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ANGELINA COLLEGE NURSING PROGRAM
RNSG 1215: HEALTH ASSESSMENT
Syllabus
Fall 2005
Notice: This syllabus is subject to revision as deemed necessary by the course instructor. Students will be notified of any
changes in writing. No portion of this syllabus may be reproduced without the written consent of the Health Careers Division
Director or Nursing Program Coordinator. 06 / 05
TABLE OF CONTENTS
CALENDAR…………….……………………………………………..Class Day 1
COURSE TITLE ......................................................................................................3
COURSE NUMBER ................................................................................................3
CREDIT HOURS.....................................................................................................3
COURSE DESCRIPTION .......................................................................................3
LEARNING OUTCOMES ......................................................................................3
STUDENT LEARNING OBJECTIVES .................................................................3
PREREQUISITES ...................................................................................................3
COREQUISITES .....................................................................................................3
PLACEMENT..........................................................................................................3
CORE COMPETENCIES ........................................................................................3
METHODS OF INSTRUCTION ............................................................................4
INSTRUCTORS ......................................................................................................4
METHODS OF EVALUATION .............................................................................4
GRADE DISTRIBUTION .......................................................................................4
GRADING SCALE .................................................................................................4
EXAMINATIONS ...................................................................................................5
PROGRESSION POLICY .......................................................................................5
ATTENDANCE POLICY .......................................................................................5
WITHDRAWAL AND DISMISSAL ......................................................................5
REQUIRED REFERENCES ...................................................................................5
UNIT 1: CULTURAL AWARENESS/HEALTH BELIEFS..…………………….7
UNIT 2: THE HISTORY AND INTERVIEWING PROCESS ..............................9
UNIT 3: THE BEDSIDE CLINICAL ASSESSMENT .........................................10
UNIT 4: FOCUSED ASSESSMENTS ..................................................................16
A. MUSCULOSKELETAL, SKIN........................................................................16
B. ABDOMEN, BREASTS, GENITALIA............................................................18
C. NUTRITIONAL ASSESSMENT……………………………………………..19
D. HEAD, NECK, EENT ......................................................................................21
E. NEUROLOGICAL ............................................................................................23
UNIT 5: PHYSICAL ASSESSMENT OF A PEER ..............................................25
APPENDIX AND FORMS
Angelina College Assessment Form ......................................................................26
Assessment Cards .................................................................................................27
Peer Assessment Documentation Form .................................................................29
Peer Assessment Performance Evaluation Form ...................................................34
Physical Assessment Write –Up Evaluation ..........................................................36
Integrated Adult Physical Assessment Guide ........................................................39
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ANGELINA COLLEGE NURSING PROGRAM
RNSG 1215 – HEALTH ASSESSMENT
FALL, 2005
COURSE TITLE:
Health Assessment
COURSE NUMBER: RNSG 1215
CREDIT HOURS: 2 credit hours
COURSE DESCRIPTION:
LEARNING OUTCOMES: The student will describe the components of a comprehensive
health assessment; and demonstrate the techniques utilized in a systematic process of health
assessment.
STUDENT LEARNING OBJECTIVES:
1. Compare and contrast effective and ineffective techniques of communication
2. Explain the steps in selected health assessment procedures.
3. Discuss factors that promote health throughout the life-cycle.
4. Identify the changes in health status that interfere with the client’s ability to meet basic
needs.
5. Describe assessment as a step in the nursing process in simulated client care situations.
6. Discuss the components of a complete physical assessment.
7. Demonstrate effective communication skills while gathering subjective assessment data.
8. Demonstrate the ability to perform and document a complete physical assessment
PREREQUISITES: Admission to the Associate Degree Nursing Program or administrative
approval and current CPR certification. Students registered in RNSG 1215 will be held
responsible for the application of knowledge from the following prerequisite courses:
BIOL 2401
CHEM 1271
PSYC 2301
PSYC 2314
ENG 1301
COREQUISITES: BIOL 2402, RNSG 1309, RNSG 1205, RNSG 1462, RNSG 1215
PLACEMENT: Fall semester of the freshman year.
CORE COMPETENCIES: SCANS (Secretary of Labor’s Commission on Achieving Necessary
Skills): Students are expected to demonstrate basic competency in academic and workforce
skills. The following competencies with evaluation are included in RNSG 1215.
SCANS SKILLS
Foundation Skills
EVALUATION
Oral presentation (Case studies)
Required readings
Critical thinking (Case studies)
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Computer Assisted Instruction
Class participation
Written/Online examinations
Workforce Competencies
Computer Assisted Instruction
Application of knowledge in the clinical/lab settings
Application of knowledge of legal/ethical issues
METHODS OF INSTRUCTION:
Group discussion
Lecture
Individual conferences
Computer assignment
Audiovisual aids
Role playing
Independent study
Skills Laboratory
INSTRUCTORS: Multiple instructors are involved in this team-teaching course. They will
coordinate learning events and evaluation. Carol Havis is the Level I coordinator and primary
point of contact for the course. Instructors are:
Winifred Ferguson – Adams
Mary Girard
Carol Havis
Martha Keel
Angela Jones
202A
202E
202C
202H
203
633-5279
633-5376
633-5272
633-5277
633-5264
METHODS OF EVALUATION:
Unit exams
Quizzes
Peer Assessment
Testing/Remediation Specialist
Final exam
GRADE DISTRIBUTION:
1- Unit exam (Bedside Clinical Assessment) 25%
5- Unit Quizzes 5% each for total of 25%
1- Peer Assessment 25%
1- Final exam 25%
GRADING SCALE:
A = 90-100
B = 80-89
C = 74.5-79
F = <74.5
EXAMINATIONS: Students are expected to be present for all unit examinations. If an exam is
missed due to an emergency the student must notify the Level I coordinator as soon as possible.
The program director will assign a make-up day at the end of the semester. Attendance at the
final examination is required and may be rescheduled only with the approval of the dean of
instruction.
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Students must bring a Scantron answer sheet and a number 2 pencil to each examination. If
online testing is done, no pencil or answer sheet will be required.
PROGRESSION POLICY: The student must earn a minimum grade of “C” or “Pass” in all
required courses in order to progress through the nursing program. All nursing courses must be
taken in the appropriate sequence.
ATTENDANCE POLICY: See ACNP Student Handbook for policies regarding attendance and
other important topics. Three consecutive or four cumulative absences in the classroom may
result in withdrawal from the course and possible course failure.
WITHDRAWAL AND DISMISSAL: Students considering withdrawal from the program
should talk to either the Level I Coordinator or Program Coordinator for withdrawal or re-entry
information.
All necessary forms can be obtained in the Office of Admissions and Records. When a learner
does not officially withdraw in the Office of Admissions, an “F” will appear on the transcript for
the courses in progress at that time.
REQUIRED REFERENCES:
Angelina College Nursing Program Student Handbook. (2005-2006).
Ackley, B.J., Ladwig G.B. (2004) Nursing Diagnosis Handbook. (6th ed.) St. Louis MO: Mosby.
Anderson D., (2002). Mosby’s Medical, Nursing & Allied Health Dictionary. (6th ed.) St Louis
MO: Mosby.
Corbett, J.V. (2004). Laboratory Tests and Diagnostic Procedures with Nursing Diagnosis. (6th
ed.) Upper Saddle River NJ: Prentice Hall.
Josephson, D.L. (1999) Intravenous Infusion Therapy for Nurses. Albany, NY: Delmar.
Karch, A.M. (2005) Lippincott’s Nursing Drug Guide. Philadelphia PA: Lippincott Williams &
Wilkins.
Kee, J.L., & Hayes, E.R. (2003) Pharmacology: A Nursing Process Approach. (4th ed.)
Philadelphia PA: W. B. Saunders.
Kozier, B., Erb, G., Berman, A. & Snyder, S. (2004) Fundamentals of Nursing. (7th ed.) Upper
Saddle River NJ: Prentice Hall.
Kozier, B. et al. (2004) Techniques in Clinical Nursing (5th ed.) Upper Saddle River NJ: Prentice
Hall.
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Lewis, Heitkemper, Dirksen, O’Brien, Giddens, & Bucher (2004). Medical–Surgical Nursing.
(6th ed.) St Louis MO: Mosby.
Lewis, et al. (2004) Study Guide for Medical Surgical Nursing. (6th ed.) St Louis MO: Mosby.
Moore, M.C. (2001) Pocket Guide to Nutritional Care. (4th ed.) St. Louis: Mosby.
Nursing Practice Act: On reserve at the library or On-line at www.bne.state.tx.us
Seidel, H.M., Ball J.W., Dains J.E., & Benedict, G.W. (2002) Mosby’s Guide to Physical
Examination. (5th ed.) St. Louis MO: Mosby.
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Unit 1: Cultural Awareness/Health Beliefs
Learning Objectives:
1.
2.
3.
4.
5.
6.
7.
Discuss health, the five dimensions of wellness and the term, well being.
Identify factors affecting health status, beliefs and practices.
Differentiate illness from disease, and acute illness from chronic illness.
Identify Parson’s four aspects of the sick role and Suchman’s stages of illness.
Describe the effects of illness on individuals and family member’s roles and functions.
Describe the roles and functions of the family.
Identify the components of a family health assessment and the common risk factors regarding
family health.
8. Discuss components of Cultural Care nursing, heritage consistency and HEALTH traditions.
9. Identify factors related to communication with culturally diverse patients and colleagues.
10. Explain the concept of holism and the goal of holistic nursing.
11. Discuss the concepts of spirituality and religion as they relate to nursing and health care.
12. Describe the influence of spiritual and religious beliefs about diet, dress, prayer and
meditation, and birth and death on health care.
13. Discuss selected frameworks for identifying stages of grieving and dealing with various types
of loss.
14. Describe helping clients die with dignity.
Required Reading:
Seidel, et al, Mosby's Guide to Physical Examination, (5th ed), 2003, Chapter 2
Kozier B. et al, Fundamentals of Nursing (7th ed), 2004, Prentice Hall, Unit 3: Health Beliefs
and Practices, Chapters 11-14 and Unit 9: Promoting Psychosocial Health, Chapters 39 and 41.
Media Link: www. prenhall.com/kozier and student CD/ROM additional resources/activities
for these chapters.
Content Outline:
I.
II.
III.
IV.
V.
VI.
VII.
VIII.
Concepts of health and well being
Models of health and wellness
Variables influencing health status, beliefs and practices
Health belief models
Health care adherence
Illness and disease
A.
Illness behaviors
B.
Effects of Illness
Individual health
Family health
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IX.
X.
XI.
XII.
XIII.
XIV.
XV.
XVI.
XVII.
XVIII.
XIX.
Functions of family
Assessing the health of families
Cultural care nursing
Concepts related to Cultural care nursing
Heritage consistency and health traditions
Providing Cultural Care
Concepts of holism and holistic nursing
Spirituality described
Spiritual practices affecting nursing care
Loss and grief
Dying and death
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Unit 2: The History and Interviewing Process
Learning Objectives:
1. Discuss the goals of the history and interviewing process.
2. Describe the ethical context of the patient partnership.
3. Define the terms allopathic, complementary, and alternative care as they relate to patient
partnership.
4. Review factors that enhance communication with the patient during the history and
interview process.
5. Discuss the importance of the nurse "knowing" themselves and recognizing the role of
personal beliefs, values and attitudes in the nurse-patient relationship.
6. Identify guidelines and various parts of the history and interview process.
7. Describe kinds of histories.
Required Reading:
Seidel, et al, Mosby's Guide to Physical Examination, (5th ed), 2003, Chapters 1
Seidel, et al, Mosby's Guide to Physical Examination Handbook, (3rd ed), 2003, Chapter 1.
Content Outline:
I. Partnership with the patient
A. Ethical context with the patient
B. Allopathic, complementary, and alternative care
II. Communicating with the Patient
A. Factors that enhance communication
B. Knowing yourself
III. The history
A. Setting for the interview
B. Structure of the history
C. Taking the history
D. Approaching sensitive issues
E. Outline of the clinical history
F. Kinds of histories
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UNIT 3: Bedside Clinical Assessment
Learning Objectives:
1. Describe the purposes and uses of bedside clinical assessment.
2. Describe the process of collecting subjective and objective data for a bedside clinical
assessment.
3. Name and describe all the components of a bedside physical assessment.
Learning Activities:
1. Perform, on at least one peer, a bedside clinical assessment.
2. Document the results of this assessment on AC nursing form
Required Reading:
Kozier, B., Erb, G., Berman, A. & Snyder, S. (2004) Fundamentals of Nursing. (7th ed.) Upper
Saddle River NJ: Prentice Hall. Chapter 28
Seidel, H.M., Ball J.W., Dains J.E., & Benedict, G.W. (2002) Mosby’s Guide to Physical
Examination. (5th ed.) St. Louis MO: Mosby. Chapter 4, Chapter 7, pp. 170-177, Chapter 12, pp.
356-397, Chapter 13, pp. 415-439, Chapter 14, pp. 462-488, and Chapter 24.
Content Outline:
I. Purpose and Uses of Bedside Clinical Exam
II. Bedside History
A. Analyzing history already obtained
B. Integrating brief ROS with each body system
III. Physical Assessment
A. General Survey/Vital Signs
B. Skin Assessment
1. Review Anatomy and Physiology, Nursing Knowledge base and hygiene
2. ROS questions
3. Summary of Skin Assessment
a. Inspection: skin and mucous membranes (pink)
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Color: uniform tanned, exposure to the elements, cyanosis, pallor circulation,
redness, edema, heat, jaundice, scars, melanin, colored skin moles (should be
reported).
Check pressure points if bed or chair fast (see pressure staging guide)
Scars – describe location, length, color, healing
Odor: bacterial decomposition of secretions from apocrine sweat glands (axilla,
genitals), draining lesions, gangrene
b. Texture – smooth in infants; rough at elbows and feet; dryness in
hypothyroidism
Turgor – lift a fold of skin and note the ease with which it return to place;
decreased dehydration
Moisture – skin usually warm to the touch with mucous membranes moist:
fluid loss, fever, skin hot and dry; heat and stress with perspiration,
skin oily with adolescence
Temperature – increases with vasodilation and decreases with vasoconstriction;
inflammation, warm and hot
4. Summary of fingernail/toenail inspection
a. Fingernail Inspection
color – stained, capillary refill time
cracks – peeling, should be smooth
Ridges – vertical, horizontal
b. Toenail Inspection
Thickness – fungus, should not be extra thick or extra thin
Discoloration – injuries
5. Assess hair for color and pigmentation quantity, texture and for infections/infestations.
C. Neurological Assessment/Mental Status/ Brief Musculoskeletal & ADL Level
1. ROS questions
2. Objective data summary
a. Level of Consciousness (LOC)
Orientation – person, place, time
Pain level – must be assessed on scale of 1-10
b. Unexpected LOC:
1. Confusion
2. Lethargy
3. Delirium
4. Stupor
5. Coma
c. General MS Function/ ADL Level:
Ability to move all extremities
Ambulatory ability
D. Thorax Assessment
1. ROS questions
2. Objective data, summary
a. Thorax inspection:
Shape – anteroposterior (AP) diameter 1:2 ratio,
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barrel chest, funnel chest, pigeon chest
Symmetry – retraction, bulging of intercostals
Bony Deformities – kyphosis, osteoporosis
Movement – equal bilaterally
Tenderness – masses, muscle soreness, ribs
Respiratory Rate – rhythm, depth, rate
b. Lung Sounds
Vesicular – low pitched, inspiration greater than expiration
Broncho vesicular – heard below clavicles and between scapulae; medium
pitch; inspiration and expiration equal
Bronchial – heard over trachea, anywhere else abnormal; expiration greater
than inspiration, frequently associated with fever and dehydration
of pneumonia
ABNORMAL FINDINGS:
Crackles – discontinuous sound usually heard on inspiration
Fine – dry crackling sound (rubbing hair together)
Medium (fizzing of a carbonated drink)
Coarse – wet bubbling sound (air though a straw into water causing bubbles)
Rhonchi – continuous sound usually hear on expiration
Sonorous – snoring sound
Sibilant – wheezing, whistling sound; asthma, C.F., obstruction
Friction Rubs – dry surfaces rubbing together, heard both on inspiration and
expiration.
Fremitus – vibration perceptible on palpation
Wheezes – narrowed airways.
E. Cardiovascular Assessment
1. ROS questions
2. Objective data summary
a. Inspection:
Skin – peripheral cyanosis – cold, diminished blood flow
to periphery
Central cyanosis – warm, cyanosis of lips, earlobes,
mucous membranes: restricted or obstructed lung disease
Nail beds – capillary refill, clubbing, hypoxia
Neck Vein Distention – systemic edema, right sided failure
b. Palpation:
Apical Pulse/PMI – light localized tap felt, Apical pulse=Radial pulse
at fifth left intercostal space: palpate one full minute
c. Auscultation:
First Heart Sound – S1
Second Heart Sound – S2
Rate – Bradycardia – slow heart rate; below 60
Tachycardia – fast heart rate; above 100
Rhythm – Regular – steady, consistent
Irregular – consistent, occasional
Abnormal Findings:
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Extra Heart Sounds – S3, S4
Murmurs – intracardiac turbulence, “swishing”, “flushing”
Causes – 1. increased blood flow over normal valves
2. blood flow through a stenotic valve
3. blood flow into a dilated chamber or vessel
4. Backward blood flow through a damaged valve or septal defect.
Bruits – extracardiac turbulence, abnormal clicking sounds
Pericardial Friction Rubs – inflammation of layers of pericardium
F. Peripheral Vascular Assessment
1. ROS questions
2. Objective data summary
a. Inspect and palpate peripheral pulses bilaterally for symmetry, strength, and equality
Apical-Radial – should be equal
Brachial – inner arm
Temporal – beside the eye
Carotid – neck, auscultate for bruit with bell of stethoscope
Femoral -- grain
Posterior Tibial – behind medial malleolus
Dorsalis Pedis – top of foot, occasionally congenitally absent
Popliteal – behind the knee
b. Homan’s sign: Have patient bend knee slightly and dorsiflex foot while examiner
checks calf area for pain or tenderness; perform on both legs
H. Gastrointestinal Assessment
1. ROS questions
2. Objective data summary
a. Inspection:
Contour- flat, round, scaphoid or concave
Scars/Striae – describe stretch marks, old (silver), Cushing’s Syndrome
(pink/purple)
Engorged Veins – inferior vena cava obstruction
Visible Peristalsis – sometime normal in very thin people, abnormal in
intestinal obstructions
Visible Pulsations – aortic pulsations see in thin people, abnormal in aortic
aneurysm
Visible Masses – distended bladder, pregnant uterus
b. Auscultation:
Quality – listen for 5 minutes before deciding bowel sounds are absent
Quantity – 5-30 seconds in each quadrant
Hyperactive Sounds – increased bowel sounds
Hypoactive Sounds – decreased bowl sounds
Normactive Sounds- 5-35 per minute
Bruits – vascular sounds resembling systolic heart murmurs
Friction Rubs – over liver and spleen are suspicious of liver tumors,
gonococcal infections, or splenic infarctions
c. Percussion:
Organs – bowels not normally palpated
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Masses – note locations, size, shape, mobility
Muscle Rigidity – acute abdomen, pain
Tenderness – rebound tenderness suggests peritoneal inflammation
d. Note: Remember to assess patient’s oropharynx, especially in bedridden or
comatose patients
I. Genitourinary Assessment
1. ROS questions
2. Object data summary
At bedside, a subjective assessment is primarily performed unless the situation
dictates otherwise, e.g. in the cases of genitourinary dysfunction.
J. Miscellaneous – IV sites, drains, etc.
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Study Guide
I. Rationale for a nursing assessment.
A. Basis for care
1. Allows the nurse to collect data systematically about the patient’s health and
to plan, implement and evaluate care. Assessment is the foundation step of
the nursing process, and the nursing process is the backbone of professional
nursing.
2. The step of the nursing process
Step 1 = ASSESSMENT: Systematic collection of objective and subjective
data.
Step 2 = NURSING DIAGNOSIS: Nursing judgments about actual or
potential health conditions.
Step 3 = PATIENTS GOALS: Statements of desired outcomes of patient’s
health status with well-defined goal statements. These goal statements are
always written in patient-centered terms with clearly defined criteria identified
for achievement.
Step 4 = NURSING IMPLEMENTATION/INTERVENTION: Carrying out
the plan of care (POC) or plan of action to meet the desired outcome.
Step 5 = EVALUATION: Review of the goal statements to determine if they
were obtained. If they were not met, determine why this occurred.
B. Legalities
C. Hospital policy/Joint Commission of Administration of Hospital requirements (JCAH)
II. Distinguish types of data
A. Subjective data: Information collected by the nurse through history taking. It is what
the patient and family tells the nurse about the health.
B. Symptoms: Information reported by the patient and cannot be seen, heard, felt or
measured.
C. Objective data: Information collected from a variety of sources, including physical
examination, laboratory tests and diagnostic tests.
D. Signs: Information that can be seen, heard, felt or measured.
III. Type of Health Assessment
A. Complete: Involves a comprehensive examination of all subjective and objective data.
B. Focused: Narrows the examination of subjective and objective data to a specific
problem or health care need.
IV. Cultural considerations.
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UNIT 4: FOCUSED ASSESSMENTS
UNIT 4A: Assessment of Skin, Hair, Nails, and Musculoskeletal System
Learning Objectives:
1. Conduct a history related to skin, hair, nails and musculoskeletal system.
2. Discuss examination techniques for skin, hair, nails, and musculoskeletal system.
3. Identify normal age and condition variations to skin, hair, nails, and musculoskeletal
system.
4. Recognize findings that deviate from expected findings.
5. Relate symptoms or clinical findings to common pathologic conditions.
Learning Activities:
1. Have students work in pairs to perform a complete musculoskeletal examination and skin
assessment.
2. Have the students brainstorm the precautions that must be taken during a range-of-motion
assessment.
3. Using a skeletal mode, have students locate the anatomic structures and articulation areas
of the following:
a. head and supine
b. upper extremities
c. lower extremities
Required Reading:
Kozier, et al (2004) Fundamentals of Nursing (5th ed.) Upper Saddle River NJ: Prentice Hall.
Chapter 28, pp 535-543, 599-602.
Seidel, et al (2003) Mosby’s Guide to Physical Examination (5th ed.) St. Louis: Mosby.
Chapters 7 & 20.
Content Outline:
I. Anatomy & Physiology
II. Review of Related History
d. Present Illness
e. Past Medical History
f. Family History
g. Personal & Social History
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III. Physical Examinations
a. Inspection & Palpation of Skin
1. Primary Lesions
2. Secondary Lesions
3. Morphologic Characteristics of Skin Lesions
b. Inspection & Palpation of Nails
c. Inspection of Hair
d. Common Abnormalities of Skin, Hair, and Nails
e. Inspection & Palpation of Musculoskeletal System
f. Range of Motion & Muscle Strength Assessment
g. Limb Measurements & Assessment
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Unit 4: FOCUSED ASSESSMENT
UNIT 4B: Abdomen, Breasts & Genitalia
Learning Objectives:
1. Explain the methods of examining the breasts, abdomen, and genitalia.
2. Discuss the significance of physical findings, including expected and unexpected
findings.
3. Discuss variations in the examination techniques appropriate for clients of different
developmental ages.
4. Review sample documentation of findings of the assessment.
Learning Activities:
1. Assemble equipment needed for examination.
2. Using models of breast and genitalia perform breast exams and testicular exams.
3. Practice abdominal assessment as outlined in assessment handbook.
Required Reading:
Seidel, et al, Mosby's Guide to Physical Examination, (5th ed), 2003, Chapters 15, 16, 17,
& 18.
Seidel, et al, Mosby's Guide to Physical Examination Handbook, (3rd ed), 2003, Chapters
13, 14, 15, & 16.
Additional Resources:
Kozier, Fundamentals of Nursing Clinical Handbook (7th ed), 2004, Unit 2, Physical
Examination.
Content Outline:
I.
Anatomy and physiology of breast and axillae
II.
Review of related history and risk factors
III.
Examination and findings
A. Equipment
B. Breast Self Examination
C. Examine techniques of inspection, palpation
D. Findings and documentation
IV.
Anatomy and physiology of abdomen
V.
Review of related history
VI.
Examination and findings
A. Equipment and preparation
B. Inspection, auscultation, percussion, & palpitation
C. Findings and documentation
VII. Anatomy and physiology of female genitalia
VIII. Review of related history and risk factors
IX.
Examination and findings review of equipment, preparation and procedures
X.
Documentation of findings
XI.
Anatomy and physiology of male genitalia
XII. Review of related history and risk factors
XIII. Examination and findings review of equipment, preparation and procedures
XIV. Documentation of findings
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UNIT 4: FOCUSED ASSESSMENT
Unit 4C: Nutritional Assessment
Learning Objectives:
1. Discuss a physical assessment of nutritional status.
2. Discuss clinical signs of malnutrition.
3. Discuss a dietary assessment (nutritional history).
4. Identify anthropometric data and data collection.
5. Identify laboratory data pertinent to a nutritional assessment.
6. Identify risk factors for nutritional problems.
Learning Activities:
1. Perform a physical assessment to indicate nutritional status.
2. Practice gathering anthropometric data.
3. Practice interpreting laboratory analysis pertinent to nutrition.
4. Perform a dietary assessment (nutritional history).
Required Reading:
Kozier, B. et al. (2004). Fundamentals of Nursing (7th ed) Upper Saddle River
NJ: Prentice Hall. Chapter 45
Moore, Mary. (2001). Nutritional Care (4th ed.). St. Louis, Missouri. Mosby, Inc. p. 35-65
Content Outline:
I. Perform a physical assessment to indicate nutritional status.
A. Hair
B. Head and Neck
C. Eyes
D. Mouth
E. Skin
F. Nails
G. Heart
H. Abdomen
I. Musculoskeletal
J. Neurologic/Mental
II. Practice gathering anthropometric data
A. Height and weight
B. Ideal Body weight
C. Body Mass Index Evaluation
D. Skin Fold Measurements
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E. Resting Energy Expenditure
F. Estimating Caloric Needs
G. Percentage of Weight Loss
III. Practice interpreting laboratory analysis
A. Serum proteins
B. Hematologic Values
C. Urinary Values
D. Nitrogen Balance
IV. Perform a dietary assessment (nutritional history)
A. Socioeconomic data
B. Food Preparation
C. Physical activity
D. Appetite
E. Allergies, intolerances, avoidances
F. Oral health
G. GI problems
H. Mental and physical illness
I. Medications
J. Weight change
K 24 hour recall of food intake
V. Identify risk factors for nutritional problems
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UNIT 4: FOCUSED ASSESSMENT
UNIT 4D: Assessment of the Head, Neck, Eyes, Ears, Nose and Throat
Learning Objectives:
1.
2.
3.
4.
5.
Conduct a history related to the head, neck, eyes and vision, ears, nose, and throat.
Discuss examination techniques for head, neck, eyes, ear, nose and throat.
Identify normal age and condition variations to the head, neck, eyes, ears, nose, and
throat.
Recognize findings that deviate from expected findings.
Relate symptoms or clinical findings to common pathologic conditions.
Required Reading:
Kozier, et al (2004) Techniques in Clinical Nursing (5th ed.) Upper Saddle River NJ: Prentice
Hall. Pp 63-87.
Seidel, et al (2003) Mosby’s Guide to Physical Examination (5th ed.) St. Louis: Mosby.
Chapters 9, 10 and 11.
Equipment:
Bring stethoscope, nonsterile gloves, tongue depressors and applicator swabs to class.
Content Outline:
1.
2.
Head, face and neck assessment
a. Review-of-systems questions
b. Head
1.
Skull contour/size
2.
Scalp texture/color
3.
Hair distribution/quantity/quality/foreign bodies/hygiene
c. Face
1.
Symmetry/color/expression
2.
Movements
3.
Emphasis on cranial nerves V (trigeminal) and VII (facial)
d. Neck
1.
Evaluate head and neck movements
2.
Inspect and palpate trachea
3.
Inspect and palpate thyroid
4.
Assess lymph nodes of head, face and neck
Eye Assessment
a. Review-of-systems questions
b. Perform measurement of distant vision (CN II) with Snellen Chart
c. Measure near vision
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3.
4.
d. Test for peripheral visual field
e. Test for extraocular movement (EOM)
1.
Movement of eyes in six cardinal fields of gaze (CN III, IV, VI)
2.
Corneal light reflex and cover/uncover test
f. Test pupillary response
1.
Direct and consensual light reactions
2.
Accommodation
g. Test corneal reflex (CNV) – simulated in lab
h. External ocular structures
i. Internal eye using opthalmoscope - optional in lab but information testable on
written exams
1.
Red reflex
2.
Optic disc margin – shape, size, color, physiological cup
3.
Retinal background
4.
Macula
5.
Vitreous body, cornea and anterior chamber
Ear assessment guidelines
a. Review-of-systems questions
b. Inspect both ears for alignment and configuration
c. Inspect and palpate external ear
d. Otoscopic exam
2.
External auditory canal
3.
Tympanic membrane – characteristics, color, landmarks
e. Screening evaluation of auditory function
1.
Whisper test
2.
Tuning fork tests
a.
Rinne
b.
Weber
Nose, mouth and throat assessment guidelines
a. Review-of-systems questions
b. Nose and sinuses
2.
General appearance of nose
3.
Sense of smell and odor identification (CN I)
4.
Internal nasal cavity
5.
Sinuses (frontal and maxillary)
c. Mouth and throat
1.
Lips and gums
2.
Teeth – number and condition
3.
Tongue – symmetry and movement (CN XII)
4.
Floor of mouth – hard and soft palates (CN IX & X)
5.
Oropharynx – landmarks, color, surface characteristics
22
UNIT 4: FOCUSED ASSESSMENT
Unit 4E: The Neurological Exam
Learning Objectives:
1. Conduct a history related to the neurological exam.
2. Discuss examination techniques for the neurologic system.
3. Identify normal age and condition variations of the neurologic system
4. Recognize the findings that deviate from expected findings.
5. Relate symptoms or clinical findings to common pathologic conditions.
6. Identify aspects of an interview that facilitates mental status examination.
7. Describe techniques to assess mental status in the following areas: physical appearance,
cognitive abilities, emotional stability, speech, and language skills.
Learning Activities:
1. Demonstrate a screening neurologic examination on a peer.
2. Document the findings of a neurologic assessment.
3. Demonstrate a mental status exam on a peer.
4. View Springhouse video- “Identifying Neurological Deficits”
Required Reading:
Seidel, H.M. et al (2002) Mosby’s Guide to Physical Examination (5th ed.) St Louis MO:
Mosby. Chapter 21.
Seidel, H.M. et al The Physical Handbook which accompanies the text. Chapter 2, pp.9-18,
Chapter 18 pp. 225-252.
Seidel, H.M. et al Student Workbook which accompanies the text Chapter 4, pp. 23-28, Chapter
21, pp 159-168.
Content Outline:
I. Review structures of the brain
II. Mental status assessment
A. Posture
B. Gait
C. Motor Movements
D. Dress
E. Hygiene
F. Facial expression
G. Speech
H. Mood
23
I. Abstract reasoning
J. Memory
K. Sensory perception
III Cranial nerve assessment
IV. Sensory nerve assessment
V. Motor assessment
VI. Cerebellar assessment
24
Unit 5: Physical Assessment of a Peer
Learning Objectives:
1.
2.
3.
4.
5.
6.
Perform a comprehensive history and physical examination that includes all body systems.
Analyze the findings from a comprehensive assessment.
Display confidence and comfort in the use of assessment techniques.
Display respect for the client while performing assessment techniques.
Use an organized approach in performing a comprehensive history and physical examination.
Document findings, clearly and accurately, from a comprehensive physical assessment.
Required Reading:
Seidel, D. et al (2003) Mosby’s Guide to Physical Examination (5th ed.) St Louis: Mosby.
Chapter 22 and 24.
Angelina College Nursing Program video “Head to Toe Assessment.”
Content Outline:
I.
Interviewing the client
A. Client reliability
II.
Examination sequence
A. Skin
B. Head
C. Eyes
D. Ears
E. Nose/ sinuses
F. Neck
G. Thorax
H. Breasts
I. Cardiovascular
J. Peripheral vascular
K. Abdomen
L. Genital/ rectal
M. Musculoskeletal
III.
Equipment/ supplies for the exam
IV.
Documenting the information
V.
Assessment of the students performance
25
ANGELINA COLLEGE NURSING PROGRAM
ASSESSMENT FORM (Page 1)
IDENTIFIERS
Patient’s Initials: _________ DOB: __________ Age: ________ Sex: M F Race: ________
Current Residence: _______________________________________________________________
II. CHIEF COMPLAINT OR REASON FOR SEEKING HEALTH CARE INITIALLY
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
III. HISTORY OF PRESENT ILLNESS AND PATIENT’S CURRENT UNDERSTANDING OF
HEALTH STATUS: _____________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
IV. PATIENT HISTORY/HABITS (Include dates):
_____ High Blood Pressure _____ TB
______ Diabetes
______ Renal Disease
_____ Heart Disease
_____ Asthma
______ Hypoglycemia ______ Mental Illness
_____ Stroke
_____ COPD
______ Ulcer
_______Cancer
_____ Rheumatic Fever
______ Hepatitis
______ Epilepsy
_______ Anemia
_____ Other (list): ________________________________________________________________
Major Illness & Injury/Surgeries (include Ob/Gyn history for females): _____________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
Childhood Illnesses/Immunizations & Developmental History: _________________________ __
Allergies:
______ Yes ______ No Type ____________________________ __
Use of tobacco:
______ Yes ______ No Type ___________________________ __
Use of alcohol
______ Yes ______ No Type ___________________________ __
Current Home Medications (List med, strength, dose, route, & freq. Continue on back of this page PRN)
____________________________________________________________________________ __
____________________________________________________________________________ __
____________________________________________________________________________ __
____________________________________________________________________________ __
____________________________________________________________________________ __
____________________________________________________________________________ __
V. FAMILY HISTORY:
______ Heart Disease ______ Diabetes ______Stroke _____Hypertension _____Cancer
______ Other ________________________________________________________________ __
VI. SOCIOECONOMIC:
Marital Status: S M D W
Lives With: ______ Family ______ Friends ______ Alone
Occupation: ________________________________ Education: _______________________ __
Dwelling: ______ Dormitory ______Apt ______ House ______ Other________________ __
ADL’s: ______ Independent ______ Needs Asst With ______________________________ __
Social Worker Consult done: ______ Yes ______ No If yes, date: __________________ __
Other: ______________________________________________________________________ __
I.
26
ASSESSMENT FORM (page 2)
General Survey: __________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
__
__
__
__
Vital Signs: _________T _________P _________R _________BP _________Ht _________Wt
Neuro/MS/ADL Level: ____________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
__
__
__
__
Skin: ___________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
__
__
__
__
Respiratory: _____________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
__
__
__
__
Cardiovascular / Peripheral Vascular: _______________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
__
__
__
__
__
__
__
GI: ____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
__
__
__
__
GU: ____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
__
__
__
__
MISC: __________________________________________________________________________ __
____________________________________________________________________________ __
____________________________________________________________________________ __
____________________________________________________________________________ __
Signature of Examiner: ___________________________________________________________ __
27
LABORATORY ANALYSIS
Normal Values
Complete Blood Count
RBC
Hgb
Hct
Platelets
WBC
Neutrophils
Monocytes
Lymphocytes
Eosinophils
Basophils
Urinalysis (UA)
Sp
RBC
WBC
Bacteria
pH
Electrolytes
Na+
K+
ClCO2
Other Chemistries
Glucose
BUN
Creatinine
Calcium
Uric Acid
Cholesterol
Unconjugated
Bili
Conjugated Bili
Total Bilirubin
ALT (SGPT)
AST (SGOT)
ALP
LDH
GGT
CPK (CK)
CK-MB
Troponin
Date
Date
Date
28
RESPIRATORY ASSESSMENT
CARDIOVASCULAR ASSESSMENT
 Rate, rhythm, depth
 Edema
 Labored breathing? (dyspnea,
 Apical pulse (1 min) (rate, rhythm,
accessory muscles, nasal flaring,
quality) (aortic, pulmonic, tricuspid,
retractions)
mitral areas)
 Cough (frequency,production) describe
 Heart sounds - S1, S2
mucus (color, consistency, amount)
 Peripheral pulses (=& strong X 4)
 O2 (cannula, mask, # liters, tubing
 PMI-palpable or non-palpable
irritation) O2 Sat
 AP=RP
 TC&DB
 Homan’s Sign
 Breath sounds (ant., post., lat.)
NEUROVASCULAR ASSESSMENT
(Circulation/ Movement/ Sensation)
C
M
S
Color
wiggles
feeling
Temp
fingers
pain
Cap refill
& toes
numbness
Pulses
tingling
3 Edema
burning 4
CLIENT DATA / GENERAL SURVEY
SKIN / HYDRATION ASSESSMENT
 Name
 Skin color, temp, turgor, moisture,
intact? Lips, mucous membranes
 Age
color and moisture
 Allergies
 Red areas, lesions, rashes
 Vital Signs T, P, R, B/P
 Wounds: size, location, color, odor,
 ABC’s-Affect, behavior, and
drainage
communication
 Prevent breakdown measures in
o Affect- facial expression
effect? i.e. egg crate mattress
o Behavior- describe
o Communication-Get subjective
 IV’s location, type, fluid, rate
data i.e. How are you feeling?
PAIN ASSESSMENT
 Environment setting
 Location? Intensity? Onset?
Duration?
 Chief Complaint (quote)
 Character? Precipitating or
 Independent / Needs Assistance
aggravating factors?
 Relief measures? Last med taken?
1
5
GI / GU ASSESSMENT
 Bowel sounds
 Distention? Tender? Soft, Hard?
 Flatus? N/V?
 Diet / Appetite
 NG or PEG, placement and residual
 Last BM? Normal Pattern? Aides?
 Bladder status: last void? time?
amount? dysuria? distention?
 Urine: color? clarity? odor?
 I&O past 24 hrs
 Catheter?
NEUROLOGIC ASSESSMENT
 Level Of Consciousness-Alert,
oriented X3
 Memory
 Speech (slurred, slow)
 PERRLA
 Hand grips (= & strong)
 Abnormal movements
MUSCULOSKELETAL
 Full Range of Motion
 Strength of extremities (= & strong)
 Ambulation (describe)
 Independent/Needs Assistance
6
2
29
ANGELINA COLLEGE NURSING PROGRAM
PEER ASSESSMENT FORM (Page 1)
IDENTIFIERS
Patient’s Initials:_________ DOB: __________ Age: ________ Sex: M F Race: _________
Current Residence: _______________________________________________________________
CHIEF COMPLAINT OR REASON FOR SEEKING HEALTH CARE INITIALLY
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
HISTORY OF PRESENT ILLNESS AND PATIENT’S CURRENT UNDERSTANDING OF HEALTH
STATUS: __________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
PATIENT HISTORY/HABITS (Include dates):
_____ High Blood Pressure ______ TB
______ Diabetes
______ Renal Disease
_____ Heart Disease
______ Asthma
______ Hypoglycemia ______ Mental Illness
_____ Stroke
______ COPD
______ Ulcer
______ Cancer
_____ Rheumatic Fever
______ Hepatitis
______ Epilepsy
______ Anemia
_____ Other (list): ________________________________________________________________
Major Illness & Injury/Surgeries (include Ob/Gyn history for females): _____________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
Childhood Illnesses/Immunizations & Developmental History: _________________________ __
Allergies:
______ Yes ______ No Type ____________________________ __
Use of tobacco:
______ Yes ______ No Type ____________________________ __
Use of alcohol
______ Yes ______ No Type ____________________________ __
Current Home Medications (List med, strength, dose, route, & freq. Continue on back of this page PRN)
____________________________________________________________________________ __
____________________________________________________________________________ __
____________________________________________________________________________ __
____________________________________________________________________________ __
____________________________________________________________________________ __
____________________________________________________________________________ __
FAMILY HISTORY:
______ Heart Disease ______ Diabetes ______Stroke _____Hypertension _____Cancer
______ Other ________________________________________________________________ __
VI. SOCIOECONOMIC:
Marital Status: S M D W
Lives With: ______ Family ______ Friends ______ Alone
Occupation: ________________________________ Education: _______________________ __
Dwelling: ______ Dormitory ______Apt ______ House ______ Other________________ __
ADL’s: ______ Independent ______ Needs Asst With ______________________________ __
Social Worker Consult done: ______ Yes ______ No If yes, date: __________________ __
Other: ______________________________________________________________________ __
30
GENERAL SURVEY: __________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
T_______ P _______ R _______ BP _______ HT. _______ Wt. _______
MENTAL STATUS:
Reports (Subjective )
_____ Disoriented/ Confused
______ Depression
______Anxiety
Exhibits (Objective) ABC’s (Affect, Behavior, Communication)
_____________________________________________________________
______________________________________________________________________________
HEAD/FACE:
Reports (Subjective)
_____ Frequent or Unusual Headaches
____ Dizziness
____Syncope
_____ Severe Head Injuries
____Periods of loss of consciousness _____TMJ
_____ Other (Explain) ___________________________________________________________
Exhibits (Objective) _____________________________________________________________
______________________________________________________________________________
EYES:
Reports:
_____ Visual Acuity
_____ Problems – If yes, explain___________________
_____ Use of eye medications
_____ History of Trauma or Familial Eye Disease
_____ Last Eye Exam
Exhibits: (Objective) _____________________________________________________________
______________________________________________________________________________
EOM Function _________________________________________________________________
Pupillary Responses _____________________________________________________________
External ______________________________________________________________________
______________________________________________________________________________
EARS:
Reports (Subjective)
_____ Hearing Loss
_____ Pain
_____ Discharge _____ Tinnitus
_____ Vertigo
Exhibits (Objective) _____________________________________________________________
______________________________________________________________________________
External ______________________________________________________________________
Internal _______________________________________________________________________
Hearing _______________________________________________________________________
31
NOSE, MOUTH, AND THROAT:
Reports: (Subjective)
_____Alterations in Sense of Smell
_____ Frequent Colds;
_____ Bleeding or swelling of gums
_____ Recent tooth abscesses or extractions
_____ Soreness of tongue or Buccal mucosa
_____Disturbance of taste
Last Dental Exam _______________________________________________________________
Exhibits: (Objective) ____________________________________________________________
______________________________________________________________________________
NECK:
Reports: (Subjective):
_____ Thyroid abnormalities
_____ “Swollen glands” or neck lumps
_____ Pain or stiffness in the neck
Exhibits: (Objective): ____________________________________________________________
______________________________________________________________________________
THORAX:
Reports: (Subjective):
_____ Cough
_____ Sputum (color, quantity)
_____ Hemoptysis
_____ Wheezing
_____ Asthma
_____ Bronchitis
_____ Emphysema _____ Pneumonia
_____ TB
Last CXR and results: ___________________________________________________________
Exhibits (Objective): ____________________________________________________________
______________________________________________________________________________
CARDIOVASCULAR:
Reports: (Subjective): _____Chest pain or dizziness – if yes, explain _______________________
_____ Palpitations _____ Dyspnea _____ Orthopnea _____ Hypertension _____ Previous MI
Other (explain) _________________________________________________________________
Date & results of any EKGs, Cardiac tests ____________________________________________
Exhibits: (Objective) _____________________________________________________________
______________________________________________________________________________
PERIPHERAL VASCULAR:
Reports: (Subjective): _____Edema _____Varicosities _____Claudication
_____Peripheral neuropathies _____History of DVT
Exhibits: (Objective): ____________________________________________________________
______________________________________________________________________________
ABDOMEN:
Reports: (Subjective):
_____ Pain
_____ Dysphagia
_____ Frequent Heartburn _____ N&V
_____ Diarrhea
_____ Constipation _____ History of Ulcers
_____ Hepatitis
Other (explain) _________________________________________________________________
Bowel pattern: __________________________ Urinary pattern: _________________________
Diet: ________________________________________________________________________
Exhibits (objective): _____________________________________________________________
______________________________________________________________________________
32
GENITAL/RECTAL:
Males:
Reports: (Subjective):
_____Hernias _____Discharge or sores on penis _____ Testicular pain or masses
_____History of sexually transmitted diseases and treatment: _____________________________
Dates and results of last rectal exam and PSA level if applicable: _________________________
Exhibits (Objective) DEFERRED
Females:
Reports: (Subjective):
Breast: ____Pain _____Tenderness
_____Discharge ______Lumps
Frequency of BSE:__________________________ Mammograms: _____________________
Menses – Age at Menarche _____ LMP______________________________________________
Frequency and duration of periods __________________________________________________
Menstrual difficulties (describe) ____________________________________________________
Age at menopause/symptoms ______________________________________________________
Hormone therapy _______________________________________________________________
Date and Results of last Pap smear & rectal exam ______________________________________
Pregnancies: _____G ______T _____P _____A _____L
Complications: _________________________________________________________________
Exhibits: (Objective) DEFFERRED _________________________________________________
______________________________________________________________________________
MUSCULOSKETAL:
Reports: (Subjective): _____Muscle or joint stiffness pain _____ Arthritis _____ Backache
Exhibits: (Objective): ___________________________________________________________
NEUROLOGICAL:
Reports (Subjective) _____Seizures _______Weakness _______Paresthesia _____ Numbness
_______Tremors ______Trauma
_________Headaches
__________Alzheimer’s
Exhibits (Objective)_____________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
SKIN:
Reports (Subjective) _____________________________________________________________
______________________________________________________________________________
Exhibits (Objective) ` ____________________________________________________________
______________________________________________________________________________
SUMMARY STATEMENT
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Signature: _________________________________
Date: _____________________________________
33
ANGELINA COLLEGE NURSING PROGRAM
RNSG 1215 - PHYSICAL ASSESSMENT PERFORMANCE EVALUATION
Student Name: ______________________________________________ Date: ____________
I.
II.
GENERAL SURVEY/VITAL SIGNS:
__________Height and weight
__________B/P (left arm sitting)
__________Temp.
__________Pulse
__________Respirations
_____ ROS Questions
MENTAL STATUS:
__________Responds appropriately to questions
__________Oriented to time, place, and person
__________Reasoning abilities
__________Able to follow directions
__________Memory intact (immediate, recent, past)
_____ROS Questions
I. Total = /5
II. Total= /5
III.
HEAD/FACE:
_____ ROS Questions
__________Examines hair and scalp
__________Tests ability to move face muscles (expressions) (CN VII)
__________Palpate jaw muscles for strength(CN V), and TMJ joint
IV.
EYES:
_____ ROS Questions
__________Observes lids, conjunctiva, and lacrimal glands
__________Tests visual acuity using Snellen eye chart (CN II)
__________Checks extraocular movements (CN III, IV, & VI)
__________Tests pupillary response to light (directly, indirectly)
__________Estimate periphera
IV. Total = /5
V.
EARS:
__________Inspects and palpates external ear
__________Inspects canal
_________ Otoscopic exam
__________Gross hearing screen using Whisper Test
_____ ROS Questions
NOSE:
__________Observes and palpates external
__________Internal exam – use penlight
__________Palpates maxillary and frontal sinuses
_____ ROS Questions
VI.
V. Total = /4
VI. Total= /3
34
VII.
MOUTH AND THROAT:
______ROS Questions
__________Observes oral mucosa, throat and structures
__________Observes teeth
__________Inspect movement of tongue, uvula, and gag reflex (CN IX, X)
VII. Total = /3
VIII. NECK:
_____ ROS Questions
__________Palpates Lymph nodes
__________Palpates Trachea
__________Evaluate head and neck movements
__________Palpate thyroid
__________Tests CN XI (sternomastoid and trapezium muscles)VIII. Total = /5
IX.
X.
THORAX:
_________Observes AP/Lateral diameter
_________Observes Symmetry
_________Palpation (Excursion of diaphragm)
_________Checks nail bed/ capillary refill time
_________Auscultate breath sounds in all fields
_____ ROS Questions
HEART:
__________Inspect skin and nail beds
__________Check for neck vein distention
__________Apical/radial pulse rate
__________Palpation PMI
__________Auscultate cardinal areas
_____ ROS Questions
IX. Total= /5
X. Total = /5
XI.
PERIPHERAL VASCULAR SYSTEM:
_____ ROS Questions
__________Checks temporal pulses
__________Checks carotid pulses (bilaterally, but not simultaneously)
__________Checks brachial pulses
__________Checks femoral pulses
__________Checks dorsalis pedis pulses
__________Posterior posterior tibial pulses
XI. Total = /2
XII.
ABDOMEN:
_____ ROS Questions
__________Inspect for symmetry, markings, pulsations
__________Auscultate bowel sounds in four quadrants
__________Palpate suprapubic area for bladder
__________Check for CVA tenderness (costal vertebral angle-indirect)
__________Palpate for tenderness, masses, rigidity
XII. Total = /5
35
XIII. BREAST, GENITALIA, RECTUM: (Female; Male)
__________Inspection of models (genitalia; rectum)
__________Breast exam on models
_____ ROS Questions
XIII. Total = Pass/Fail
_____ ROS Questions
XIV. MUSCULOSKELETAL:
__________Observe and palpate spine
__________Observes gait
__________Evaluate joint ROM (upper & lower, left and right)
__________Inspect and palpate muscle mass (upper & lower left and right)
__________Evaluate muscle strength (upper & lower left and right)
XIV. Total = /5
XV. NEUROLOGICAL:
_____ ROS Questions
__________Cerebellar Function
Evaluate coordination (finger-nose, rapid alternating movements)
Evaluate balance (Romberg)
__________Sensory Perception
Test superficial touch and superficial pain
Test vibratory response ( 3 joints)
___________Deep Tendon Reflexes
Triceps, patellar, plantar
XV. Total = /3
XVI. SKIN:
_____ ROS Questions
__________Skin Inspection
(Note: The student is expected to integrate skin assessment throughout the exam; the
cranial nerves and lymphatic system have been integrated throughout the assessment to
facilitate evaluation.)
XVI. Total = /5
XV.
OVERALL:
__________Performs examination with a systematic organization
__________Provides for the safety of the client at all times
__________Uses medically aseptic principles
__________Demonstrates effective use of interpersonal skills with the client
__________Obtains pertinent facts with a brief review of systems incorporated within the
exams
__________Conducts exam using professional demeanor and a thorough, conscientious
approach
XVII. Total = /12
Overall Total = /75 points physical assessment
/25 points documentation
Instructor: ______________________________
36
ANGELINA COLLEGE NURSING PROGRAM
PHYSICAL ASSESSMENT WRITE-UP EVALUATION
1. Student uses a format, which facilitates readability.
2. Findings are recorded clearly and concisely, complete sentences not necessary but phrases
must facilitate understanding.
3. Findings are recorded descriptively. Define “normals” and be specific.
4. Medical/nursing terminology and abbreviations are used appropriately.
5. Subjective information is distinguished from objective information when appropriate. Be sure
patient completes all subjective information.
6. The findings reflect consistency with the physical assessment performance.
7. The student categorizes findings within each body system logically and systematically.
8. The student organizes findings within each body system logically and systematically.
9. The findings are recorded thoroughly and comprehensively.
10. The findings are appropriately summarized.
Example:
“Physical exam reveals…
“Past history is significant for…
“Recommendations include…
Total Points =
Overall Total =
/25
/100
37
38