TRINITAS SCHOOL OF NURSING NURE 212 HEALTH AND PHYSICAL ASSESSMENT COURSE DESCRIPTION: NURE 212 builds upon

the foundation of LPN education and introduces the student to holistic health assessment and physical examination. The course aims to develop the student’s abilities in gathering data to determine client’s health status, practices and goals as influenced by his/her own culture. Starting with assessment of normal health parameters, the student will learn to differentiate between what is within and out of acceptable limits. Within the context of care of the perioperative or gerontological client, the student will learn and use physical assessment techniques of inspection, palpation, percussion and auscultation as well as other forms of data collection, such as, client interview, chart review, and analysis of laboratory and diagnostic results. The roles of the RN and the LPN in physical assessment/data collection will be discussed. The student will practice physical assessment skills and participate in laboratory experiences using scenarios involving a patient simulator in the Skills laboratory and in the application of concepts in acute health care settings. Students will also review and perform basic clinical nursing skills. Theory Hours: Clinical Hours: Credits: Duration: FACULTY: 2 hours/week 6 hours/week 4 credits 15 weeks

Ariel Almacen, APN, PsyD, MSN, FNP, CCRN, CEN, RN, C M. E. Kelley, MSN, MEd, RN, CNE Proof of current LPN license Satisfactory completion of NJ Basic Skills Test/Course or waiver G.P.A. 2.3 BIO 105, BIO 106, BIO 108,CHE 105 or CHE 113/114 ENG 101, ENG 102, PSY 101, PSY 205, SOC 101, HUMANITIES ELECTIVES (6 credits) One year employment as an LPN in a health care setting NURE 211

PRE-REQUISITES:

CO-REQUISITES:

THE STUDENT IS RESPONSIBLE FOR ALL INFORMATION CONTAINED IN THE STUDENT HANDBOOK
Copyright 2006-2007. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior permission of Trinitas School of Nursing.

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Demonstrate psychomotor ability in performing basic clinical nursing skills 7. an application for re-entry is required. EFFECTIVE JANUARY 2006: If a student exits the program or if the sequence is not maintained. and the skills and computer laboratories. 4. All students enrolled in Trinitas School of Nursing NURE/NREL courses will be required to adhere to zero tolerance of: Academic Misconduct. secure. Professional Misconduct and Illegal Activities The commitment to a Zero Tolerance policy fosters and upholds academic and professional integrity. a student not registered for courses at UCC must submit a no. Integrate knowledge of anatomy and physiology in the physical assessment process and interpretation of findings. Perform a comprehensive health and physical assessment of a client/individual. To stay active. and healthy environment to learn and work. Academic Dishonesty. Utilize the nursing process and critical thinking in determining client’s health status. There is no guarantee of re-entry into the Nursing Program. 2 . Utilize available technological resources in the libraries. 6.fee application form each semester. Therefore. Demonstrate the use of effective and culturally-sensitive communication techniques in history taking and interviews with clients.COURSE OBJECTIVES FOR NURE 212 Upon completion of this course. Zero Tolerance involving the above behaviors is subject to disciplinary processes up to and including dismissal from Trinitas School of Nursing. 5. Document assessment findings and health history accurately using available resources. The student must submit the application to the Dean and a minimum GPA of 2. 3. the student will: 1. It creates a safe. 2.5 is required.

5) or better in this course is required in order to continue in the nursing sequence Teaching Methods/Materials: Lecture. If available.g. assigned readings.elsevier. The universal patient simulator and other computerized manikins will also be utilized. Course Requirements: Completion of examinations and quizzes with a grade of ‘75’ or higher Health/physical assessment on-line exercises/quizzes accessed through http://evolve. seminar discussion.com and are due as indicated on the course calendar. Demonstration of a cephalocaudal physical examination Submission of a comprehensive written history and physical examination of an adult Satisfactory demonstration of the following procedures: IV therapy/IV Piggyback Tracheostomy care and suctioning Colostomy care Foley catheter insertion Wound dressing See the Student Handbook for general information on nursing course requirements Grading System: 1) 2) 3) 4) 5) 2 Unit exams – 15% each = 30% total 4 Quizzes – 5% Lab Practical on psychomotor performance of cephalocaudal physical examination – 20% Written health history and physical examination of an adult individual – 20% Written final examination – 25% A grade of “C+” (2. clinical psychomotor practice. on-line assignments. the instructor may use a clinical setting at Trinitas Hospital e. audio-visual and computerassisted instruction. writing assignment 3 . the perioperative or gerontological units for health and physical assessment of an actual client with a health deviation.CLINICAL EXPERIENCE: Most of the clinical/lab experiences will be within the Skills Laboratory where students will practice and perform health and physical assessments. Username and password will be provided by the instructor.

Louis: Mosby. P. Davis 4 . (2002).REQUIRED TEXTS: Jarvis. C. & Pagana. Physical examination and health assessment 4th ed. (2003). Taber’s Cyclopedic Medical Dictionary 19th ed. Mosby’s manual of diagnostic and laboratory tests 2nd ed. T. Quick and easy medical terminology 4th ed. St.A. Jarvis. Philadelphia: Saunders. (ed) (2001). (2004). RECOMMENDED TEXTS: Leonard. K. (2004). Philadelphia: F. Philadelphia: Saunders/Elsevier Pagana. C. Venes. D. Philadelphia: Saunders/Elsevier. Student Manual of Physical Assessment 4th ed.

emergency database C. Participate in discussions on the role of assessment as a point of entry in the ongoing process of nursing care. 2. follow-up. Comprehensive assessment factors 2. Health-related beliefs and practices 3. describe the type of data collection indicated: complete. Assessment of the whole person 1. 8. Discuss demographics of your town and develop a list of appropriate transcultural considerations for the ethnic groups in your area. 2. 6. psychosocial. Chapters 1. 3. Critical thinking in health assessment 2. 5. Transcultural expression of illness LEARNING ACTIVITIES Unit I Required Readings: Jarvis. Complete on-line assignment and submit by the designated date on course calendar. Identify the components of the health belief system and their influence on health practices and illness perception/expression.TRINITAS SCHOOL OF NURSING NURE 212 BEHAVIORAL OBJECTIVES UNIT I Overview of Health Assessment Given information in class. Types of databases a. cognitive. Consider growth and development stage when evaluating health data. Using a professional journal article as a basis for identifying health problems. Assessment throughout the life cycle 1. Discuss the role of assessment as the starting point of clinical reasoning. Diagnostic reasoning in clinical judgment 3. 9. required readings. 10. laboratory. 4. CONTENT Unit I Overview of Health Assessment A. developmental stages b. 5 . Religious beliefs and practices 2. 3 Student Activities: 1. Describe expected physical. (2004). 4. episodic c. Philadelphia: Saunders. 2. Discuss the basic characteristics of culture and its role as a potential source of conflict between nurse and client within the health assessment process. developmental screening tests 2. Complete open-book quizzes at the end of each chapter (non-graded) 5. Describe the types of databases used in different clinical situations 7. the student will be able to: 1. complete b. C. Nursing process in clinical judgment B. Physical examination and health assessment 4th ed. and planned learning experiences. Describe the use of diagnostic reasoning in clinical judgment. Discuss the use of the nursing process in clinical judgment. or emergency 3. follow-up database d. episodic. and behavioral milestones of a patient based on developmental stage. Expanding the concept of health 1. Transcultural considerations in assessment 1. Developmental tasks and health promotion across the life span a. Identify the purpose of data collection and physical assessment. Hereditary influences D. Discuss the expanded concept of health and relate it to the process of data collection.

documentation CONTENT LEARNING ACTIVITIES UNIT II Required Readings: Jarvis. clients with special needs 6. 6 . 2. Cross-cultural communication 1. UNIT II The Interview A. 6. special needs or cultural practices. initial interview b. The professional relationship 2. children and adolescents b. assessment b. Use the specified communication techniques appropriately to gather data. Stages of therapeutic communication a. Techniques of communication 3. working phase c. history c. Therapeutic communication 1. State the ten traps of interviewing. Demonstrate ability to establish the parameters for a health interview 3. 9. Both students should identify facilitators and barriers. Screening for intimate partner violence a. Discuss the health effects of violence. Discuss the meaning of common nonverbal modes of communication. Video or audio recorders may be used with the permission of students involved in the role play. Identify local resources available for domestic violence as well as for elder abuse/neglect. The process of communication 2. 7. Overcoming communication barriers B. Effective interviewing skills 5. At the completion of the interview. Paired students will role play an interview between nurse and client based on an identified problem/concern that the client wants to discuss. physical exam d. Nonverbal cross-cultural communication C. Functional use of space 3. 5 Student Activities: 1. Domestic violence assessment 1. 11. termination phase 4. Developmental considerations a. 4. Describe the use of the Abuse Assessment Screen (AAS) when one is screening for intimate partner violence. Discuss working with and without an interpreter in order to overcome communication barriers. Modify communication techniques according to client’s developmental stage. Explain the aspects of assessment and history taking for suspected abuse.TRINITAS SCHOOL OF NURSING NURE 212 BEHAVIORAL OBJECTIVES UNIT II The Interview 1. Recognize health care professional’s role as mandatory reporters of abuse. 4th edition Chapters 4. 3. 8. State facilitators and blockers of effective communication. Use the performance checklist as a basis for the critique. 2. 10. Health effects of violence 2. the older adult c. 5. Discuss “red flags” of abuse and neglect that may be found during an assessment. the student/client will give feedback to the student/interviewer.

4. Define the behaviors that are considered in assessment of a person’s mental status. developmental considerations 3. State the purpose of the complete health history 2. Developmental considerations 1. 3. Perception of health B. Document the results of the assessment and formulate associated nursing diagnoses. developmental considerations b. Identify the components of a nutritional assessment. 2.TRINITAS SCHOOL OF NURSING NURE 212 BEHAVIORAL OBJECTIVES UNIT III The Complete Health History 1. components of mental status examination 2. Identify interviewing techniques that were most or least helpful. Define nutritional status 9. Children and adolescents 2. 8 Student Activities: 1. Defining mental status a. 7 . Describe the data that must be gathered for each category of a health history. thought processes and perceptions e. 7. 10. 6. Functional assessment 8. The older adult C. 11. Past health 5. 8. History of present illness 4. Mental Status Assessment 1. obtain a health history from each other. 5. Describe developmental considerations of a mental status examination. Complete a mental status assessment on an assigned client. complete a MiniMental State Examination on an assigned partner. Family history 6. CONTENT UNIT III The Complete Health History A. Describe the role of culture and values in a client’s nutritional intake. cognitive functions d. Search the Internet for available mental status assessment instruments and assess instrument for completeness 4. Describe the eight characteristics that should be addressed for each symptom identified 5. 13. List categories of information contained in a health history 3. Use nutritional assessment in the provision of care. Abnormal findings a. State the purpose of nutritional assessment. 12. 4th edition Chapters 6. 6. Objective data a. Using the School’s or the hospital’s health history form and working in pairs. Using the form provided in the text. Source of history 3. Review of systems 7. The health history 1. 7. Use anthropometric measures and laboratory data to assess nutritional status of clients. nursing diagnoses LEARNING ACTIVITIES UNIT III Required Readings: Jarvis. appearance b. behavior c. Relate the developmental considerations to be addressed during a health history for a child or older adult. Complete a nutritional assessment of a person from a different culture and describe the nutritional implications of the cultural values of the person. Biographical data 2.

Laboratory studies – biocultural variations. dietary practices of selected cultures d. Subjective data – health history questions for specific populations 3. developmental considerations b. Objective data – clinical signs and anthropometric measures 4. Effective documentation of findings 1. Define nutritional status a.TRINITAS SCHOOL OF NURSING NURE 212 BEHAVIORAL OBJECTIVES CONTENT UNIT III continued D. Comprehensive history LEARNING ACTIVITIES 8 . Review of systems 2. purposes and components of nutritional assessment 2. transcultural considerations c. serial assessment E. Nutritional status Assessment 1.

Body structure 3. Percussion 4. Infants and children 2. Describe the use of inspection. Pain Assessment – the 5th vital sign 1. Developmental considerations across the life span. Differentiate the different types of pain 9. D. Neuroanatomic pathway 2. 7. and bimanual palpation. Describe correct procedures for assessing vital signs. Write a general survey description of a “client”. Discuss the physical changes that may occur because of poorly controlled pain. Vital signs G. 4. 12. 8. Palpation 3. 6. Mobility 4. Equipment 2. Participate in a seminar discussion of personal pain experiences and how it was managed. Practice handling an otoscope and ophthalmoscope. auscultation and percussion as physical examination techniques. Physical appearance 2. 10. 2. deep. Cultivating your senses . 3.Physical examination techniques 1. 5. 9 . Working in pairs. 11 Student Activities: 1. Describe initial pain assessment. 2. CONTENT UNIT IV BEGINNING THE PHYSICAL EXAMINATION PROCESS A. Measurement – height and weight F. and gender considerations regarding pain. Application and critical thinking H. palpation. Additional techniques H. Behavior E. General survey 1.TRINITAS SCHOOL OF NURSING NURE 212 BEHAVIORAL OBJECTIVES UNIT IV BEGINNING THE PHYSICAL EXAMINATION PROCESS 1. transcultural. 4. Describe developmental. Differentiate between light. Discuss relevant developmental considerations in relation to a general survey. Compare available pain assessment tools 11. 10. Use different pain assessment tools to rate pain. students will practice the techniques used in physical examination. 5. Safe environment 3. Auscultation B. Discuss appropriate infection control measures to prevent spread of infection during physical assessment. Transcultural considerations G. 6. Approaching the client C. Nociception 3. Sources of pain LEARNING ACTIVITIES Required Readings: Jarvis 4th edition Chapters 9. List information considered in each of the four areas of a general survey. Inspection 2. Practice listening to heart and lung sounds using SimMan and on each other. Developmental considerations 1. 3. The clinical setting 1. The aging adult F. State developmental considerations in preparing clients for physical examination. Abnormal findings I.

infants b. aging adult 5.TRINITAS SCHOOL OF NURSING NURE 212 BEHAVIORAL OBJECTIVES CONTENT UNIT IV BEGINNING THE PHYSICAL EXAMINATION PROCESS CONTINUED LEARNING ACTIVITIES 4. pain assessment tools 7. Objective data 8. initial pain assessment b. Documentation 10 . Subjective data a. Types of pain a. Gender differences 6.

young adults. Describe equipment used in performing examination and observations 4. descriptive manner using appropriate terminology. and older adults. Peripheral vascular system and lymphatic system 10. rectum. Documentation LEARNING ACTIVITIES Required readings: Jarvis. Identify normal and abnormal findings across the life span 9. 3. Body systems examination 1. Describe proper positioning for the client. 2. Complete a comprehensive health assessment project. 3. 4th edition Chapters 12 – 28 Student Activities: 1. 4. Use of critical thinking to determine client health status and recommendation for health promotion 2. 11 . Demonstrate techniques used during a physical examination 2. 11. State adjustments which may be necessary to accommodate cultural. Describe methods to incorporate health teaching into the physical assessment. 2. CONTENT UNIT V PHYSICAL EXAMINATION A. hair and nails Head and neck. Incorporation of health teaching into the physical assessment 3. 8.TRINITAS SCHOOL OF NURSING NURE 212 BEHAVIORAL OBJECTIVES UNIT V PHYSICAL EXAMINATION 1. 7. Anus. Complete and submit assigned on-line exercises. and prostate B. Discuss how assessment findings influence the nursing process. Identify differences in assessing children. 6. 10. one to follow the checklist and textbook. 5. Male/Female genitalia 12. 6. Thorax and lungs 8. Document findings in a concise. Head and neck vessels 9. mouth. Complete a physical assessment of each body system in a systematic manner. 5. Integration of physical assessment 1. spiritual. Document data obtained using the selected History and Physical Assessment Form. Skin. perform a physical examination of assigned body system. Neurological system 11. List techniques to promote physical and psychological comfort during a physical examination. View assigned Bates’ Physical Assessment video tapes. throat Breasts and regional lymphatics 7. Working in groups of three. 4. lymphatics Eyes Ears Nose. or developmental considerations 3. 5. and one to act as client. Each student will rotate roles to allow each to be an examiner. one to perform the examination.

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