RNSG 1215 Health Assessment Student Information Plan

Transcription

1 RNSG 1215 Health Assessment Student Information Plan Prepared by: Christy G. Scales, MS, RN Wendy Stewart, MSM, RN, CNE Fall

2 Health Assessment CLASS SCHEDULE for Fall 2014 DATE TOPIC CLASS PREP #1 Aug 27 or 28 Review SIP: Introduction & Course Requirements Read: Ch 1-5 Introduction to The Point Overview, Interviewing Techniques Health History Components #2 Sept 3 or 4 General Survey; Mental Status; Vital Signs Bring stethoscopes to class Skin, Hair, Nails Assessment Read: Ch.6,8; 9, 14 #3 Sept 10 or 11 Head & Neck Assessment Watch & Learn Video Eyes, Ears, Mouth, Throat, & Nose Assessment Bring stethoscopes & penlight to class #4 Sept 17 or 18 EXAM 1 Open Lab Practice #5 Sept 24 or 25 Cultural and Social Assessments Culture Quiz Practice Assessment Techniques studied up to this point #6 Oct. 1 or 2 Thoracic & Lung Assessment Bring stethoscopes & penlight to each class Watch & Learn Video #7 Oct. 8 or 9 Heart & Neck Vessels Assessment Peripheral Vascular Assessment Watch & Learn Video #8 Oct 15 or 16 EXAM 2 Open Lab Practice #8 Oct 22 or 23 Abdominal Assessment Genital-Urinary Assessment Watch & Learn Video Read: Ch 15,16,17,18 The Point- Unit III Nursing Scantron, ACC ID #, #2 pencils Read: Ch. 11 The Point- Unit II Read: Ch 19 The Point- Unit III; Ancillary Content: Lung Sounds Read: Ch. 21,22 The Point- Unit III; Ancillary Content: Heart Sounds Nursing Scantron, ACC ID #, #2 pencils Read: Ch. 23, 26, 27 Appendix E The Point- Unit III: #10 Oct 29 or 30 Musculoskeletal & Neurological System Assessments Health History Paper Due at beginning of class Watch & Learn Video Read: Ch. 24, 25 The Point: Unit III, Ch. 26; Unit IV, Ch.32; Concepts in Action- Ch. 12, Unit II #11 Nov. 5 or 6 Geriatric & Nutritional Assessment; Functional Assessment Read: Ch. 32, 13 #12 Nov 12 or 13 Mistreatment / Abuse & Neglect Assessment Read: Ch. 10, 28 The Point-Unit II-journal Dress Rehearsal: Putting it All Together article Watch & Learn Video DOCUMENTATION Notebook- DUE BY end of class Unit III: Ch. 28- Putting it All Together, Conclusion # 13 Nov 19 or 20 EXAM #3 (comprehensive) Open Lab Practice Dec. 3 or 4 FINAL PRACTICUM- individual times TBA Practice, Practice, Practice Dec. 10 or 11 FINAL PRACTICUM- individual times TBA Practice, Practice ** Note: To access to Watch & Learn Assessment Videos: go to thepointlww.com and sign in. Scroll to Unit III, Chapter 28, and click on the assessment video you want to see to prepare for class.*** 2

3 COURSE INTRODUCTION RNSG 1215 Health Assessment (2 credit hours). Development of skills and techniques required for a comprehensive health assessment within a legal/ethical framework. (1 lecture hour and 2 lab hours per week). End-of-Course Outcomes: Describe the components of a comprehensive nursing health assessment; and demonstrate professional nursing roles in a systematic process of health assessment. Prerequisites: BIOL 2401 and/or Admission into the ADN Program. INSTRUCTORS Tana Hafner-Burton, MSN, RN Office: S 112 Office Telephone: tburton@alvincollege.edu Christy G. Scales, RN, MS Office S 117 Office Telephone: cscales@alvincollege.edu Wendy Stewart, MSN, RN, CNE Office S 114 Office Telephone: wstewart@alvincollege.edu The preferred method for communicating with your instructor is through the ACC My Blackboard , or you may call the office telephone extensions and leave a message with your name, number and a brief message. You may expect a response within 48 hours Monday-Thursday and by the next business day Friday-Sunday. Office hours are posted on each instructor s door. Disclaimer: The instructor reserves the right to modify this syllabus as needed and will notify the students of any changes using the ACC or My Blackboard or announcements. TEXTBOOK INFORMATION Up-to-date textbook information (including the correct ISBN number) for this course may be found at Once on this website, select the semester, the department, your course and the section number and the textbook and other requirements for that class will be displayed below. Also from this website, the textbook can be purchased online and mailed directly to your residence. The textbook may also be purchased in the ACC bookstore, room E-112, which is open Monday through Thursday 7:30 a.m. to 7:00 p.m. and Friday 7:30 a.m. to 2:00 p.m. Bookstore hours can vary during holidays so please call for more information. Textbook: required Weber, J.R., & Kelley, J.H. (2014). Health Assessment in Nursing, (5th ed). Philadelphia:Wolters Kluwer/Lippincott Williams & Wilkins. METHODS OF INSTRUCTION This course includes both theory and lab components. The classroom format will be conducted primarily as lecture/discussion and problem-solving sessions. The student is expected to attend class prepared by reading the assigned materials and reviewing basic anatomy and physiology and health assessment of the systems being covered. Students may receive additional assignments by the instructor as a part of the lab 3

4 component of classroom. Students are not allowed to film or take photos during class/lab. Lecture recordings are allowed with instructor s permission if no objection from classmates. EXAMS Three exams will be given during this course, and one Final Practicum. Exams will only be given during the allotted time. Exams 1 and 2 each have 25 questions, and students have 30 minutes to complete them. The third exam is comprehensive with 50 questions and 60 minutes to complete. Unit objectives from the syllabi provide a blueprint as a study-guide for testing. See course schedule for exam dates. Bring a Scantron, #2 pencil, and student ID for each exam. No other items will be allowed in the exam room. If a student is found to be in possession of a cell phone during an exam, the exam will be collected and the student will receive a score of zero for that test. The Scantron is the official grading tool. Please take care when making your mark. Tiered-Testing: Immediately after taking Exams 1 & 2 (not Exam 3), students may opt to re-take the test in a small, randomly selected group. If the student must leave the room after completing the exam, he/she will not be allowed to re-enter the exam room for tiered testing. The group will have 30 minutes to re-take the test and submit one Scantron from the group. Any student choosing to participate must submit his/her Scantron when completing the initial exam, wait in the classroom until all others complete their initial exams, and then move to the small group. The small group will take the exam jointly. Points will be added to your individual exam according to the following schedule: 22, 23 correct answers: 1 point 24, 25 correct answers: 2 points Test Review: Students are given an opportunity to check their answers during a test review session. Further help with test questions is available during the instructor s office hours. Further questions regarding that exam must be submitted in writing within one calendar week of the exam date. After that time, the exam grade is nonnegotiable. Any student scoring below a 75 (less than 19 out of a possible 25 points) on the exam, reviewing the exam with the instructor is required within 2 weeks after the exam. It is the responsibility of the student to make the appointment. EXAM ABSENCE If a student is to be absent on exam day, he/she must notify the instructor no later than the exam day to schedule a make-up exam to be taken prior to the next class day. Make-up exams will include essay-type questions. If the student does not follow this protocol, he/she will not be eligible to take the exam, and will receive a score of zero for the missed exam. CLASS PARTICIPATION: To guide and reinforce student learning, and to document class and lab participation, there will be several graded classroom and lab activities throughout the semester. Since these assignments document class participation, the student must be present in class and lab to earn the points. These activities may include guided worksheets for lab practice, short quizzes, and/or brief written or computer module assignments; each will be due at the end of the class period in order for participation points to be earned. Each assignment will be worth 1 to 3 points, depending on the activity. The maximum total amount of participation points a student may earn is 15. DOCUMENTATION NOTEBOOK: This series of written activities offer practice and provide feedback for documenting and communicating subjective and objective data collected during the health assessment, using information systems that support safe nursing practice. The student will keep a notebook containing physical assessment documentation from each class lab practice. This notebook will be submitted to course 4

5 instructor by the due date (see Class Schedule in SIP). This documentation activity is worth 10 points. No late assignments will be accepted for this activity. HEALTH HISTORY PAPER: The purpose of this assignment is to offer the student experience to engage in basic communication skills with a community member, to identify standards of practice, and to increase awareness of psychosocial and physiological health needs when performing a client interview as part of a comprehensive health assessment. This assignment also gives the student the opportunity to use basic clinical reasoning skills to address the self-care potential of culturally and socially diverse individuals. This paper must be no more than 2 pages long, which does not include the cover sheet, Integrity Statement, or written consent. It must be neatly organized and contain the most important information that pertains to a complete and thorough health history. Please Staple papers together in the following order: Cover Sheet, Grade Sheet, Integrity Statement, Written Consent, Health History Paper. Do not put in a folder. Final Practicum: (worth 50 points). This is where the student demonstrates that he/she has met the Student Learning Outcomes for this course. While performing the head-to-toe assessment, the student will demonstrate safe, quality care, and follow standards of practice. (See Student Learning Outcomes in SIP), which are the assessment skills practiced in the lab throughout the semester. It is each student s responsibility to request additional assistance from his/her instructor if unsure of assessment technique during lab practice. These same skills will be evaluated during the final practicum. The intent of the final practicum is to test the student s knowledge and psychomotor skills in performing the assessment. The Final Practicum is a Competency Exam, so a minimum of 38 out of 50 points (75%) is required. Any student who does not score at least 38 points on the Final Practicum Competency Exam will be allowed one more attempt within a scheduled timeframe set by the instructor, where the student will be given another opportunity to pass (38 out of 50) the final practicum. The score from the first attempt will be recorded. In order to pass the course, the student must pass the final practicum by the second attempt. If the student does not pass the Final Practicum Competency Exam, the student will receive a D or F, and will not pass the course. Students will be given assigned times for the final practicum. Refer to course schedule for the date. Late Course Work Policy: 1. Students are expected to have their assignments done by the due dates. Late work will be penalized. 2. Late assignments submitted 7 days late will be accepted with 1 point off each day, including weekends and holidays. Participation worksheets are not accepted after the due date. Lab Participation Worksheets are due at end of each class, and will not be accepted late. 3. Assignments are not accepted after 7 days and the grade assigned will be a zero. Student Learning Outcomes: Upon completions of Health Assessment RNSG 1215 the student will: 1. Use novice clinical reasoning skills in the introduction and application of the assessment portion of the nursing process to provide safe, quality care. 2. Identify the elements of competent, safe, effective nursing assessment techniques that addresses the self-care potential of culturally and socially diverse individuals with psychosocial and physiological health needs. 5

6 3. Engage in basic communication skills. 4. Identify the standards of practice when performing a comprehensive health assessment within legal, ethical, and regulatory frameworks of the professional nurse. 5. Identify the advocate role of a professional nurse to promote and provide quality, patient-centered health assessments. 6. Use client care technologies and information systems that support safe nursing practice. 7. Promote safety and quality improvement when performing a comprehensive health assessment. EVALUATION (Grade Points) POINTS EVALUATIVE METHOD DESCRIPTION 15 Participation Points Lab Activities i.e. Worksheets, Quizzes (SLO #2) 10 Documentation Notebook- 10 points (SLO #6) 25 Major assignments: Health History Paper - 25 points (SLO #2, 3, 4) 50 Exam 1-25pts (SLO #1,2,5) Twenty-five item multiple-choice format exams Exam 2-25 pts 50 Final Practicum (SLO #3,7) Demonstrate head-to-toe assessment 50 Exam 3 (SLO #1,2,5) Comprehensive fifty (50) item multiple-choice exam. 200 TOTAL COURSE POINTS *The student needs to achieve a minimum of 150 points out of the 200 maximum points (75% average) in order to progress and receive a "C" or better in the course. If 150 points are not achieved, the student receives a course grade of "D" or "F" and is ineligible to progress in the Associate Degree Nursing Program. Grades are based on point totals. Grades are not averaged and points are not rounded upward A % A B 80-89% B C 75-79% C D 60-74% D F 0-59% F SUCCESSFUL CLASS, LAB, and TEST PREPARATION To prepare for each class day and the tests, students should allocate a minimum of 9 hours per week on textbook readings, lab practice, completing assignments, and preparing for class discussions. Students should utilize the ACC campus computers or have a workable computer that can access the course website. Any technical problems on the student s side WILL NOT be an acceptable excuse for late work. A student scoring 75% (19 points out of 25) on an exam is required to schedule an appointment with the instructor to review study strategies. ATTENDANCE POLICY Class and lab begins promptly at the scheduled time. Class time will be divided between lecture and lab time to practice skills learned that day. Attendance will be taken at the beginning of each class period. Scheduled exams will begin promptly at the beginning of class and will last minutes. Students are expected to attend all theory and lab classes. Refer to ACC Student Nurse Handbook. Attendance records will be maintained (per ACC Policy). 6

7 TARDINESS Tardiness is an not a professional behavior and is disruptive to classmates and to instructors. The expectation is for students to be seated and ready to start class when it is scheduled. Please sync your clocks to the classroom clock. Each student is given two free passes with tardies. After two tardies, the student who is late to class will lose five points from the total course grade for each tardy. WITHDRAWAL The instructor cannot withdraw a student from the course. The student must contact Admissions & Academic Advising to formally withdraw. If the student stops coming to class and does not withdraw, the student will receive the earned grade. The Associate Degree Nursing Program follows and enforces the ACC Code of Academic Integrity and Honesty and Behavior located in the ACC Student Handbook. STUDENT DISMISSAL As required by the Texas Board of Nursing and written in the Texas Administrative Code Rule 215.8, students may be dismissed from the program for demonstration of the following, including, but not limited to: 1. Evidence of actual or potential harm to patients, clients or the public; 2. Criminal behavior whether violent or non-violent, directed against persons, property or public order and decency; 3. Intemperate use, abuse of drugs or alcohol, or diagnosis of or treatment for chemical dependency, mental illness, or diminished mental capacity; and 4. The lack of good professional character as evidenced by a single incident or an integrated pattern of personal, academic and/or occupational behaviors which, in the judgment of the faculty, indicates that an individual is unable to consistently conform his or her conduct to the requirements of the Nursing Practice Act, the Boards rules and regulations, and generally accepted standards of nursing practice including, but not limited to, behaviors indicating honesty, accountability, trustworthiness, reliability and integrity. BEHAVIOR POLICY Whenever the student is in the classroom, a clinical agency, on a field trip, at an off-campus activity or attending a convention, he/she is a representative and advocate of the Associate Degree Nursing Program at Alvin Community College and is expected to behave in an appropriate manner. The Code of Student Conduct from the ACC Student Handbook is in effect for all nursing related activities. Disciplinary action will be taken against any student who violates the code. The Associate Degree Nursing Program follows and enforces the ACC Code of Academic Integrity and Honesty located in the ACC Student Handbook. STUDENT SUPPORT Computers are available for use by all registered ACC students in any of the 23 ACC/PCC computer labs, including the Cyber Lab, room A-173. Cyber Lab hours vary. Call for more information about all ACC computer labs. The ACC Library website: The ACC Learning Lab and Writing Center, A-235, is for help with writing assignments, tutoring, exams, and additional computer access: 7

8 MyBlackboard -Any technical problems or issues with MyBlackboard should be directed to the Distance Education Department at Include your first and last name, student ID number and a description of the problem. Students will not be penalized if there is an interruption in MyBlackboard service and the instructor is notified of such an issue by the Distance Education Department. For WebACCESS, Passwords or Computer Labs: contact the IT Dept. Help Desk at CODE OF ACADEMIC INTEGRITY AND HONESTY Students at Alvin Community College are members of an institution dedicated to the pursuit of knowledge through a formalized program of instruction and learning. At the heart of this endeavor, lie the core values of academic integrity which include honesty, truth, and freedom from lies and fraud. Because personal integrity is important in all aspects of life, students at Alvin Community College are expected to conduct themselves with honesty and integrity both in and out of the classroom. Incidents of academic dishonesty will not be tolerated and students guilty of such conduct are subject to severe disciplinary measures. AMERICANS WITH DISABILITIES ACT ACC complies with ADA and 504 Federal guidelines by affording equal access to individuals who are seeking an education. Students who have a disability and would like classroom accommodations must register with the Office of Disability Services, (281) Instructors are not able to provide accommodations until the proper process has been followed. BEHAVIORAL INTERVENTION TEAM (BIT) The Behavioral Intervention Team (BIT) at Alvin Community College is committed to improving community safety through a proactive, collaborative, coordinated, objective and thoughtful approach to the prevention, identification, assessment, intervention and management of situations that pose, or may reasonably pose, a threat to the safety and well-being to the campus community. College faculty, staff, students and community members may communicate concerns to the BIT by , BIT@alvincollege.edu, or through an electronic reporting option located on the BIT page of the college website, 8

9 Health History Paper for RNSG 1215 This paper must be no more than 2 pages long, which does not include the cover sheet, consent, or grade sheet. It must be neatly organized and contain the most important information that pertains to a complete and thorough health history. Please Staple papers together in the following order: Cover Sheet, Grade Sheet, Integrity Statement, Consent form, Health History Paper. Due Date: Name: Date: Grading Criteria Health History Paper Grading Criteria Total Points Points earned Signed consent from client / 2 Integrity Statement Biographical Data / General 4 Survey Pertinent Health History (i.e. Past Health History, Family 4 History, Lifestyle Practices) Review of Systemscomplete; includes all 10 systems; subjective data with pertinent negatives and positive findings documented; COLDSPA included Presentation neat, well organized; follows directions as outlined in SIP; this grading sheet included; Succinct, well written, uses correct medical terminology 5 Total Points 25 9

10 RNSG 1215 Class Preparation for Each Unit: Before Each Class: 1. Read corresponding text for each unit; Define chapter terms (refer to course calendar). 2. View corresponding Watch and Learn video clips on (refer to course calendar). ** Note: To access to Watch & Learn Assessment Videos: go to thepointlww.com and log on. Scroll to Unit III, Chapter 28, and click on the assessment video you want to see to prepare for class.*** 3. Unit Content will be posted on Blackboard each week. Students are advised to print out the Content Outline to bring to each class day. The Content Outline assists students in note-taking for the lecture segment of Health Assessment. Unit Content/Objectives During all class activities with each unit, the student will: 1. Allocate time to study and practice activities, and understand, prepare, and follow schedules as outlined in the SIP. 2. Make the best use of facility resources such as utilizing lab equipment, supplies, and space. 3. Participate as a member of a team by practicing cooperatively with lab partners. Overview and interviewing techniques (II C-2a) (SCANS: C1, C3) Objectives-At the end of the presentation the student will be able to: 1. Describe the phases of the Nursing Process. 2. Discuss the Assessment portion of the Nursing Process in clinical judgment. 3. Contrast medical diagnosis with nursing diagnosis. 4. Use the assessment as a guide for data collection. 5. Differentiate among the terms subjective data (symptoms), objective data (signs), and data base. 6. Identify characteristics of holistic health care. 7. Describe health assessment as a process that includes both data collection and analysis. 8. Describe the purpose of the assessment interview. 9. Recognize the three interrelated phases of an effective interview. 10. Apply principles of therapeutic communication to the interview process 11. Identify factors that may influence the interview process, including culture and developmental level 12. Allocate time to study and practice activities, and understand, prepare, and follow schedules as outlined in the SIP. 13. Make the best use of facility resources such as utilizing lab equipment, supplies, and space. Health history (II B-3; IV D-1) (SCANS: C1, C3) Objectives-At the end of the presentation the student will be able to: 1. State the purpose of the complete health history. 2. List the categories of information contained in the health history. 3. Describe the data or information that must be gathered for each category of a health history. 4. Describe the (i.e. COLDSPA) characteristics included in the summary of each patient symptom. 10

11 5. Recognize the importance of the health history as a component of the assessment of health beliefs, cultural and social practices, experiences, and status. 6. Differentiate lifestyle factors that enhance health status from those that are a risk to health status. Learning activity LAB PRACTICE Using a systematic approach, students will collaborate with their lab partners and practice data collection interviewing skills, using Health History format as guideline. Students will apply therapeutic communication skills to the interview. Case Studies: The Nurse s Role in Health Assessment: Collecting and Analyzing Data. The General Survey, Mental Status Assessment;Vital Signs, Pain (II B-1, 3; C-2a; III C2b;IV D-1) (SCANS: C1, C3) Objectives-At the end of the presentation the student will be able to: 1. List assessment findings included in the General Survey. 2. Observe and document patient s mental status and level of consciousness. 3. Describe the characteristics of objective data that are collected in a nursing assessment. 4. Demonstrate safe and proper patient positioning when taking vital signs. 5. Demonstrate the four assessment techniques. 6. Identify correct placement and proper use of equipment when assessing vital signs. 7. Review anatomy and physiology concepts related to vital signs. 8. Identify nursing diagnosis with indicators derived from assessing vital signs. 9. Identify correct procedure for measurement of weight and height. 10. List various routes of temperature measurements. 11. Demonstrate appropriate procedure for assessing normal respirations and counting them. 12. List the indications for evaluating vital signs. 13. Differentiate between systolic and diastolic blood pressure. 14. Describe and document the different characteristics of pain. 15. Identify Assessment Alerts (abnormal findings or risks) and necessity of communicating findings to health care provider in timely manner. (III C2b; IV D-1) 16. Demonstrate the use of different assessment tools to evaluate pain. 17. Use basic clinical reasoning to determine which pain assessment tool is appropriate for diverse patients across the lifespan. Learning activity LAB PRACTICE Students will: Follow standards of practice and use a systematic approach to practice taking vital signs on the mannequins and on lab partners. Evaluate BP, lying, sitting and standing. Document and chart VS on graphing paper. Calculate norm values for the class and compare them to standard set norms. Students will refer to the assigned journal article found on The Point, Unit 1, Ch 4: Chart Smart: Documenting General Observations to perform a General Survey on a classmate. Skin, Hair, Nails (II B-4, C-3; IV D-1 ) (SCANS: C1, C3) Objectives-At the end of the presentation the student will be able to: 1. Recall anatomy and physiology concepts related to skin, hair, and nails. 2. Describe differences in the skin of young and elderly people. 3. State health history questions used to collect subjective data for the skin, hair, nails assessment. 4. Prepare client for a skin assessment while respecting the client s cultural and social sensibilities. 5. Describe / document various lesions and the distribution on the body 6. Evaluate and stage pressure ulcers and describe their locations on the body using mannequins and/or photos. 11

12 7. Identify Assessment Alerts (abnormal findings) and necessity of communicating findings to health care provider in timely manner. (IV D-1) 8. Teach clients skin self-evaluation as a strategy for Skin Cancer Disease Prevention and Health Promotion. (II C-3) Learning activities LAB PRACTICE (SCANS: C 9, C10) Students will: Follow standards of practice and use a systematic approach to practice assessing skin, hair, and nails. Describe/document skin lesions (based on picture/ wound module) List other possible information needed that relates to the problem. Explain use of various assessment tools used to assess skin. Participate as a member of a team by practicing cooperatively with lab partners. Head and Neck (II B-4; III C2b; IV D-1)) (SCANS: C1, C3) Objectives-At the end of the presentation the student will be able to: 1. Describe the significant characteristic features and landmarks of the head and neck. 2. Demonstrate correct procedure for assessing Cranial Nerves I through XII. 3. Identify names and location of lymph nodes of head and neck. 4. Demonstrate correct procedure for palpating lymph nodes and sinus cavity. 5. Identify neck vessels and demonstrate assessing them. 6. Identify Assessment Alerts (abnormal findings or risks) and necessity of communicating findings to health care provider in timely manner. (III C2b; IV D-1) Learning activities LAB PRACTICE (SCANS: C 9, C10) Students will: Follow standards of practice and use a systematic approach to practice assessing the head and neck. Practice correctly assessing head and neck on lab partners. Practice identifying and palpating head and neck lymph nodes on lab partner. Document subjective and objective findings. Eye and Ear assessment, Mouth, Throat and Nose assessment (II B-4; III C2b; IV D-1) (SCANS: C1, C3) Objectives-At the end of the presentation the student will be able to: 1. Recall anatomy and physiology concepts related to eyes, ears, mouth, throat, and nose. 2. Identify external structures and landmarks for assessment. 3. Recall the cranial nerves that are related to eye, ear, mouth, nose and throat. 4. State health history questions used to collect subjective data for the eyes, ears, mouth, throat, nose assessment. 5. Perform and document a visual acuity examination. 6. Perform a visual field test. 7. List main functions of the auditory system. 8. Perform a whisper test to evaluate hearing. 9. Identify the location, function and grouping of lymph nodes. 10. Identify Assessment Alerts (abnormal findings) and necessity of communicating findings to health care provider in timely manner. (III C 2b; IV D-1) 11. Demonstrate mouth assessment and identify possible problems with: o Mucous membranes o Tonsils o Dental hygiene/ teeth 12. Demonstrate eye assessment and identify possible problems with: Visual acuity, Peripheral vision, Eye movements, 12

13 Visual fields Ocular muscle dysfunction Abnormalities of the external eye 13. Demonstrate assessment of the ear and identify possible problems with: Hearing Abnormalities of the external ear (external signs of infection) Asking about dizziness: characteristics and onset Learning activities LAB PRACTICE: (SCANS: C 9, C10) Students will: Follow standards of practice and use a systematic approach to practice assessing the head and neck including: eyes, ears, mouth, lymph nodes. Correctly use pen light to test for pupil constriction. Describe and document findings various eye abnormalities. Participate as a member of a team by practicing cooperatively with lab partners. Thoracic and Lung assessment (IIA-2a; II B-4; III C2b; IV D-1) (SCANS: C1, C3) Objectives-At the end of the presentation the student will be able to: 1. Recall anatomy and physiology concepts related to the thorax and lung. 2. Identify landmarks of the thoracic cage. 3. State health history questions used to collect subjective data for the thorax and lung assessment. 4. Distinguish between abnormal shapes of the chest. 5. List common abnormal findings of the lung assessment. 6. Identify common lung sounds. 7. List common diseases of the lung and associated lung sounds. 8. Demonstrate appropriate patient positioning. 9. Demonstrate correct assessment techniques and proper use of the stethoscope. 10. Differentiate respiratory rates: bradypnea, tachypnea, Kussmaul, Cheyne-Stokes, hyperventilation, hypoventilation. 11. Focus priority assessment based on patient respiratory health status and individual characteristics. 12. Identify Assessment Alerts (abnormal findings or risks) and necessity of communicating findings to health care provider in timely manner. (III C2b; IV D-1) Learning activities LAB PRACTICE: (SCANS C9, C10) Students will follow standards of practice and use a systematic approach to practice: Listening to lung sounds using care technologies such as SIM-Anne and computer software. Listening to lung sounds on lab partners. Documenting and communicating subjective and objective findings. Participating as a member of a team by practicing cooperatively with lab partners. Heart, Neck vessels and Peripheral Vascular System (II A-2a; II B-1,3,4; III C2b ) (SCANS: C1, C3) Objectives-At the end of the presentation the student will be able to: 1. Recall anatomy and physiology concepts related to the heart, neck vessels and peripheral vascular system. 2. Identify the significant anatomical features of the heart. 3. Differentiate between diastole and systole. 4. Restate the electrical conduction of the heart. 5. Obtain and document pertinent objective and subjective data for heart and vascular related problems. 6. Demonstrate correct use of stethoscope when listening to CV sounds. 13

14 7. Identify heart sounds (rate, rhythm, abnormal sounds) -S1, S2, S3, S4, murmurs, clicks, bruits, and friction rubs 8. Identify risk factors associated with heart disease and stroke. 9. List common problems of vascular system. 10. List findings associated with the heart (rate and rhythm) and vascular system; evaluate jugular veins and carotid arteries. 11. Focus priority assessment based on patient cardiac health status and individual characteristics. 12. Identify Assessment Alerts (abnormal findings or risks) and necessity of communicating findings to health care provider in timely manner. (III C2 ;IV D-1) Learning activities LAB ACTIVITIES: (SCANS C9, C10) Students will follow standards of practice and use a systematic approach to practice Listening to heart sounds on software programs Assessing heart sounds using SIM Anne Listening to and identifying heart sounds on classmate Documenting findings using subjective and objective data Abdominal Assessment (II B-4; III B-1a,b, 2; III C2b) (SCANS C1, C3) Objectives-At the end of the presentation the student will be able to: 1. Recall anatomy and physiology concepts related to the abdomen. 2. Identify organs located within each of the four abdominal quadrants. 3. Identify the abdominal regions. 4. List common problems related to the organs in the abdominal cavity: Stomach Liver- ascitis Intestine Kidneys 5. Describe various characteristics of abdominal pain. 6. Obtain and document pertinent subjective and objective data relating to various organs in the abdomen. 7. Demonstrate safe patient handling and a systematic approach to examination of the abdomen. 8. Identify Assessment Alerts (abnormal findings or risks) and necessity of communicating findings to healthcare provider in timely manner. (III C2b;IV D-1) Learning activities (SCANS C9, C10) Students will follow standards of practice and use a systematic approach to practice Listening to bowel sounds. Listening for vascular sounds. Percussing for tympany/dullness. Assessing the abdomen in correct sequence. Documenting and communicating findings. Simulation Participating as a member of a team by practicing cooperatively with lab partners. Male and Female Genito-Urinary System, Breast and Prostate exams (II B-4 III C2b) (SCANS C1, C3) Objectives-At the end of the presentation the student will be able to: 1. Recall anatomy and physiology concepts related to the GU, breast, and prostate. 2. State health history questions used to collect subjective data for the GU, breast, prostate assessment. 14

15 3. Perform a general assessment of the outer structures of the genital area of a female. 4. Perform a general assessment of the outer structures of the genital area of a male. 5. Explain the importance of teaching and performing a breast (females) and testicular (males) selfexamination and when to schedule regular check-ups. 6. Inspect the perianal and sacrococcygeal areas and note abnormal and normal findings 7. Identify subjective data to assess for BPH (interview questions). 8. Identify subjective data to assess menstrual periods, discharge, pain, masses, pregnancies, medications 9. Identify objective data- inspection of outer structures, skin color, presence of discharge, swelling, or obvious masses. 10. Explain to report abnormal findings or disease risks to appropriate members of the interdisciplinary health care team in a timely manner. (III C2b; IV D-1) Learning ativities LAB PRACTICE Case Studies from The Point: Unit III: Musculo-Skeletal and Neurologic system;: (II B-4; III B-1a,b, 2) (SCANS C1, C3) Objectives-After the presentation the students will be able to: 1. List the joints, articulations and landmarks of the upper and lower extremities. 2. Describe the shape and surface of the spine. 3. State health history questions used to collect subjective data for the mental status, musculo-skeletal and neurologic assessment. 4. Document characteristics note in inspection, and palpation of the muscles, bones and joints. 5. Safely Assess range of motion of joints; assess and rate muscle strength of upper and lower extremities. (III B-1a,b,2) 6. Describe various functions of the central nervous system; collecting subjective and objective data. 7. Describe the functions of the peripheral nervous system. 8. Relate the name and function of each of the 12 cranial nerves to its assessment. 9. Demonstrate the correct sequence of performing a complete neurological nursing assessment. 10. Identify the assessment techniques used for the brief neuro-check. 11. Demonstrate testing for sensation, balance and coordination. 12. Identify principles of Health Promotion related to the musculoskeletal system. Learning activities: (SCANS C9, C10) LAB PRACTICE Students will follow standards of practice and use a systematic approach to practice Completing a mental status and neurological assessment on a classmate. Role-playing the assessment of the musculoskeletal system, demonstrating the inspection, palpation, and assessment of range of motion (ROM). Completing appropriate documentation. Demonstrating the tests performed for meningeal irritation. Documentation Notebook: (II C-2a) (SCANS: C5,C6) Objectives- at the end of the module the student will be able to: 1. Identify techniques of communication using written and electronic information technologies. 2. Identify principles of documentation and the impact on nursing practice. 3. Submit assessment documentation paperwork / electronic record. Geriatric Assessment (II B-4; III B- 2) (SCANS C1, C3) Objectives-at the end of the presentation the student will be able to: 1. Compare various assessment tools that are appropriate when assessing the elderly. 2. Discuss methods for providing a safe assessment environment for the elderly patient. 3. List at least 3 common characteristics when assessing elderly patients. 15

16 4. Compare the causes of Delirium and Dementia. 5. Describe 5 indicators of malnutrition. 6. List 6 indicators of pain in the cognitively impaired. Learning activities: Compare and contrast differences in assessment findings with elderly patient and younger adult, keeping in mind various life span stages of physical and psychosocial growth and development. Functional assessment Objectives-at the end of the presentation the student will be able to: 1. Define functional assessment and the terminology related to functional assessment. 2. Describe some characteristics of functional decline in older persons. 3. Identify co-morbid conditions that might impact negatively on the functional status of an older adult. 4. Assess function using validated functional assessment tools. Learning activities/ LAB PRACTICE: Discuss the importance of a functional assessment; demonstrate the various functional assessment tools Practice performing a functional assessment on lab partner. Nutritional Assessment Objectives-at the end of the presentation the student will be able to: 1. State the purpose of a nutritional assessment. 2. Collect pertinent data for nutritional history. 3. Describe the technique of anthropometric measurements. 4. Compare 2 different nutritional assessment tools. Learning activities: Discuss parameters for evaluation. Collaborate with classmates and complete a nutritional assessment and evaluation on each other. Calculate BMI; identify advantages and disadvantages of using the Body Mass Index Chart Cultural, Social,(I B-3; II B-5; II C-1a) (SCANS: C14) Objectives-at the end of the presentation the student will be able to: 1. Identify cultural issues affecting the registered nurse role and the delivery of culturally-sensitive care to diverse patients and their families. 2. Distinguish definitions of culture, race, ethnicity, ethnocentrism, and minority. 3. Describe cultural differences of patients across the lifespan and major needs of vulnerable patients. 4. Identify basic principles of establishing nurse-patient relationship in regards to cultural aspects of care. (II C-1a) 5. Demonstrate working well and collaborating with diverse individuals with a variety of ethnic, social, and educational backgrounds in the Health Assessment Practice Lab setting. Learning activities/ LAB PRACTICE: Role play: discuss the importance of a cultural and social assessment. Demonstrate professional characteristics such as respecting human dignity and equality. Practice Social and cultural assessment on lab partner. Mistreatment/Abuse and Neglect (II B- 5; III B-1b, 2; C2-b; IV B-4; D-1) (SCANS C5) Objectives-at the end of the presentation the student will be able to: 1. Identify obvious signs of mistreatment. 2. Accurately describe and document statements and findings from the patient. 3. Appropriately report suspicion of abuse and mistreatment. (IV B-4) 16

17 4. Identify adverse consequences associated with care giving. 5. Identify the possible causes of elder mistreatment. 6. List priority of care for victims of physical assault. 7. Demonstrate acquiring and evaluating information from existing sources. 8. Identify Assessment Alerts / warning signs of abuse and neglect, and necessity of communicating findings to appropriate health care providers in timely manner. (III C2-b; IV D-1) Learning Activities Students will refer to the assigned journal article found on The Point, Unit II, Ch 9: Taking an Intimate Look at Domestic Violence, and identify screening questions, interviewing tips, and documentation recommendations. Putting it All Together (II B-1,2,3) (SCANS C1, C3) Learning activities: Watch the Putting it all together video (Dress Rehearsal: as required for the check-off) Practice performing a systematic, comprehensive head to toe assessment. Sign-up sheet will be distributed for Practicum Exam 3- Comprehensive: refer to course schedule Final Practicum Your Final Practicum is an abbreviated Head to Toe Assessment. Timed head to toe assessment Times to be scheduled according to Sign-up sheet Date: (refer to class schedule) 17

18 EXAMINATION OF CRANIAL NERVES CRANIAL NERVE SENSORY FUNCTION MOTOR FUNCTION 1 Olfactory Smells (alcohol swab, fresh burned match, or coffee). 2 Optic Vision & visual fields (6 cardinal fields of gaze). 3 Oculomotor Extraocular & pupillary eye movements, lens shape. 4 Trochlear Down & inward eye moves. 5 Trigeminal Sensation of face, scalp, Palpate masseters with cornea, oral & nasal mucosa clenched teeth 6 Abducens Lateral eye movements. 7 Facial Taste on anterior 2/3 of tongue. Facial moves, (eye closure, smile, frown, puff cheeks, raise eyebrows). 8 Acoustic Hearing & balance. 9 Glossopharyngeal Taste posterior 1/3 of tongue, gag reflex, ear drum & ear canal sensation. 10 Vagus Sensations of pharynx, viscera, carotid body, carotid sinus. Swallowing & vocal cord movement. Swallowing & talking muscles of palate, pharynx, larynx, (makes guttural sounds). 11 Spinal Trapezius & sternocleidomastoid movements (move head, shrug shoulders). 12 Hypoglossal Tongue movements (protrude tongue). 18

19 Summary of complete HEAD TO TOE HEALTH HX: Perform Complete Interview Subjective Data (ROS)- p. 15 in text GENERAL APPEARANCE 1. Age, race, sex, Ht. Wt., hygiene, grooming nutritional status, build, VS. 2. LOC & orientation X 4 (person, place, time, situation). 3. Speech, understanding, memory, facial expression, mood, affect, gen. knowledge. 4. Obvious physical deformities, and involuntary movements. 5. General Mobility - posture, stability, gait & assistive devices 6. Assess nutrition & bowel habits. HEENT 1. Inspect & palpate scalp, hair, cranium. 2. Palpate temporal artery 3. Frontal & maxillary sinuses. 4. Test light facial sensation. 5. Inspect EENT external structures. 6. Check 6 cardinal fields (CN III, IV, VI). 7. Visual acuity (CN II). 8. Inspect conjunctiva, sclera, PERRLA. 9. Hearing voice test (CN VIII). 10. Palpate messenters with clenched teeth (CN V, VII), temporomandibular joint, inspect teeth, gums, tongue, palate, uvula. 11. Check tonsil fossa: Say ah (CN IX, X), swallow reflex intact. 12. Pt. Protrudes tongue (CN XII). NECK 1. Inspect carotids & jugulars. 2. Palpate carotids (separately). 3. Auscultate carotids for bruits. 4. Palpate all cervical & neck lymph nodes. 5. Note trachea midline. 6. Shrug shoulders (CN X1). 7. Note ROM neck. 8. Assess skin turgor. UPPER EXTREMITIES 1. Assess skin, hair, nails. 2. Assess ROM and strength. 3. Assess hand grips. 4. Palpate & assess radial pulses (rate, rhythm, & force), cap. refill. Revised 02/28/2013 Abrams CHEST (Lungs) 1. Inspect, then palpate post., lat. & ant. chest. (P,L.A) 2. Assess tactile fremitis. 3. Check expansion at T9-T Percuss side to side (resonance). (P,L.A) 5. Auscultate for adventitious sounds, posterior, anterior, & lateral. 6. Note spinal curvatures. 7. Assess for CVA tenderness. 8. Palpate axillary lymph nodes. 9. Ask about breast self-exam (females). HEART 1. Inspect for pulsations & palpate at PMI. 2. Auscultate apical-radial, & apical-carotid (amplitude, rhythm, rate). 3. Auscultate at A2, P2, T1, M1. 4. Identify S1, S2. 5. Listen for murmurs, clicks. 6. Listen for S3, S4 gallops. ABDOMEN 1. Inspect color, contour, pulsations. 2. Auscultate bowel & aortic sounds. 3. Percuss 4 quadrants (tympany). 4. Lightly palpate 1cm. over 4 quadrants. 5. Check for ascites. 6. Check for hernias (umbilical). 7. BM s: freq, color, amt. LOWER EXTREMITIES 1. Assess skin, ROM and strength. 2. Palpate & assess posterior tibial, and dorsalis pedis pulses. 3. Check for edema. 4. Assess Babinski reflex. 5. Inspect toes & cap. refill. 6. Check skin sensation on lower extremities (evaluate based on dermatome levels). GU 1. Urine color, clarity, etc. 2. (PRN) HX of menses (females); prostate problem, testicular exam (males); STD s. 19

20 INTEGRITY STATEMENT By signing below I am acknowledging that the following work is my own. I also acknowledge that if I am found to have cheated or used any assistance not specifically allowed by the instructor, Alvin Community College has the right to remove me from the course and take the appropriate punitive measures, in accordance with the Code of Academic Integrity and Honesty. Student name (print): Student signature: Date 20

21 ALVIN COMMUNITY COLLEGE Student Agreement Health Assessment RNSG 1215 This certifies that I have received a copy of the RNSG 1215 Syllabus. The following have been reviewed: class schedule grading policy attendance policy dress policy behavioral expectations assignments I have read & understand the syllabus and will abide by its contents. Student Name (Print) Student Signature Date This form is to be signed, dated, & turned in to the instructor on the first day of class. 21