II. DESCRIPTION SYLLABUS I. GENERAL INFORMATION

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1 INTER AMERICAN UNIVERSITY OF PUERTO RICO METROPOLITAN CAMPUS SCIENCE AND TECHNOLOGY FACULTY CARMEN TORRES DE TIBURCIO SCHOOL OF NURSING SYLLABUS I. GENERAL INFORMATION Course title : Health Assessment Code Reference Number : NURS 3120 Credits : 4 Credits Academic Term : Professor : Office Hours : Office phone : Ext. 2159, II. DESCRIPTION Application of knowledge and skills for comprehensive health assessment of the client throughout the life cycle. Emphasis on the compilation and organization of data by means of the physical examination and diagnostic reasoning. Requires 30 hours of lecture and 60 hours of closed presential lab. Co-requisites: NURS 3100, III. COURSE COMPETENCIES 1. Apply the nursing process for decision-making, which demonstrates critical thinking skills while offering safe, effective, efficient, timely, and equitable direct and indirect nursing care to patient/clients in mock scenarios throughout the lifecycle for the continuity of care. (Critical thinking, Patient safety, Nursing Process) 2. Offer patient-centered care to patient/clients throughout the lifecycle, their families, and caregivers considering their needs, values, preferences, and cultural insights, which promote a continuous healing relationship, by assuming an active and leadership role. (Cultural sensitivity, leadership/teamstepps) 3. Show competence in therapeutic, evidence-based interventions while giving nursing care to patient/clients throughout the lifecycle along the continuity of care in wellness and illness continuum for the promotion, maintenance, and restoration of health in mock scenarios. (Evidence-based practice, Health- Disease, Patient Safety) 4. Use the communication process and information technology skills effectively for continuous quality improvements in healthcare and within the interdisciplinary team. (Communication, Nursing informatics) 5. Integrate evidence-based knowledge for decision-making process when offering nursing care to patient/clients throughout the lifecycle. (Research) 1

2 IV. TERMINAL OBJECTIVES It is expected that by the end of the course, students should: 1. Use the basic knowledge of the nursing process as a frame of reference to guide its practice of health assessment. (C #1, C #5, C #3) 2 Integrate the concepts and principles of patient safety, cultural sensitivity, humanistic care, leadership/teamstepps, evidence-base practice, health literacy, structured communication and nursing informatics while performing health assessment. (C#2, C#4) 3. Perform a holistic health assessment to the patient/client through the life span in the wellness-illness continuum integrating the collection of subjective and objective data with an emphasis on physical examination skills. (C#1, C#3, C#4) 4. Apply diagnostic reasoning process for decision-making through data analysis, to formulate appropriate Nursing diagnoses. (C#1, #3) 5. Recognize proactive methods and strategies to effect personal lifelong learning within the profession and for its advancement (C#5) V. CONTENTS A. Unit I Assessment of the whole person (Holistic Care) 1. Evidence-Based Assessment (Research, Informatics & Leadership) 2. Cultural Competence 3. The Interview 4. The Complete Health History a) Collecting Subjective Data (nursing process) i. Definition. ii. Purpose iii. Types of health history iv. Collection tools v. Components of health history and data collection b) Collecting objective Data i. Definition ii. Purpose iii. Equipment iv. Preparing and approaching the client 5. Mental Status Assessment 6. Substance Use Assessment 7. Domestic & Family Violence Assessment B. Unit II Approach to the clinical setting 1. Assessment Techniques and Safety in the Clinical Setting (Patient-Centered Care) a Inspection b) Palpation c) Percussion d) Auscultation 2. General Survey, Measurements & Vital Signs a) 8 critical characteristics of a symptom b) Anthropometric measurements 3. Pain Assessment: The Fifth Vital Sign 2

3 4. Nutritional Assessment C. Unit III Physical Examination (wellness- Illness) 1. Anatomy & Physiology Review 1. Physical Examination across the Lifespan Cycle a) Mental, Substance Abuse, Domestic Violence & Pain b) Thorax-Lungs, Heart & Neck Vessels, Peripheral Vascular & Lymphatics c) Abdomen & Musculoskeletal d) Eyes, Ear, Nose, Mouth & Throat (EENT) and Neurologic e) Male & Female GU System, Anus & Rectum and Breast & Lymphatics 2. Diagnostic reasoning a) Data analysis (Critical thinking, decision making) i. Evidence-based practice (Research & Informatics) b) Inferences & Scientific Rationale c) Nursing Diagnoses- NIC 6520 i. Standardized Vocabulary (NANDA).3. Documentation of findings-nic 1630 a) Guidelines for documentation (NIC 7920) b) Structured Communication i. Standard vocabulary (Terminology) ii. TeamSTEPPS (leadership and management) D. Unit IV Integration: Putting it all together 1. The Complete Health Assessment & Physical Examination 2. Bedside Assessment and Electronic Health Record 3. Functional Assessment of the Older Adult VI. TRIMESTER WEEKLY SCHEDULE Week Theory Laboratory 1 Introduction: Course Orientation Expectations: Review syllabus/trimester schedule, methods of evaluations -Bring laptop, tablet (digital device) -All Assignments are to be submitted to Bb Assignment link for grading -Attendance: It is in your best interest to attend class. This is a dynamic, interactive, and intense course, where team collaboration is essential. Laboratory practice: -Expectations: Review syllabus/trimester schedule, methods of evaluations -Collaborative team work (Team STEPPS) and/or simulation with a fellow student assuming the role of a client and the other assuming the role of examiner. -Starting on Week 2, you are expected to have read the chapters (Jarvis) and watch 3

4 the Lecture ppts (Bb) that will be covered in the classroom. In this fashion you will be able to actively participate and apply knowledge in the assignments and case scenarios for the week. Evidence-Based Assessment, Cultural Competence (Jarvis Chapters 1-2) 2 Lecture: Interview, Health History, Functional Assessment of Older Adult (Jarvis Chapters 3,4 & 31) Laboratory practice: -Interview process: health history -Anthropometrical measurement & Nutritional Assessment -Vital Signs -Culture-gram graphical design and Genogram. -Assessment Skills 3 TO-1, 4 4 Lecture: Assessment Techniques & Safety, General Survey, Measurement & Vital Signs, Bedside Assessment & Electronic Health Record (Jarvis Chapters 8, 9 & 29) -Case Studies Lecture: Mental Status, Substance Abuse, Domestic and Family Violence Assessment (Jarvis 5-7) Performance Checklist #1 Assessment Skills: Inspection, Palpation, Percussion & Auscultation, Measurements & VS Case Scenario #1 Diagnostic Practice Performance Checklist #2 Mental, Substance Abuse, Domestic Violence & Pain 5 TO-2, 3, 4 -Case Studies Exam 1 (chapters 1-4,8,9,29 & 31) -Performance Checklist #2 Evaluation: Mental, Substance Abuse, Domestic Violence & Pain -Case Scenario #2 Diagnostic 6 Lecture: Pain Assessment & Nutrition (Jarvis Chapters 10-11) Practice Performance Checklist #3 Thorax-Lungs, Heart, Peripheral Vascular & Lymphatic 4

5 7 TO-2, 3, 4 Lecture: Thorax & Lungs, Heart, Neck Vessels, Peripheral Vascular & Lymphatic Systems (Jarvis Chapter 18-20) -Performance Checklist #3 Thorax-Lungs, Heart, Peripheral Vascular & Lymphatic Case Scenario #3 Diagnostic 8 Exam 2 (chapters 5-7, 10, 11 & 18-20) Practice Performance Checklist #4 Abdomen & Musculoskeletal 9 TO-2, 3, TO-2, 3, 4 Lecture: Abdomen & Musculoskeletal (Jarvis Chapters 21-22) Lecture: Eyes, Ears, Nose, Mouth & Throat, Neurologic System (Jarvis Chapters & 23) Exam 3 (chapters & 21-23) -Performance Checklist #4 Abdomen & Musculoskeletal Case Scenario #4 Diagnostic Practice Performance checklist #5 Ears, Nose, Mouth & Throat, Neurologic -Performance Checklist #5 Eyes, Ears, Nose, Mouth & Throat, Neurologic Case Scenario #5 Diagnostic 12 Male GU System, Anus, Rectum & Prostate, Breast & Regional Lymphatics, Female GU System (Jarvis Chapters 24, 25, 17 & 26) -Comprehensive Head-to-Toe Physical examination -Case Scenario Head-to-Toe Diagnostic Reasoning & Documentation or Head-to-Toe Narrative Documentation with 7 systems abnormalities 5

6 13 Final Exam-Comprehensive (chapters 1-26, 29 & 31) -Comprehensive Head-to-Toe Physical examination -Case Scenario Head-to-Toe Diagnostic Reasoning & Documentation or Head-to-Toe Narrative Documentation with 7 systems abnormalities VII. TEACHING-LEARNING ACTIVITIES 1. Assignments 11. Check list and tools 2. Lecture 12. On-line resources 3. Discussion 13. Interactive and animations programs 4. Laboratory practice on partner 14. Anatomic Illustrations 5. Simulations: Health care provider feedback 6. Demonstrations 7. Search on web 8. Collaborative/ group work 9. Written exercises 10. Case studies VIII. EVALUATION Theory Component POINTS % OF THE FINAL GRADE -Partial exams: Quizzes and/or Assignments -Comprehensive Final exam 50 points 150 points 5% 15% SUB TOTAL 500 POINTS 50% Laboratory Component Attendance Practice of Regional Assessment skills -5 Regional Physical examination skills on a peer or patient in the laboratory or clinical setting including Interview techniques & Health history (20 points each) -5 Diagnostic Reasoning and Normal and abnormal findings documentation (20 points each) 50 points 5% Final exam-practice of Head to Toe Physical Examination -Competence on physical examination psychomotor skillls -Diagnostic Reasoning process and Documentation 125 points 125 points 12.5% 12.5% SUB TOTAL 500 POINTS 50% Theory + Laboratory Total 1000 points 100 % 6

7 Assignments: 5% deduction per day late; after 3 days assignment will not be accepted. All assignment MUST be submitted to the Assignment link in Blackboard No make-up exams No make-up Regional Performance Checklist or Final Head-to-Toe Evaluation IX. SPECIAL NOTES A. Supportive Services or Special Needs Students requiring additional services or special assistance must request these at the beginning of the course or as soon as they learn that they need them, through the appropriate4 register in the office of M. Jose Rodrigues, at the University Orientation Program located at the first floor of Harris Building. B. Honesty, Fraud, and Plagiarism The lack of honesty, fraud, plagiarism, and any other inadequate behavior in relation to academic work constitutes major infractions sanctioned by General Student Regulations. Major infractions, according to General Student Regulation, may result in suspension from the University for a definite period of time greater than one year or the permanent expulsion from the University, among other sanctions. C. Use of electronic devices: Cellular (mobile) telephones, IPODS, and any other electronic device that could interrupt the teachinglearning process or disrupt a milieu favorable for academic excellence will be deactivated. Critical situations will be dealt with in an appropriate manner. The use of electronic devices that permit accessing, storing or sending data during tests or examinations is prohibited. D. Special Requirements of Practice and Internship Centers Some academic programs of the University require students to complete a practice or internship in a real work scenario as part of the degree requirements. These external centers may be state and federal agencies, hospitals, and nongovernmental organizations, among others. It is the student s responsibility to comply with the external practice center, these requirements may be doping tests, HIV tests, an immunization certificate against hepatitis, a health certificate, a negative criminal record, or any other requirement that the institution or practice center may stipulate. If students refuse or are not able to meet any of the requirements, they will be unable to complete their practice or internship and, therefore will not pass the practice or internship course or meet the graduation requirements of their academic program. XI. EDUCATIONAL RESOURCES Textbooks Jarvis, C. (2015) Physical examination and health assessment (7 th ed.). Canada: Elsevier. Reference book Jensen, Sharon. (2014). Nursing health assessment (2 nd ed.). Philadelphia: Lippincott 7

8 Audiovisuals Resources Video guide to clinical nursing skills Image bank Animations Student CD ROM text Electronics Resources: Alfaro Lefevre R: Critical thinking indicators-2006 evidence based version, 2006 available on Teach Smart.com Joint Commission on Accreditation of Healthcare Organizations: National Patient Safety Goals, 2004 available on Center for Disease Control and Prevention, National Center for injury Prevention and Control: Suicide prevention fact sheet available on Self-study on cultural competency: www. thinkculturalhealth.org/ccnm/ The Joint Commission. Hospital, language and culture: American Cancer Society: Center for Disease Control and Prevention: Trends in tuberculosis, (2004): American Heart Association: American Stroke Association Hob dell E: Infant neurologic assessment, J Neurosci Nurs 33(4):190, From University of Michigan-Ann Arbor, Health and Wellness Resource Center website: A.D.A.M. Education Student Learning Resources-Jarvis Physical Examination and Health Assessment, 7nd.ed center.com Tutorial on evidence based practice XII. BIBLIOGRAPHY Bickley, L.S. and Szilagyi, P.G. (2012). Bates Nursing guide to physical examination and 8

9 history taking (11 th ed.). México: McGraw Hill. Lewis, P. and Foley, D. (2014). Health assessment in nursing (2 nd ed.). Philadelphia: Lippincott Williams & Wilkins Nettina, S. M. (2013). Lippincott manual of nursing practice (10 th ed.). Philadelphia: Lippincott Williams & Wilkins Rhoads, J. (2013). Advanced health assessment and diagnostic reasoning. Philadelphia: Lippincott Williams & Wilkins Weber, J.R. and Kelley, J.H. (2011). Health assessment in nursing (5 th ed.). Philadelphia: Lippincott Williams & Wilkins Recent revision by: O. Neubaur, June