1. Overview | 2. Welcome Video | 3. Unit Learning Outcomes | 4. Learning Activities and Resources | 5. Review | 6. References
As a LPN you learned to complete health assessments. Accurate and complete health assessment and data collection are prerequisites to the diagnosis, planning, and intervention steps of the nursing process (Lewis, Heitkemper & Dirksen, 2014). Evidence based comprehensive health assessment provides the "evidence" needed to deliver competent nursing care. Consider such health assessment as a systematic framework that includes all aspects of your patient's health status. An excellent assessment utilizes your knowledge, skills, and appropriate tools and techniques.
This unit provides a review and a more in-depth study of comprehensive evidence based health assessment. The knowledge and skills gained in this unit will assist you with focusing on health exam data collection as well as with synthesis and documentation of findings.
After completing Unit 10, you will be able to meet or exceed the following:
10.4.1 Quick Review: Health History
Review what you know about conducting a health history and all of the components of the health history. Write down what you remember as the necessary components and then compare your list to what you learn by watching this video called Taking a Patient Clinical History. (Hint: think systems)
10.4.2 Physical Assessment Review
A physical health assessment is a collection of both subjective and objective data to identify and evaluate problems or concerns that arise and to assist the nurse with planning care (Jarvis, 2012).
Read Assessment of the Patient.
Review the Health Assessment Module on your CNHS Moodle home page. Try the activities related to checklists, crossword puzzles and quizzes.
Consider guides you could use when completing a physical assessment. Locate some appropriate physical assessment guides and other tools you think will be helpful to you in NURS 401 and share your discoveries in the webquest forum.
10.4.3 Physical Assessment: Determining Care Priorities and Priority Patients
Review the specific techniques for assessment of each body system. Note the sequence of the assessment. The most consistent physical assessment framework is head to toe and the techniques normally follow the order of inspection, palpation, percussion then auscultation (Jarvis, 2012). Part of physical assessment is determining patients who require urgent or emergent care.
Review chapter 5 in Brunner and Suddarth's (3rd ed.) Canadian textbook of medical-surgical nursing (Paul, Day, & Williams, 2016). Focus your reading on completing a head-to-toe health assessment and practice the recommended health assessment techniques.
Note: There are multiple student resources associated with the Paul, Day & Williams (2016) Brunner and Suddarth's Canadian textbook of medical-surgical nursing (3rd ed.) located online through thepoint.lww.com. Instructions for accessing these resources are just inside the front cover of the textbook.
Review the following videos (and others you locate on this topic) and reflect on these questions
Nursing Simulation Scenario: Physical Assessment
Conducting a Bedside Physical Assessment
Nursing Assessment of the Integumentary System
Physical assessment (and appropriate response) is critical in emergent care situation.
Read this chapter on Early Patient Assessment and Response.
Read the patient scenarios at Nurse, Who Should see the Doctor First (2013).
Contact your study buddy or another student in the course through course mail and discuss your thoughts on the nurse’s role in triage.
Assessment findings need to be documented in a clear, organized and sequential manner. Read the CARNA Documentation Standards for Regulated Members (2013) and note what you learned in your learning journal.
Complete the Normal Male Assessment and the Normal Female Assessment and compare your findings with those provided.
If you enjoyed these learning activities try some of the other scenarios including the Assessment Post Appendectomy and the Assessment Congestive Heart Failure.
How well did you document the assessment findings?
Read Stay out of Court with Proper Documentation. Make a promise to yourself related to documentation in your learning journal.
Austin, S. (2011). Stay out of court with proper documentation. Nursing, 41(4), 24-29. Retrieved from http://journals.lww.com/nursing/Fulltext/2011/04000/Stay_out_of_court_with_proper_documentation.11.aspx
Boyd, C. (2013). Chapter 10: Early patient assessment and response. In C. Boyd (Ed.) Student survival skills: Clinical skills for nurses (pp. 161-173). San Francisco, CA: John Wiley and Sons. Retrieved from http://0-site.ebrary.com.aupac.lib.athabascau.ca/lib/athabasca/reader.action?docID=10667409&ppg=173
Coffey, F., & Neely, I. (2009). Assessment of the patient. In J. Randle, F. Coffey, & M. Bradbury (Eds.) Oxford handbooks in nursing: Oxford handbook of clinical skills in adult nursing (pp. 23-74). Oxford: Oxford University Press. Retrieved from http://0-site.ebrary.com.aupac.lib.athabascau.ca/lib/athabasca/reader.action?docID=10581607&ppg=38
College and Association of Registered Nurses of Alberta. (2006). Documentation guidelines for registered nurses. Edmonton: Author. Retrieved from http://www.nurses.ab.ca/content/dam/carna/pdfs/DocumentList/Standards/DocumentationStandards_Jan2013.pdf
Denman, S., & Woodruff, K. (2007). Head-to-toe assessment pt 1 or 6 (video). Springhouse corporation. Retrieved from https://www.youtube.com/watch?v=jGf8NvqoTNs
Freenursetutor (n.d.). Normal male assessment. Retrieved from http://freenursetutor.com/menuparent-assessment-nursing-process-charting/assessment-normal-male-assessment.html
Freenursetutor (n.d.). Normal female assessment. Retrieved from http://freenursetutor.com/menuparent-assessment-nursing-process-charting/assessment-normal-female-assessment.html
Freenursetutor (n.d.). Male patient post appendectomy. Retrieved from http://freenursetutor.com/menuparent-assessment-nursing-process-charting/assessment-male-patientpost-appendectomy.html
Freenursetutor (n.d.). Assessment of CHF. Retrieved from http://freenursetutor.com/menuparent-assessment-nursing-process-charting/assessment-congestive-heart-failure.html
Jarvis, C. (2012). Physical
examination and health assessment (6th ed.). St. Louis:
W.B. Saunders. Elsevier Canada.
Learners TV. (2014). Conducting a bedside assessment video
lecture (video). Retrieved from http://www.learnerstv.com/video/Free-video-Lecture-8293-Nursing.htm
Lewis, S. M., Heitkemper, M. M., & Dirksen, S. R. (2014). Medical-surgical nursing in Canada: (3rd ed.). Toronto, ON: Lippincott.
Martin, S. (2013).Nurse, who should see the doctor first? The Globe and Mail. Retrieved from http://www.theglobeandmail.com/life/health-and-fitness/health/the-hospital/nurse-who-should-see-the-doctor-first/article15588266/
Montgomery College (2013). Nursing
simulation scenario: Physical assessment (video).
Retrieved from https://www.youtube.com/watch?v=CZ9M-2UdODg
Paul, P., Day, R.A., & Williams, B. (2016). Brunner and Suddarth's Canadian textbook of medical-surgical nursing (3rd ed.). Philadelphia, PA: Wolters Kluwer.
Stamer, K. (2010). Head to toe nursing assessment (video). Retrieved from http://www.youtube.com/watch?v=9Fxb8icOTOA
US army medical department center and school. (2008). Nursing 411.org series. Integumentary system. Lesson 2: Physical assessment of the integumentary system. Retrieved from http://nursing411.org/Courses/MD0575_Integumentar_System/2-Lesson_Integum_Syst.html
Ward, H. (2011). Taking a patient clinical history (video). Retrieved from https://www.youtube.com/watch?v=AH2IXVYXA80