Representing Alabama s Public Two-Year College System NUR 103. Health Assessment. Plan of Instruction. Effective Date: 2006 Version Number:

Transcription

1 lm Deprtment of Postsecondry Eduction Representing lm s Pulic Two-Yer ollege System NUR 103 Helth ssessment Pln of Instruction Effective Dte: 2006 Version Numer: OURSE DESRIPTION This course is designed to provide students the opportunity to lern nd prctice history tking nd physicl exmintion skills with individuls of ll ges, with emphsis on the dult. The focus is on symptom nlysis long with physicl, psychosocil, nd growth nd development ssessments. Students will e le to utilize criticl thinking skills in identifying helth ltertions, formulting nursing dignoses nd documenting findings pproprite to nursing. This course supports IP codes nd REDIT HOURS Theory 0 credit hours L 1 credit hour linicl 0 credit hours Totl 1 credit hour Totl ontct Time 3 hours NOTE: Theory credit hours re 1:1 contct to credit rtio. L credit is 3:1. linicl credit is 3:1. The lm ollege System opyright 2006

2 Helth ssessment NUR 103 PREREQUISITE OURSES IO 103 Principles of iology I (or stisfctory performnce on the lm ollege System pproved plcement exm) NOTE: Only required if student is tking IO 201 nd 202 sequences. O-REQUISITE OURSES NUR 102 Fundmentls of Nursing NUR 104 Introduction to Phrmcology IO 201 Humn ntomy nd Physiology or NUR 101 ody Structure nd Function (if selected y PN students) MTH 116 Mthemticl pplictions (or higher level) INSTRUTIONL NOTE: onsider communiction, culturl influences, growth, nd developmentl spects in ech module. PROFESSIONL OMPETENIES Explin the chrcteristics of growth nd development of individuls throughout the lifespn. Otin helth history to gther sujective dt. Perform systemtic (hed to toe) physicl ssessment to gther ojective dt. Document ssessments. INSTRUTIONL GOLS ognitive - comprehend foundtionl knowledge of the process of gthering helthrelted informtion. Performnce - pply foundtionl knowledge of gthering helth-relted informtion in simulted environment. PROFESSIONL OMPETENIES/OJETIVES Unless otherwise indicted, evlution of student s ttinment of cognitive nd performnce ojectives is sed on knowledge nd skills gined from this course. ompetencies specified for ech module my e set y certifiction gencies, ntionl nd stte codes, helth cre fcility policies, loclly developed l/clinicl ssignments, or ny comintion. Students re expected to utilize relevnt technology for client cre nd documenttion. 2

3 Helth ssessment NUR 103 MODULE GROWTH ND DEVELOPMENT THROUGHOUT THE LIFESPN PROFESSIONL OMPETENIES 1.0 Explin the chrcteristics of growth nd development of individuls throughout the lifespn. () LERNING OJETIVES PERFORMNE OJETIVES 1.1 This module is evluted cognitively Define key terms ssocited with growth nd development Descrie common developmentl theories ssocited with growth nd development Descrie norml growth nd development chrcteristics throughout the lifespn. L SKILLS None KS Indictor MODULE HELTH HISTORY PROFESSIONL OMPETENIES PERFORMNE OJETIVES 1.0 Otin helth history to gther sujective dt. (/2) 1.1 Otin comprehensive helth history using interview techniques. 2.0 Document ssessment. (2c) 2.1 Given informtion reltive to client s helth history, document the helth history. LERNING OJETIVES KS Indictor Identify fctors influencing the interview process Identify stges of the interview process Identify interview techniques Identify elements of comprehensive helth history Explin the importnce of documenting nd reporting helth history. c Identify required elements of documenting helth history Explin the process of documenting helth history. L SKILLS Interview techniques Otin helth history Documenting nd reporting 3

4 Helth ssessment NUR 103 MODULE GENERL SURVEY PROFESSIONL OMPETENIES 1.0 Perform systemtic (hed to toe) physicl ssessment to gther ojective dt. (/2) 2.1 Document results of helth ssessment. (2c) LERNING OJETIVES PERFORMNE OJETIVES 1.1 onduct generl survey. 1.2 Use physicl ssessment techniques. 2.1 Given informtion reltive to client s physicl ssessment, document nd report physicl ssessment. KS Define components of the generl survey Explin the process of conducting generl survey Explin the process of conducting Mini Mentl Sttus Exm Recognize norml findings Identify physicl ssessment techniques Explin procedures for physicl ssessment techniques. L SKILLS Stndrd precutions Inspect, plpte, percuss, uscultte Perform generl survey Height/weight/ody mss index Vitl signs Documenting nd reporting Indictor 4

5 Helth ssessment NUR 103 MODULE D PHYSIL SSESSMENT OF HEENT PROFESSIONL OMPETENIES D1.0 Perform systemtic (hed to toe) physicl ssessment to gther ojective dt. (/2) PERFORMNE OJETIVES D1.1 Perform physicl ssessment of the hed, eyes, ers, nose nd throt. D2.0 Document results of helth ssessment. (2c) D2.1 Given informtion reltive to physicl ssessment, document nd report findings. LERNING OJETIVES KS Indictor D1.1.1 Define terminology relted to ssessment of hed, eyes, ers, nose, nd throt (HEENT). D1.1.2 Descrie ntomy nd physiology of hed nd neck. D1.1.3 Identify equipment. D1.1.4 Identify positioning. D1.1.5 Identify techniques. D1.1.6 Explin the process of performing hed/neck physicl ssessment. D1.1.7 Recognize norml findings. L SKILLS Stndrd precutions Use ssessment equipment Use ssessment techniques Position clients for ssessments Document nd report findings 5

6 Helth ssessment NUR 103 MODULE E PHYSIL SSESSMENT OF INTEGUMENTRY SYSTEM PROFESSIONL OMPETENIES E1.0 Perform systemtic (hed to toe) physicl ssessment to gther ojective dt. (/2) E2.0 Document results of helth ssessment. (2c) LERNING OJETIVES PERFORMNE OJETIVES E1.1 Perform physicl ssessment of the integumentry system. E2.1 Document nd report ssessment of the integumentry system. E1.1.1 Define terminology relted to ssessment of the integumentry system. E1.1.2 Descrie ntomy nd physiology of integumentry system. E1.1.3 Identify equipment. E1.1.4 Identify positioning. E1.1.5 Identify techniques. E1.1.6 Explin the process of performing n ssessment of the integumentry system. E1.1.7 Recognize norml ssessment findings. L SKILLS Stndrd precutions Use ssessment equipment Use ssessment techniques Position clients for ssessments Document nd report findings KS Indictor 6

7 Helth ssessment NUR 103 MODULE F PHYSIL SSESSMENT OF THE RESPIRTORY SYSTEM PROFESSIONL OMPETENIES F1.0 Perform systemtic (hed to toe) physicl ssessment to gther ojective dt. (/2) PERFORMNE OJETIVES F1.1 Perform physicl ssessment of the respirtory system. F2.0 Document results of helth ssessment. (2c) LERNING OJETIVES F1.1.1 F1.1.2 F1.1.3 F1.1.4 F1.1.5 F1.1.6 F2.1 Document nd report ssessment of the respirtory system. Define terminology relted to ssessment of the respirtory system. Descrie ntomy nd physiology of the respirtory system. Identify equipment. Identify positioning. Identify techniques. Explin the process of performing n ssessment of the respirtory system. Recognize norml ssessment findings. F1.1.7 L SKILLS Stndrd precutions Use ssessment equipment Use ssessment techniques Position clients for ssessments Document nd report findings KS Indictor 7

8 Helth ssessment NUR 103 MODULE G PHYSIL SSESSMENT OF IRULTORY/LYMPHTI SYSTEM PROFESSIONL OMPETENIES G1.0 Perform systemtic (hed to toe) physicl ssessment to gther ojective dt. (/2) PERFORMNE OJETIVES G1.1 Perform physicl ssessment of the circultory/lymphtic system. G2.0 Document results of helth ssessment. (2c) G2.1 Document nd report ssessment of the circultory/lymphtic system. LERNING OJETIVES KS Indictor G1.1.1 Define terminology relted to ssessment of the circultory/lymphtic system. G1.1.2 Descrie ntomy nd physiology of the circultory/lymphtic system. G1.1.3 Identify equipment. G1.1.4 Identify positioning. G1.1.5 Identify techniques. G1.1.6 Explin the process of performing n ssessment of the circultory/lymphtic system. G1.1.7 Recognize norml ssessment findings. L SKILLS Stndrd precutions Use ssessment equipment Use ssessment techniques Position clients for ssessments Document nd report findings 8

9 Helth ssessment NUR 103 MODULE H PHYSIL SSESSMENT OF THE REST ND XILLE PROFESSIONL OMPETENIES PERFORMNE OJETIVES H1.0 Perform systemtic (hed to toe) physicl ssessment to gther ojective dt. (/2) H1.1 Using clinicl simultions or models, perform physicl ssessment of the rest nd xille. H1.2 Tech the technique of rest self-exmintion for mles nd femles. H2.0 Document results of helth ssessment. (2c) H2.1 Document nd report ssessment of the rest nd xille. LERNING OJETIVES KS Indictor H1.1.1 Define terminology relted to ssessment of the rest nd xille. H1.1.2 Descrie ntomy nd physiology of the rest nd xille. H1.1.3 Identify equipment. H1.1.4 Identify positioning. H1.1.5 Identify techniques. H1.1.6 Explin the process of performing n ssessment of the rest nd xille. H1.1.7 Recognize norml ssessment findings. H1.2.1 Explin the steps for performing the rest self-exmintion for mles nd femles. L SKILLS Use ssessment equipment Use ssessment techniques Position clients for ssessments ulturl influences, growth, nd developmentl considertions Document findings 9

10 Helth ssessment NUR 103 MODULE I PHYSIL SSESSMENT OF THE DOMEN PROFESSIONL OMPETENIES I1.0 Perform systemtic (hed to toe) physicl ssessment to gther ojective dt. (/2) I2.0 Document results of helth ssessment. (2c) LERNING OJETIVES PERFORMNE OJETIVES I1.1 Perform physicl ssessment of the domen. I2.1 Document nd report ssessment of the domen. I1.1.1 Define terminology relted to ssessment of the domen. I1.1.2 Descrie ntomy nd physiology of the domen. I1.1.3 Identify equipment. I1.1.4 Identify positioning. I1.1.5 Identify techniques. I1.1.6 Explin the process of performing n ssessment of the domen. I1.1.7 Recognize norml ssessment findings. L SKILLS Use ssessment equipment Use ssessment techniques Position clients for ssessments ulturl influences, growth, nd developmentl considertions Document findings KS Indictor 10

11 Helth ssessment NUR 103 MODULE J PHYSIL SSESSMENT OF THE REPRODUTIVE SYSTEM PROFESSIONL OMPETENIES PERFORMNE OJETIVES J1.0 Perform systemtic (hed to toe) physicl ssessment to gther ojective dt. (/2) J1.1 Using clinicl simultions or models, ssist with performing physicl ssessment of the mle nd femle reproductive systems. J1.2 Tech the technique of testiculr selfexmintion for mles. J2.0 Document results of helth ssessment. (2c) J2.1 Document nd report ssessment of the mle nd femle reproductive system. LERNING OJETIVES KS Indictor J1.1.1 Define terminology relted to ssessment of the mle nd femle reproductive systems. J1.1.2 Descrie ntomy nd physiology of the mle nd femle reproductive systems. J1.1.3 Identify equipment. J1.1.4 Identify positioning. J1.1.5 Identify techniques. J1.1.6 Explin the process of ssisting with ssessment of mle nd femle reproductive systems. J1.1.7 Recognize norml ssessment findings. J1.1.8 Explin the exmintion of the rectum, perineum, nd prostte. J1.2.1 Explin the testiculr self-exmintion. L SKILLS Stndrd precutions Use ssessment equipment Use ssessment techniques Position clients for ssessments Document nd report findings 11

12 Helth ssessment NUR 103 MODULE K PHYSIL SSESSMENT OF THE MUSULOSKELETL SYSTEM PROFESSIONL OMPETENIES K1.0 Perform systemtic (hed to toe) physicl ssessment to gther ojective dt. (/2) K2.0 Document results of helth ssessment. (2c) LERNING OJETIVES PERFORMNE OJETIVES K1.1 Perform physicl ssessment of the musculoskeletl system. K2.1 Document nd report ssessment of the musculoskeletl system. K1.1.1 Define terminology relted to ssessment of the musculoskeletl system. K1.1.2 Descrie ntomy nd physiology of the musculoskeletl system. K1.1.3 Identify equipment. K1.1.4 Identify positioning. K1.1.5 Identify techniques. K1.1.6 Explin the process of performing n ssessment of the musculoskeletl system. K1.1.7 Identify norml ssessment findings. L SKILLS Stndrd precutions Use ssessment equipment Use ssessment techniques Position clients for ssessments Document nd report findings KS Indictor 12

13 Helth ssessment NUR 103 MODULE L PHYSIL SSESSMENT OF THE NEUROLOGIL SYSTEM PROFESSIONL OMPETENIES L1.0 Perform systemtic (hed to toe) physicl ssessment to gther ojective dt. (/2) L2.0 Document results of helth ssessment. (2c) LERNING OJETIVES PERFORMNE OJETIVES L1.1 Perform physicl ssessment of the neurologicl system. L2.1 Document nd report ssessment of the neurologicl system. L1.1.1 Define terminology relted to ssessment of the neurologicl system. L1.1.2 Descrie ntomy nd physiology of the neurologicl system. L1.1.3 Identify equipment. L1.1.4 Identify positioning. L1.1.5 Identify techniques. L1.1.6 Explin the process of performing n ssessment of the neurologicl system. L1.1.7 Identify norml ssessment findings. L SKILLS Stndrd precutions Use ssessment equipment Use ssessment techniques Position clients for ssessments Document findings KS Indictor 13

14 Helth ssessment NUR 103 OURSE ONTENT OUTLINE MODULE GROWTH ND DEVELOPMENT THROUGHOUT THE LIFE SPN Peditric dult Geritric MODULE HELTH HISTORY Otining helth history Interview techniques omprehensive helth history o iogrphic dt o hief complint o History of present illness (symptom nlysis) o Pst medicl history o lterntive therpies o ulturl influences Norml ssessment findings Documenting nd reporting ssessment MODULE LIENT GENERL SURVEY onducting generl survey omponents o Generl ppernce o Git o Posture o Vitl signs o Speech o Signs of distress o ody type o Hygiene o Height/weight/ody mss index o Ethnicity o Mentl sttus nd level of consciousness Procedure for generl survey Mini Mentl Sttus Exm Norml ssessment findings Documenting nd reporting generl survey Techniques Inspection Plption Percussion usculttion 14

15 Helth ssessment NUR 103 MODULE D PHYSIL SSESSMENT OF HEENT HEENT ssessment Terminology ntomy nd physiology of HEENT Equipment Positioning Techniques Performing n HEENT physicl ssessment Norml ssessment findings Documenting nd reporting HEENT ssessment MODULE E PHYSIL SSESSMENT OF THE INTEGUMENTRY SYSTEM Integumentry system physicl ssessment Terminology ntomy nd physiology of the integumentry system Equipment Positioning Techniques Performing n integumentry system ssessment Norml ssessment findings Documenting nd reporting integumentry system ssessment MODULE F PHYSIL SSESSMENT OF THE RESPIRTORY SYSTEM Respirtory system physicl ssessment Terminology ntomy nd physiology of the respirtory system Equipment Positioning Techniques Performing respirtory system ssessment Norml ssessment findings Documenting nd reporting respirtory system ssessment 15

16 Helth ssessment NUR 103 MODULE G PHYSIL SSESSMENT OF THE IRULTORY/LYMPHTI SYSTEM ircultory/lymphtic system physicl ssessment Terminology ntomy nd physiology of the circultory/lymphtic system Equipment Positioning Techniques Performing circultory/lymphtic system ssessment Norml nd norml ssessment findings Documenting nd reporting circultory/lymphtic system ssessment MODULE H - PHYSIL SSESSMENT OF THE REST ND XILLE rest nd xille physicl ssessment Terminology ntomy nd physiology of the rest nd xille Equipment Positioning Techniques Teching nd performing rest nd xille self-exmintion Norml ssessment findings Documenting nd reporting rest nd xille ssessment MODULE I PHYSIL SSESSMENT OF THE DOMEN domen physicl ssessment Terminology ntomy nd physiology of the domen Equipment Positioning Techniques o Inspection o usculttion o Percussion o Plption Performing n dominl ssessment o Gstrointestinl o Urinry Norml ssessment findings Documenting nd reporting dominl ssessment 16

17 Helth ssessment NUR 103 MODULE J PHYSIL SSESSMENT OF THE REPRODUTIVE SYSTEM Reproductive system ssessment Terminology ntomy nd physiology of the mle nd femle reproductive systems Equipment Positioning Techniques Performing mle nd femle reproductive systems ssessment Teching nd performing testiculr self-exmintion Exmintion of the rectum, perineum, nd prostte Norml ssessment findings Documenting nd reporting mle nd femle reproductive systems ssessment MODULE K PHYSIL SSESSMENT OF THE MUSULOSKELETL SYSTEM Musculoskeletl system ssessment Terminology ntomy nd physiology of the musculoskeletl system Equipment Positioning Techniques Performing musculoskeletl system ssessment Norml ssessment findings Documenting nd reporting musculoskeletl system ssessment MODULE L PHYSIL SSESSMENT OF THE NEUROLOGIL SYSTEM Neurologicl system ssessment Terminology ntomy nd physiology of the neurologicl system Equipment Positioning Techniques Performing neurologicl system ssessment Norml ssessment findings Documenting nd reporting neurologicl system ssessment 17

18 Helth ssessment NUR 103 LERNING OJETIVES TLE OF SPEIFITIONS The tle elow identifies the percentge of cognitive ojectives for ech module. Instructors should develop sufficient numers of test items t the pproprite level of evlution. Fcts/ Nomenclture Principles/ Procedures nlysis/ Operting Principles Evlution/ omplete Theory / / /c D/d Module 33% 67% 0 0 Module 72% 14% 14% 0 Module 33% 50% 17% 0 Module D 57% 29% 14% 0 Module E 57% 29% 14% 0 Module F 57% 29% 14% 0 Module G 57% 29% 14% 0 Module H 50% 38% 12% 0 Module I 57% 29% 14% 0 Module J 44% 44% 12% 0 Module K 57% 29% 14% 0 Module L 57% 29% 14% 0 18

19 Helth ssessment NUR 103 Performnce ility Knowledge of Skills Knowledge ffective Knowledge, Skills, nd ttitudes (KS) Indictors Vlue Key Word(s) Definition 4 Highly Performs competency quickly nd ccurtely. Instructs others how to do Proficient the competency. 3 Proficient Performs ll prts of the competency. Needs only spot check of completed work. 2 Prtilly Proficient Performs most prts of the competency. Needs help only on hrdest prts. 1 Limited Proficiency Performs simple prts of the competency. Needs to e told or shown how to do most of the competency. d omplete Theory Predicts, isoltes, nd resolves prolems out the competency. c Operting Identifies why nd when the competency must e done nd why ech step Principles is needed. Procedures Determines step-y-step procedures for doing the competency. Nomenclture Nmes prts, tools, nd simple fcts out the competency. D Evlution Evlutes conditions nd mkes proper decisions out the suject. nlysis nlyzes fcts nd principles nd drws conclusions out the suject. Principles Identifies reltionship of sic fcts nd sttes generl principles out the suject. Fcts Identifies sic fcts nd terms out the suject. *5 hrcteriztion y Vlue *4 Orgniztion cting consistently with the new vlue Integrting new vlue into one's generl set of vlues, giving it some rnking mong one's generl priorities *3 Vluing Showing some definite involvement or commitment *2 Responding Showing some new ehviors s result of experience *1 Receiving eing wre of or ttending to something in the environment lph Scle Vlues - ny item with n upper cse letter (,,, D) y itself is tught s generl informtion on topic. This informtion my e relted to the competency or encompss multiple competencies. Exmples might include mthemticl computtions or knowledge of principles such s Ohm s Lw. lower cse letter indictes level of Knowledge of Skills." Individuls re tught informtion pertining to performing competency. These my e indicted lone or in conjunction with numericl scle vlue. lower cse letter y itself indictes the individul is not required to perform the tsk-just know out the tsk. (exmple: n stte or explin procedures for doing tsk). Numericl Scle Vlues - The numers reflect the levels the individul will e le to perform competency. Numer vlues re lwys ccompnied y lower cse letters (i.e. 1, 2, 3c...etc.) in order to specify the level of knowledge of skills ssocited with the competency. Exmple: n individul with competency with scle indictor of 3 hs received trining of knowledge of skills wherey he or she cn determine the correct procedures nd perform with limited supervision; only requiring evlution of the finished product or procedure. sterisk items indicte desired ffective domin levels nd re used to indicte the desired level for given competency. They my e used independently or with other indictors (i.e. 1-*1, 2c-*3). If used with nother indictor, seprte with hyphen. NOTE: odes indicte terminl vlues. 19