACROSS THE LIFESPAN Course Number: NUR 307 Section Number(s): 001 – 008 Clinical Section(s): 010 – 017 Fall 2010 Course Instructor Tammy Harris, MSN, RN, FNP-BC Clinical Only Instructors Della Connor, MSN, RN, FNP-BC Sherry Van Meter, MSN, RN ALL INFORMATION IN THIS SYLLABUS IS SUBJECT TO THE WRITTEN POLICIES AND PROCEDURES OF THE SCHOOL OF NURSING, STEPHEN F. AUSTIN STATE UNIVERSITY, NACOGDOCHES, TEXAS. IN THE CASE OF COMMISSION, OMISSION, AMBIGUITY, VAGUENESS, OR CONFLICT, THE POLICIES AND PROCEDURES OF THE SCHOOL OF NURSING SHALL CONTROL. EACH STUDENT SHALL BE RESPONSIBLE FOR ACTUAL AND/OR CONSTRUCTIVE KNOWLEDGE OF THE POLICIES AND PROCEDURES OF THE SCHOOL OF NURSING AND FOR COMPLIANCE THEREWITH. EACH STUDENT IS RESPONSIBLE FOR ALL INFORMATION IN THIS SYLLABUS. This syllabus is provided for informational purposes only.
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NUR 307 Syllabus
Fall 2010
1
Stephen F. Austin State University
DeWitt School of Nursing
ASSESSMENT ACROSS THE LIFESPAN
Course Number: NUR 307
Section Number(s): 001 – 008
Clinical Section(s): 010 – 017
Fall 2010
Course Instructor
Tammy Harris, MSN, RN, FNP-BC
Clinical Only Instructors
Della Connor, MSN, RN, FNP-BC
Sherry Van Meter, MSN, RN
ALL INFORMATION IN THIS SYLLABUS IS SUBJECT TO THE WRITTEN POLICIES AND
PROCEDURES OF THE SCHOOL OF NURSING, STEPHEN F. AUSTIN STATE UNIVERSITY,
NACOGDOCHES, TEXAS.
IN THE CASE OF COMMISSION, OMISSION, AMBIGUITY, VAGUENESS, OR CONFLICT, THE
POLICIES AND PROCEDURES OF THE SCHOOL OF NURSING SHALL CONTROL.
EACH STUDENT SHALL BE RESPONSIBLE FOR ACTUAL AND/OR CONSTRUCTIVE
KNOWLEDGE OF THE POLICIES AND PROCEDURES OF THE SCHOOL OF NURSING AND
FOR COMPLIANCE THEREWITH.
EACH STUDENT IS RESPONSIBLE FOR ALL INFORMATION IN THIS SYLLABUS.
This syllabus is provided for informational purposes only.
NUR 307 Syllabus
Fall 2010
2
Faculty Contact Information:
Name: Tammy Harris
Department: Nursing
Email: [email protected]
Phone: (936) 468-7719
Office: Room #158
Office Hours: Wednesday 10:00 – 2:00
Thursday 3:00 – 5:00
Friday 8:00 – 12:00
Or by appointment
Name: Della Connor (Clinical Only)
Department: Nursing
Email: [email protected]
Office Phone: (936) 468-7718
Office: Room # 156
Office Hours: Monday 8:00 – 10:00
Tuesday 8:00 – 12:00
Wednesday 1:00 – 5:00
Or by appointment
Name: Sherry Van Meter (Clinical Only)
Department: Nursing
Email: [email protected]
Office Phone: (936) 468-7708
Office: Room #126
Office Hours: To be announced
Class meeting time and place
Lecture: Monday 8:00 – 10:30 Room #107 (All Sections)
Lab: Monday 10:30-12:00 Room #121 (Assignments to lab will be made)
Monday 1:00-2:30 Room #121
Monday 2:30-4:00 Room #121
Monday 4:00-5:30 Room #121
Textbooks and Materials
Mosby’s Guide to Physical Examination – Text and Mosby’s Nursing Video Skills:
Physical Examination and Health Assessment Package, 6th
ed., Seidel, Mosby,
ISBN No. 978-0-323-05390-7
Health Assessment Kit: Will be handed out on the 1st day of class.
Stethoscope: Littmann is my preference, but not required. We will discuss requirements on 1st day of
class
NUR 307 Syllabus
Fall 2010
3
Course Description This course builds on a prerequisite knowledge base from the humanities, arts, sciences, and previous and
concurrent nursing courses to provide students with an opportunity for the acquisition and application of
nursing assessment skills for clients across the lifespan. The course emphasizes normal assessment findings,
professional communication skills, and the nursing process to provide a basis for critical thinking and decision
making in the holistic care of clients of diverse spiritual, socio-economic, and ethno-cultural backgrounds and
beginning collaboration with interdisciplinary healthcare team members.
Number of Credit Hours
2 credit hours (1 lecture/3 clinical practicum)
Course Prerequisites and Co-requisites
Prerequisites: NUR 304, NUR 305, Admission to Nursing Program
Co-requisites: NURS 306, NURS 308
Program Learning Outcomes Graduates of the program will:
1. Apply knowledge of the physical, social, and behavioral sciences in the provision of nursing care based
on theory and evidence based practice.
2. Deliver nursing care within established legal and ethical parameters in collaboration with clients and
members of the interdisciplinary health care team.
3. Provide holistic nursing care to clients while respecting individual and cultural diversity.
4. Demonstrate effective leadership that fosters independent thinking, use of informatics, and collaborative
communication in the management of nursing care.
5. Assume responsibility and accountability for quality improvement and delivery of safe and effective
nursing care.
6. Serve as an advocate for clients and for the profession of nursing.
7. Demonstrate continuing competence, growth, and development in the profession of nursing
General Education Core Curriculum Objectives/Outcomes
None
Student Learning Outcomes The student will:
1. Relate concepts and principles of the arts, sciences, humanities, and nursing assessment as sources for
making nursing practice decisions.
2. Demonstrate responsibility and accountability using consistent behavior patterns and professional
communication.
3. Identify moral, ethical, economic, and legal issues affecting nursing assessment.
4. Utilize the nursing process when assessing clients of diverse developmental levels, spiritual, socio-
economic, and ethno-cultural backgrounds.
5. Develop principle elements of nursing assessment skills.
6. Distinguish normal from abnormal findings in the assessment of clients.
7. Document assessment findings clearly and succinctly.
8. Interact with interdisciplinary healthcare team members to integrate socio-economic, spiritual, and
ethno-cultural factors for holistic client assessment and care.
9. Relate research findings to history taking and assessment.
NUR 307 Syllabus
Fall 2010
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Course Requirements:
Written exams, HESI computerized comprehensive exam, weekly clinical performance, clinical check-offs, and
group cultural presentation is used to determine the student’s level of performance.
Course Calendar
Course Topics and Reading Assignments Date Title Chapter
8-30 Introduction 1, 26
History & Interviewing
Recording Information
9-6 Labor Day Holiday
9-13 Examination Techniques 3, 5
General Assessment & Vital Signs
9-20 Gastrointestinal 17, 20
9-27 Lecture Test I & LAB: Clinical SIM evaluation for vital signs
10-4 Cardiovascular 14, 15
10-11 Respiratory 13
10-18 Lecture Test II & LAB: Clinical evaluation for GI, CV and Resp
10-25 Neurological 4, 22
11-1 Musculoskeletal 21
11-8 HEENT 9, 10, 11 & 12
11-15 Lecture Test III & LAB: Clinical evaluation for Neuro, MSK, and HEENT
11-22 Male & Female Genitalia 16, 18 & 19
11-29 Integumentary, Culture & Emergency Assessment 2, 8 , 24 & 27
(Cultural Presentations during lab)
12-6 HESI 8:00 am
12-13 Final (if needed) 8:00 am
NUR 307 Syllabus
Fall 2010
5
Grading Policy
Evaluation is based on achievement of the course objectives. There will be no makeup exams.
Didactic
Test 1 20%
Test 2 20%
Test 3 20%
Final (Comprehensive) or HESI Exam 20%
Cultural Presentation 15%
Genogram 5%
1. Receive a mean test grade of 75% or better based on %’s above for
(Test I, Test II, Test III, HESI/ Final)
2. Receive an overall course grade of 75% or better.
3. Pass the clinical portion of the course.
(Please refer to your student handbook for details)
Remediation Requirement for End-of-Course HESI
1. If a student scores greater than or equal to the national BSN program average HESI score on the end-of-
course HESI, no remediation is required.
2. If a student scores below the national BSN program average HESI score on the end-of-course HESI but
has earned greater than a 79 weighted test average in the course, no remediation is required.
3. If a student scores below the national BSN program average HESI score on the end-of-course HESI and
has less than or equal to a 79 weighted test average in the course, an incomplete will be given in the
course and remediation will be required. After successful completion of the Evolve Apply online
remediation and practice question sets assigned by the instructor, the incomplete will be removed and
the student may progress in the nursing program.
Absence Policy
Late Work Policy
No late tests or assignments will be given or accepted without prior notification of lead instructor. Attendance for lecture is encouraged. Attendance will be considered when a student is in jeopardy of failing.
Attending the course will increase the student’s successful completion of the course. Makeup work for absences will be at
the discretion of the instructor.
Attendance Policy
Lecture
Attendance is encouraged. Attendance will be considered when a student is in jeopardy of failing. Attending
the course will increase the student’s successful completion of the course. Makeup work for absences is usually
not acceptable and will be at the discretion of the instructor.
Acceptable Student Behavior
Classroom behavior should not interfere with the instructor’s ability to conduct the class or the ability of other
students to learn from the instructional program (see the Student Conduct Code, policy D-34.1). Unacceptable
or disruptive behavior will not be tolerated. Students who disrupt the learning environment may be asked to
leave class and may be subject to judicial, academic or other penalties. This prohibition applies to all
instructional forums, including electronic, classroom, labs, discussion groups, field trips, etc. The instructor
NUR 307 Syllabus
Fall 2010
6
shall have full discretion over what behavior is appropriate/inappropriate in the classroom. Students who do not
attend class regularly or who perform poorly on class projects/exams may be referred to the Early Alert
Program. This program provides students with recommendations for resources or other assistance that is
available to help SFA students succeed.
Academic Integrity (A-9.1)
Academic integrity is a responsibility of all university faculty and students. Faculty members promote academic
integrity in multiple ways including instruction on the components of academic honesty, as well as abiding by
university policy on penalties for cheating and plagiarism.
Definition of Academic Dishonesty
Academic dishonesty includes both cheating and plagiarism. Cheating includes but is not limited to (1) using or
attempting to use unauthorized materials to aid in achieving a better grade on a component of a class; (2) the
falsification or invention of any information, including citations, on an assigned exercise; and/or (3) helping or
attempting to help another in an act of cheating or plagiarism. Plagiarism is presenting the words or ideas of
another person as if they were your own. Examples of plagiarism are (1) submitting an assignment as if it were
one's own work when, in fact, it is at least partly the work of another; (2) submitting a work that has been
purchased or otherwise obtained from an Internet source or another source; and (3) incorporating the words or
ideas of an author into one's paper without giving the author due credit.
Please read the complete policy at http://www.sfasu.edu/policies/academic_integrity.asp
Academic Integrity Note
The Academic Integrity University policy outlines cheating, plagiarism, and student discipline. The policy
summaries do not specifically address assignments in detail so N306 expectations are listed here.
Class work and assignments must be of your own effort. We understand discussions about approaches to a
problem have educational value and are acceptable among peers. We are not discouraging group discussions
however the following applies:
Acceptable:
Clarifying what an assignment is requiring.
Helping someone find information or collaborating on clinical documents such as medication cards.
This does not include turning in another’s work as your own.
Unacceptable:
Turning in any portion of someone's work without crediting the author of that work, if the source of
that work is not the course text.
Writing for or with another student any course assignment and/ or case study.
Receiving from another person any course assignment and/ or case study.
Helping another person complete any course assignment and/ or case study.
Logging into computer programs and/or signing for another on computer or on roster.
You must abide by these expectations in addition to those expressed in the http://www.sfasu.edu/policies/academic_integrity.asp In accordance with University policy, we will submit cases of suspected cheating and plagiarism to the Level
One Coordinator and/ or Director of the School of Nursing or the designee
NUR 307 Syllabus
Fall 2010
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Withheld Grades (Semester Grades Policy A-54)
Ordinarily, at the discretion of the instructor of record and with the approval of the academic chair/director, a
grade of WH will be assigned only if the student cannot complete the course work because of unavoidable
circumstances. Students must complete the work within one calendar year from the end of the semester in which
they receive a WH, or the grade automatically becomes an F. If students register for the same course in future
terms the WH will automatically become an F and will be counted as a repeated course for the purpose of
computing the grade point average.
The circumstances precipitating the request must have occurred after the last day in which a student could
withdraw from a course. Students requesting a WH must be passing the course with a minimum projected
grade of C.
Students with Disabilities
To obtain disability related accommodations, alternate formats and/or auxiliary aids, students with disabilities
must contact the Office of Disability Services (ODS), Human Services Building, and Room 325, 468-3004 /
468-1004 (TDD) as early as possible in the semester. Once verified, ODS will notify the course instructor and
outline the accommodation and/or auxiliary aids to be provided. Failure to request services in a timely manner
may delay your accommodations. For additional information, go to http://www.sfasu.edu/disabilityservices/.
Cultural Presentation
Students will be placed in groups for work on the cultural presentation. Each group will be responsible
for putting together a presentation on their assigned culture. Each group will be responsible for turning
in 5 multiple choice questions on the cultural group for use on the test. Questions should be submitted
using Microsoft Word and e-mailed to lead instructor one week prior to presentation. Failure to turn this
in by deadline OR in the wrong format will result in points being deducted from the presentation grade.
This project will require working together!!!! Look for resources NOW in your community or at the
library. You may use guest speakers, audio visual aids, etc. be creative! This is a presentation – DRESS
PROFESSIONALLY. The presentation should be NO LONGER than 20 minutes in length and should
address the following topics:
Communication, Space & Time Orientation Dietary Practices
Religious Organization Social Organization
Biological Variations and Health Concerns Nursing Implications
Home or Folk Remedies
Special Customs Related to Birth, Death, etc.
Learning Objectives
Unit I
History, Interviewing & Recording Information
1. Recognize ethical considerations in patient-examiner relationships.
2. Describe an environment suitable for conducting an interview and physical assessment.
3. Recognize personal perceptions and behaviors that facilitate or hinder the interview process.
4. Describe and utilize techniques to facilitate an interview.
5. Adapt the interview process for the patient with special needs.
6. Describe the four different types of health history and provide an example of when each is used.
7. Identify the components of the complete health history
8. Describe how to assess the characteristics of a chief complaint.
9. Describe reasons for maintaining clear and accurate records.
10. Organize and document data according to a clinical history outline.
NUR 307 Syllabus
Fall 2010
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Unit II
Examination Techniques, General Assessment & Vital Signs
1. Describe how to maintain standard precautions during the physical assessment.
2. Describe initial assessment observations and their importance.
3. Describe purpose and utilize equipment needed to perform complete physical assessment.
4. Correctly obtain baseline data (vital signs, height and weight).
5. Discuss factors affecting respiratory rate, pulse, body temperature and blood pressure.
6. Describe how to perform inspection, palpation, percussion, and auscultation, and which areas of the
body are assessed with each technique.
7. Demonstrate inspection, palpation, percussion, and auscultation in the clinical setting.
8. Describe and utilize tools used to assess growth and developmental achievemen
Unit III
Gastrointestinal
1. Describe the physiological function of the normal gastrointestinal anatomic organs.
2. Discuss the system-specific history for the gastrointestinal tract.
3. Describe common abnormalities found in the physical assessment of the gastrointestinal tract and
discuss the pathophysiology of these problems.
4. Demonstrate the physical assessment for the gastrointestinal system.
5. Document the findings for your assessment of the GI system.
6. Describe changes in the physical assessment findings for different age groups.
Unit IV
Cardiovascular & Peripheral Vascular
1. Identify the anatomic landmarks of the chest and periphery.
2. Describe the characteristics of the most common cardiovascular chief complaints
3. Discuss the system-specific history for cardio and peripheral vascular.
4. Perform a cardiovascular assessment on a healthy adult in a clinical setting.
5. Describe common abnormalities found in the physical assessment of heart and peripheral vessels and
discuss the pathophysiology of these problems. 6. Describe changes in the physical assessment findings for different age groups.
7. Document the findings of a cardiovascular assessment.
Unit V
Respiratory
1. Describe the anatomic landmarks of the thorax.
2. Discuss the system-specific history for the respiratory system.
3. Describe the characteristics of the most common respiratory chief complaints.
4. Perform a respiratory assessment on a healthy adult.
5. Explain the pathophysiology for abnormal findings.
6. Document respiratory assessment findings.
7. Describe the changes in the physical assessment findings for different age groups.
NUR 307 Syllabus
Fall 2010
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Unit VI
Neurological System
1. Describe the divisions of the nervous system and their functions.
2. Identify the anatomical structures of the neurological system.
3. Describe the characteristics of the most common neurological complaints
4. Document a health history as it relates to the neurological system.
5. Perform a mental status assessment.
6. Assess the neurological system in a systematic manner.
7. Describe common abnormalities found in the neuro-assessment and explain the pathophysiology of each
8. Describe changes in the physical assessment findings for different age groups.
Unit VII
Musculoskeletal
1. Describe the anatomic structures of the musculoskeletal system
2. Discuss the system-specific history for musculoskeletal
3. Perform inspection and palpation of the musculoskeletal system
4. Perform ROM movements on the major skeletal joints.
5. Assess muscle strength of the upper and lower extremities.
6. Document the findings of a musculoskeletal assessment
7. Describe changes in the physical assessment findings for different age groups.
8. Perform and complete musculoskeletal assessment on an adult in the clinical setting.
Unit VIII
Head, Ear, Eyes, Nose & Throat
1. Identify the anatomic structures of the HEENT.
2. Discuss the system-specific history for the HEENT.
3. Locate lymph nodes of the head and neck.
4. Demonstrate the physical assessment of the HEENT.
5. Describe normal findings in the physical assessment of the HEENT.
6. Describe common abnormalities found in the physical assessment of the HEENT and discuss the
pathophysiology for these problems.
7. Document the findings of a HEENT assessment.
8. Describe the changes in the physical assessment findings for different age groups.
Unit IX
Male & Female Genitalia
1. Describe the anatomy and physiology of the male and female genitalia, including age relevant
transformations.
2. Discuss the techniques necessary for assessment of the male and female genitalia.
3. Identify normal findings as well as atypical findings.
4. Describe procedures for smears and cultures.
5. Describe the characteristics of the most common genital complaints.
6. Document genital findings.
7. Describe changes that occur in the reproductive system with the aging process.
8. Discuss the system-specific history for the reproductive organs
NUR 307 Syllabus
Fall 2010
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Unit X
Integumentary System
1. Describe the anatomy and physiology of the integumentary system
2. Explain the process of describing and classifying skin lesions
3. Identify common skin lesions
4. State the warning signs of carcinoma in skin lesions
5. Document the findings of an integumentary assessment
6. Describe changes in the physical findings for different age groups
Unit XI
Cultural Awareness & Emergency Assessment
1. Describe the process of providing culturally competent nursing care
2. Assess own cultural values, beliefs and behaviors
3. Identify increased health risks and disorders prevalent in selected ethnic, racial and population groups.
4. Identify health-seeking behaviors and health practices influenced by cultural values, customs and beliefs.
5. Identify potential areas of conflict between customs and values of patients and those of health care
providers.
6. Conduct and document a comprehensive cultural assessment.
Test Question Review & Protest
All tests are computerized and administered in the testing room within the nursing department. At the
completion of each test, the student will have the opportunity to review test questions and rationales.
After reviewing the test a student has one week in which they may protest test questions. The test item
protest form can be found in your syllabus.
NUR 307 Syllabus
Fall 2010
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Student Test Item Protest Form
Name________________________________________________________
Class_________________________________________________________
Test #_____________
I am protesting test item________________________________________
Rationale (Explain why you believe the test item is incorrect.)___________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
___________________________________
References (Cite two published resources to validate your protest. One
must include your textbook.)
1.________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
____________________________________
2.________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
____________________________________
Copyright, HESI, 2004
NUR 307 Syllabus
Fall 2010
12
Academic Integrity Agreement
School of Nursing
Stephen F. University State University
Fall 2010
In order to have any of your coursework graded, you must turn in this signed agreement. This is a serious
document; do not sign it without reading it.
Attached is the SFASU policy for Academic Integrity (A-9.1) and it may be downloaded from the SFASU
website under student policies. http://www.sfasu.edu/policies/academic_integrity.asp
I, the undersigned N307 student, have read the SFASU Academic Integrity document. I understand it and agree
to abide by the policy it expresses.
Name (please print)_______________________________________________
Student ID number _______________________________________________
Date: __________________________________________________________
Signature _______________________________________________________
NUR 307 Syllabus
Fall 2010
13
Clinical Syllabus
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Clinical Objectives
1. Demonstrate beginning skills in obtaining a client health history, via the client, support system and
other available resources.
2. Demonstrate a beginning competency in the correct application of psychomotor skills in the
performance of a physical examination. (Must pass 2/3 clinical exams)
3. Show evidence of adequate preparation for each clinical experience.
4. Display behaviors in accordance with the policies and procedures of the School of Nursing.
5. At all times, display safe clinical patient care.
6. Display ethical and professional behavior in clinical.
7. Demonstrate application of findings as basis for decision-making.
8. Attend and be punctual for all clinical experiences. Any student who is absent or late for lab will
receive a counseling form and a failing grade for that clinical lab day.
Clinical Evaluation
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Absence from Clinical Policy
To be an excused absence the student must be excused directly by the clinical instructor. If so directed by the
instructor, the student must bring a written excuse from the health provider. Students must inform the clinical
instructor prior to the beginning of the clinical day if unable to attend or if late. E-mail will not be accepted as
a way of notifying instructors of absence.
Unexcused absences and late arrivals will result in a clinical F Day. Unexcused absences are defined as any
absence that was not cleared with the instructor prior to the clinical experience, or any absence not directly
related to illness of self or death of immediate family member. Late arrival is defined as arriving to class 15
minutes after posted class time.
Students will receive credit for clinical or class attendance if they are present for the entire class or clinical
period. Students will not receive credit for any of the class or clinical period if they leave early unless given
permission to leave early by the instructor.
Absence from the clinical area exceeding 10% will result in a clinical failure regardless of the reasons.
See School of Nursing Policy 21 @ http://www.fp.sfasu.edu/nursing/studentpolicies.htm
NUR 307 Syllabus
Fall 2010
14
Students are responsible for compliance with all School of Nursing policies
http://www.fp.sfasu.edu/nursing/studentpolicies.htm.
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Policies for Clinical
Students must abide by School of Nursing Policies and Procedures. These policies include, but are not limited
to, current compliance with drug screening, criminal background checks, medical insurance, immunizations, TB
screens, confidentiality, dress code and infection control. The student is responsible for current compliance and
may not attend class/clinical until requirements are fulfilled.
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Students are required to wear SFA scrubs or white lab coat to clinical lab. Jewelry permitted is one small
earring per ear and a wedding ring. Watch with a second hand must be worn. Student nametag must be worn at
all times. Assessment equipment must be brought to lab each week. F-days may be given to students who are
not prepared for lab and for violation of student dress code. No smoking or tobacco use during clinical hours
is permitted.
Failure to follow the dress code and clinical guidelines will result in an F day and the student may be sent
home from the Clinical Site.
Please turn off all cell phones/pagers as these are not permitted during clinical lab.
NUR 307 Syllabus
Fall 2010
15
Check Off #1
Vital Signs
Student Name:_________________________________________________________
Basic Nursing Instructor:_________________________________________________
Attempt #1 Student Reading Mannequin Setting Comments
BP Pulse Temp Resp Wt Ht
Attempt #2 Student Reading Mannequin Setting Comments
BP Pulse Temp Resp Wt Ht
Attempt #3 Student Reading Mannequin Setting Comments
BP Pulse Temp Resp Wt Ht
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Check Off #2 Cardio, Respiratory & GI
Student Name____________________________________________________________ Basic Nursing Instructor____________________________________________________ 1. Respiratory
______ Observes AP/lateral diameter ______ Observes symmetry of A&P ______ Palpation of chest wall ______ Palpation of fremitus, A&P ______ Auscultation of all lung fields, A&P ______ Auscultation of voice sounds
2. Heart ______ Inspect symmetry, visible pulsations, JVD ______ Apical/radial pulse rate ______ Palpation for PMI ______ Auscultation of S1 & S2 ______ Auscultation all valve locations
3. Peripheral Vascular
______ Checks temporal pulses (bilaterally) ______ Checks carotid pulses (bilaterally but individually) ______ Brachial (bilaterally) ______ Radial (bilaterally) ______ Femoral (bilaterally) ______ Popliteal (bilaterally) ______ Dorsalis pedis (bilaterally) ______ Posterior tibial (bilaterally) ______ Checks for Homan’s sign (bilaterally) ______ Auscultation for bruits (temporal & carotid)
______ Checks capillary refill
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4. Abdomen
______ Inspection for symmetry, contour, artifacts, abdominal movement ______ Auscultation vascular sounds (renal, iliac, aortic, femoral) ______ Auscultation of bowel sounds ______ Percussion for tone ______ Blunt percussion of kidneys (Flank response) ______ Light palpation ______ Deep palpation ______ Palpate liver ______ Palpate spleen ______ Palpate kidneys ______ Palpate suprapubic area ______ Palpate inguinal nodes
Comments:
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Check Off #3 HEENT, Neuro, Musculoskeletal
Student Name____________________________________________________________ Basic Nursing Instructor____________________________________________________
1. Head/Face
______ Inspects symmetry of head/face ______ Examines hair and scalp ______ Tests ability to feel light touch on six areas of face; strength of temporal and
masseter muscles (part of CN V) ______ Tests ability to move face muscles by checking five expressions (part of CNVII)
Neck
______ Palpates lymph nodes (___preauricular; ___postauricular; ___occipital; ___parotid; ___submandibular; ___submental; ___anterior and posterior cervical chain; ___supraclavicular)
______ Palpates trachea ______ Palpates thyroid ______ Range of motion ______ Checks clavicles ______ Tests CN XI (sternomastoid and trapezius muscles)
Eyes
______ Observes lids, lacrimal puncta, conjunctiva, etc. ______ Tests visual acuity for distance and near vision (X’s 3) (CN II) ______ Checks peripheral fields (CN II) ______ Checks EOM (CN III, IV, VI) ______ Tests pupillary response to light directly and indirectly (CN III, IV, VI) ______ Tests accommodation (CN III) ______ Tests for parallel vision (Cover/uncover) ______ Checks corneal light reflex (Symmetry of light reflection) ______ Red reflex, fundoscopic
2. Ears
______ Inspects and palpates external ear ______ Inspects canal ______ Otoscopic Exam ______ Gross hearing screen ______ Tests CN VIII using Weber ______ Tests CN VIII using Rinne
Nose
______ Observes and palpates external nose _____ Checks patency of nasal passage ______ Internal exam
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______ Palpates maxillary and frontal sinuses Mouth and Throat
______ Observes oral mucosa and structures ______ Observes and counts teeth ______ Tests CN IX, X (gag reflex or movement of uvula) ______ Checks patency of parotid and sublingual ducts ______ Tests CN XII (tongue in cheek or tongue against blade) _____ Palpates tongue, hard & soft palate with gloves
3. Musculoskeletal
______ Observes gait ______ Observes spine posteriorly and laterally ______ Palpates spine for tenderness and spasm ______ Observes ROM and strength for TMJ and cervical, thoracic & lumbar spine _____ Test for lumbar radiculopathy (Straight leg raising test) _____ Test for carpal tunnel syndrome (Tinnel’s and Phalen’s) _____ Observes ROM ____Upper (right and left) ____Lower (right and left) ______ Muscle mass ____Upper (right and left) ____Lower (right and left) ______ Muscle strength ____Upper (right and left) ____Lower (right and left)
4. Neurological ______ Answers questions appropriately ______ LOC & Oriented to time, place and person _____ Observe appearance and behavior _____ Checks cranial nerve function ______ Rapid alternating movements OR finger thumb apposition ______ Finger to nose OR finger to nose to examiner’s finger ______ Ability to move heel of one foot down shin of other leg ______ Heel-toe walking OR hopping on each foot ______ Romberg test (CN VIII) ______ Sharp – dull OR light touch (stroke and poke) ______ Tests secondary sensory function (Graphesthesia & stereognosis) _____ Tests for meningeal irritation (nuchal rigidity) _____ DTR’s (right and left) ____Biceps ____Triceps ____Brachioradialis ____Patellar ____Achilles tendon ____Plantar (Babinski)
____Ankle clonus
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Comments:
Introduction
History and Interviewing
Recording Information
Unit I
Learning Objectives
1. Recognize ethical considerations in patient-examiner relationships.
2. Describe an environment suitable for conducting an interview and physical assessment.
3. Recognize personal perceptions and behaviors that facilitate or hinder the interview process.
4. Describe and utilize techniques to facilitate an interview.
5. Adapt the interview process for the patient with special needs.
6. Describe the four different types of health history and provide an example of when each is used.
7. Identify the components of the complete health history
8. Describe how to assess the characteristics of a chief complaint.
9. Describe reasons for maintaining clear and accurate records.
10. Organize and document data according to a clinical history outline.
Learning Activities
Read chapters 1 & 26 in textbook
View CD for above chapters
Conduct and document a complete health history
Complete a genogram on your family
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Health History
Identifying Information
Client’s Initials_______ DOB ___________________ Age ______ Sex M___ F___
Marital Status ____________________ Race _______________
Date of Exam ___________________
Chief Complaint
History of present Illness
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Past Medical History
Hospitalizations and/or surgeries (include dates and diagnosis)
Major Childhood Illnesses
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
Major Adult
Illnesses__________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
Trauma
Injuries_________________________________________________________
_________________________________________________________________
_________________________________________________________________
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Previous Health Care
Immunizations (dates) Had all childhood vaccines? Yes___ No___
Hep B________ ________ ________ TD________ TB________ Flu________
Pneu________ Meng________ ______________________________________
_________________________________________________________________
Last Physical Exam
_________________________________________________________________
_________________________________________________________________
Pap Smear________________________________________________________
Mammogram______________________________________________________
Pregnancies_______________________________________________________
_________________________________________________________________
Rectal Exam______________________________________________________
Vision Exam______________________________________________________
Last Dental Exam __________________________________________________
Transfusions ______________________________________________________
Allergies: Food____ Drug____ Seasonal____ Environmental____
Describe reaction_________________________________________________________
Emotional: Have received psychiatric treatment: Yes _____ No_____
Family History
Please include genogram on back of this sheet
History (please describe any pertinent history found on back of this sheet)
Cancer ______ Tuberculosis ______ Respiratory ______
Renal ______ Thyroid ______ Psychiatric ______
Cardiac ______ Stroke ______ Epilepsy ______
Diabetes ______ Hereditary Disease _____ Other ______
Personal/Social History
Location and type of home
_________________________________________________________________
_________________________________________________________________
Describe those living in the home
_________________________________________________________________
_________________________________________________________________
Occupation_______________________________________________________
_
Highest Level of Education __________________________________________
Insurance Information __________________________________ ____________
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Religious Preference _______________________________________________
Religious or Cultural influences on medical care
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
Other Activities
_________________________________________________________________
_________________________________________________________________
Hobbies
_______________________________________________________________
Current Health Habits
Exercise__________________________________________________________
__ ______________________________________________________________
Recent weight gain or loss___________________________________________
Diet_____________________________________________________________
_________________________________________________________________
Smoking _________________________________________________________
Alcohol __________________________________________________________
Recreational Drugs _________________________________________________
Medications_______________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
Caffeine _________________________________________________________
Salt Intake High_____ Moderate_____ Low_____ Substitute_____
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Family Genogram Guidelines
I. Introduction
A genogram is a map that gives a graphic picture of family structure, relationships and family disease
processes. It allows the nurse to obtain a quick grasp of the family, giving clues to problems and
potential problems which may have nursing implications. The family genogram is an essential part of
the family history database.
II. Directions
1. Go back at least three generations in the family.
2. The husband/father symbol is always placed to the left of the wife/mother symbol
3. Children are placed in rank order of birth, the eldest to the far left. Include all abortions and
miscarriages.
4. Data written in includes names, ages, type of work, health conditions, date and cause of death.
5. The genogram should be dated to allow adjustment of ages over time.
6. Be sure that everyone in your organization uses a standard set of symbols.
III. Key for symbols
Male:
Female:
Deceased:
Or
Living and Well:
L & W
Living together or
Common Law
Marriage
First Child: (female)
Second Child: (male)
Twins:
Cause of death: * 82 – MI (Age & cause)
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Marriage:
Marital Separation:
Divorce:
Adoption or Foster
Children:
Miscarriage or
Abortion:
12-98
Poor Relationship:
Index Patient:
Information not
known: ?
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Examination Techniques
General Assessment
Vital Signs
Unit II
Learning Objectives
1. Describe how to maintain standard precautions during the physical assessment.
2. Describe initial assessment observations and their importance.
3. Describe purpose and utilize equipment needed to perform complete physical assessment.
4. Correctly obtain baseline data (vital signs, height and weight).
5. Discuss factors affecting respiratory rate, pulse, body temperature and blood pressure.
6. Describe how to perform inspection, palpation, percussion, and auscultation, and which areas of the body
are assessed with each technique.
7. Demonstrate inspection, palpation, percussion, and auscultation in the clinical setting.
8. Describe and utilize tools used to assess growth and developmental achievement.
Learning Activities
Reach chapters 3 & 5 in textbook
View CD’s
Perform vital signs in lab
Practice and collect vital signs from family members
Practice inspection, auscultation, percussion and palpation
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Growth and Measurement Case Study
Baby Michael is a 4 hour-old neonate. You have just completed your assessment of Michael. Here are the
findings you have observed.
Measurements
Weight: 2300 gm
Length: 44.5 cm
Head circumference: 33.0 cm
Appearance
Skin: Pale pink with a few large blood vessels noted over the abdomen.
Skin has slight thickening with some peeling on the hands and feet.
No edema noted.
Lanugo: Some areas of lanugo and balding patches on the back of the head
Plantar
creases:
Slight creases observed over the entire heel.
Breast: 2 cm areola diameter, slightly raised. Breast tissue noted on both
sides about .75 cm.
Ear: Pinna reveals partial incurving of the upper pinna; firm, with instant
recoil
Genitals: Testes are descended with moderate rugae on the scrotum.
Neuromuscular Maturity
Posture: 2 pts
Square window: 2 pts
Arm recoil: 1 pt
Popliteal angle: 2 pts
Scarf sign: 2 pts
Heel to ear: 3 pts
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Questions
1. What is the maturity rating score? __________
What is the gestational age of the baby? ___________
2. Plot Michael’s measurements for length, weight, and head circumference using the graphs.
What is Michael’s length percentile? _____________
What is Michael’s weight percentile? _____________
What is Michael’s head circumference percentile? ______________
3. What does the data tell you about Michael’s gestation and size?
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Vital Sign Practice
Student Name_______________________________
Description
Temp Pulse Resp BP
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Gastrointestinal
Unit III
Learning Objectives:
1. Describe the physiological function of the normal gastrointestinal anatomic organs.
2. Discuss the system-specific history for the gastrointestinal tract.
3. Describe common abnormalities found in the physical assessment of the gastrointestinal tract and
discuss the pathophysiology of these problems.
4. Demonstrate the physical assessment for the gastrointestinal system.
5. Document the findings for your assessment of the GI system.
6. Describe changes in the physical assessment findings for different age groups.
Learning Activities
Read chapter 17 & 20
View CD’s
Perform GI/GU assessment in lab
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Cardiovascular & Peripheral Vascular
Unit IV
Learning Objectives
1. Identify the anatomic landmarks of the chest and periphery.
2. Describe the characteristics of the most common cardiovascular chief complaints
3. Discuss the system-specific history for cardio and peripheral vascular.
4. Perform a cardiovascular assessment on a healthy adult in a clinical setting.
5. Describe common abnormalities found in the physical assessment of heart and peripheral vessels and
discuss the pathophysiology of these problems. 6. Describe changes in the physical assessment findings for different age groups.
7. Document the findings of a cardiovascular assessment.
Learning Activities:
Read chapters 14 & 15
View CD’s
Perform cardiovascular assessment in lab
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Helpful Websites
Anatomy
http://www.cardiovasculardocs.com/heart1.htm
http://www.gwc.maricopa.edu/class/bio202/cyberheart/hartint0.htm
http://www.pbs.org/wgbh/nova/heart/
Auscultation
http://www.med.ucla.edu/wilkes/S4.htm
http://depts.washington.edu/physdx/heart/demo.html
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Respiratory
Unit V
Learning Objectives:
1. Describe the anatomic landmarks of the thorax.
2. Discuss the system-specific history for the respiratory system.
3. Describe the characteristics of the most common respiratory chief complaints.
4. Perform a respiratory assessment on a healthy adult.
5. Explain the pathophysiology for abnormal findings.
6. Document respiratory assessment findings.
7. Describe the changes in the physical assessment findings for different age groups.
Learning Activities
Read chapter 13
View CD’s
Perform respiratory assessment in lab
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Respiratory Websites
Auscultation practice
http://www.mceus.com/course_frame.asp?exam_id=26&directory=resp
http://www.hsc.missouri.edu/~shrp/rtwww/rcweb/docs/sounds.html
http://www.med.ucla.edu/wilkes/intro.html
http://medocs.ucdavis.edu/imd/420C/sounds/lngsound.htm
http://www.rale.ca/repository.htm
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Neurological System
Unit VI
Learning Objectives
1. Describe the divisions of the nervous system and their functions.
2. Identify the anatomical structures of the neurological system.
3. Describe the characteristics of the most common neurological complaints
4. Document a health history as it relates to the neurological system.
5. Perform a mental status assessment.
6. Assess the neurological system in a systematic manner.
7. Describe common abnormalities found in the neuro-assessment and explain the pathophysiology of each
8. Describe changes in the physical assessment findings for different age groups.
Learning Activities
Read chapters 4 & 22
View CD’s
Perform neurological assessment in lab
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Musculoskeletal
Unit VII
Learning Objectives
1. Describe the anatomic structures of the musculoskeletal system
2. Discuss the system-specific history for musculoskeletal
3. Perform inspection and palpation of the musculoskeletal system
4. Perform ROM movements on the major skeletal joints.
5. Assess muscle strength of the upper and lower extremities.
6. Document the findings of a musculoskeletal assessment
7. Describe changes in the physical assessment findings for different age groups.
8. Perform and complete musculoskeletal assessment on an adult in the clinical setting.
Learning Activities
Read chapter 21
View CD
Perform musculoskeletal assessment in lab
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Head, Ear, Eyes, Nose & Throat
Unit VIII
Learning Objectives:
9. Identify the anatomic structures of the HEENT.
10. Discuss the system-specific history for the HEENT.
11. Locate lymph nodes of the head and neck.
12. Demonstrate the physical assessment of the HEENT.
13. Describe normal findings in the physical assessment of the HEENT.
14. Describe common abnormalities found in the physical assessment of the HEENT and discuss the
pathophysiology for these problems.
15. Document the findings of a HEENT assessment.
16. Describe the changes in the physical assessment findings for different age groups.
Learning Activities
Read chapters 9, 10, 11 & 12
View CD’s
Perform assessment of HEENT in lab
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Male & Female Genitalia
Unit IX
Learning Objectives
9. Describe the anatomy and physiology of the male and female genitalia, including age relevant
transformations.
10. Discuss the techniques necessary for assessment of the male and female genitalia.
11. Identify normal findings as well as atypical findings.
12. Describe procedures for smears and cultures.
13. Describe the characteristics of the most common genital complaints.
14. Document genital findings.
15. Describe changes that occur in the reproductive system with the aging process.
16. Discuss the system-specific history for the reproductive organs.
Learning Activities
Read chapters 16, 18 & 19
View CD
Practice assessment of reproductive models in lab
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Integumentary System
Unit X
Learning Objectives
1. Describe the anatomy and physiology of the integumentary system
2. Explain the process of describing and classifying skin lesions
3. Identify common skin lesions
4. State the warning signs of carcinoma in skin lesions
5. Document the findings of an integumentary assessment
6. Describe changes in the physical findings for different age groups
Learning Activities
Read chapter 8
View CD
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Cultural Awareness &
Emergency Assessment
Unit XI
Learning Objectives
7. Describe the process of providing culturally competent nursing care
8. Assess own cultural values, beliefs and behaviors
9. Identify increased health risks and disorders prevalent in selected ethnic, racial and population groups.
10. Identify health-seeking behaviors and health practices influenced by cultural values, customs and beliefs.
11. Identify potential areas of conflict between customs and values of patients and those of health care
providers.
12. Conduct and document a comprehensive cultural assessment.
Learning Activities
Read chapter 2 & 27
View CD’s
Prepare cultural presentation
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Stephen F. Austin State University
School of Nursing
Health Assessment
N-307
Self and Peer Evaluation
Cultural Presentation
Using a scale of 1-5 in each category, assign each member of your group, including yourself one number,
giving 5’s to the individuals whom you think made the greatest contribution and 1’s to the individuals whom
you think made the least contribution.
1. Productivity (tasks toward goal): contributed suggestions and ideas; expanded on ideas; contributed
resources; sought and shared background information; sought outside persons for help or information; kept
notes; kept focused by summarizing and/or directing actions toward goal.
Self___________________________________ Grade _____
1. ___________________________________ _____
2. ___________________________________ _____
3. ___________________________________ _____
4. ___________________________________ _____
5. ___________________________________ _____
6. ___________________________________ _____
2. Responsibility (tasks toward goal): attended meetings; on time in attendance and deadlines; followed
through with tasks and duties; communicated meaningfully/effectively in person and during presentations;
contributed amount of time needed by group.
Self _______
1. _______
2. _______
3. _______
4. _______
5. _______
6. _______
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3. Maintenance (group building): supported; encouraged; contributed enthusiasm/humor; gave constructive
opinions and asked for the same from others.
Self _______
1. _______
2. _______
3. _______
4. _______
5. _______
6. _______
4. Nonfunctional (self oriented roles): negatively critical; demeaning or disrespectful, monopolizer; negative
toward goal; manipulator; sought sympathy; tried to override group; sought attention; cynical; distracting;
used group time for personal matters; lack of involvement; non-participative. Note 5=exhibited none of
these behaviors; 1=noticeably exhibited one or more of these behaviors.
Self _______
1. _______
2. _______
3. _______
4. _______
5. _______
6. _______
5. I would choose to work with this person again. 5=definite yes. 1=definite no.
Self _______
1. _______
2. _______
3. _______
4. _______
5. _______
6. _______
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