This course will introduce how to obtain a patient history, and perform a health and physical examination on an adult patient. Emphasis will focus on interviewing patients, hands on physical assessment, documentation and developing appropriate nursing diagnoses. Final project requires the successful demonstration of a comprehensive head-to-toe physical assessment at the beginner level. Recommended for students entering the nursing program, re-admitting to the program, or supplementing beginning skills and knowledge of physical assessment.
Goals, Topics, and Objectives
- Patient health and physical assessment overview and relationship to nursing practice.
- Discuss systematic method of collecting and analyzing data for the purpose of planning patient care.
- Definition, purpose, and components of patient health history and physical exam assessment.
- Demonstrate how to obtain and document a client health history and physical examination data.
- Techniques and nursing skills employed in obtaining a patient health history (subjective data) and conducting a comprehensive cephalocaudal physical assessment/examination (objective data).
- Correctly perform a cephalocaudal physical examination properly utilizing assessment techniques on an adult model while providing comfort, safety and privacy throughout the exam. Correctly document patient subjective data on health history.
- Proper documenation using medical terminology of the client history and physical assessment data.
- Accurately document patients subjective and objective data.
- Identification of expected (normal) health history and physical examination findings.
- Correlate normal and abnormal health history and physical assessment findings with subjective and objective patient data.
- Privacy and safety guidelines that affect client assessment.
- Perform assessment techniques on an adult model while providing comfort, safety and privacy throughout exam.
Assessment and Requirements
Assessments of academic achievement may include, but are not limited to completing a head -toe physical assessment skill demonstration, written assignments, and multiple choice testing.
Outcomes
Credit for Prior College-Level Learning
Health Appraisal demonstration, given in department by department faculty. Faculty will assess demonstration and determine satisfactory completion based on evaluation rubric. Evaluation rubric and student checklist located in The School of Health and Human Services office. Maximum number of attempts: two.