UNIVERSITY OF WISCONSIN-MILWAUKEE
COLLEGE OF NURSING
Graduate Course Syllabus
Spring 2013
Title: NURS 754: COMPREHENSIVE ASSESSMENT OF HEALTH:
IMPLICATIONS FOR CLINICAL DECISION MAKING
Credits: 3 units; G
Comprehensive Assessment of Health: Implications for Clinical Decision Making it a
graduate level 3-credit course. The lecture portion of the course is 2 credits, and the corequisite laboratory is 1 credit (2 contact hours).
Prerequisites: Grad st; admis to Nursing degree program; Nurs 753(P); or cons instr.
Enroll in LEC 401 & LAB 801..
Faculty:
James Bockeloh, DNP, RN, FNP-BC, APNP
e-mail: bockeloh@uwm.edu
Office: Cunningham 522
UWM Ph#414 229-5556
Cell Ph# 262-880-6415
Office Hours: By Appointment
Lab Instructor :
Susan A. Fontana, PhD, APRN, FNP-BC
Associate Professor and Family Nurse Practitioner-Board Certified
University of Wisconsin-Milwaukee
PO Box 413
Milwaukee, WI 53201
Program Director : Kim Litwack PhD RN APNP FAAN
Email address: litwack@uwm.edu
Office phone number: 414-229-5098
Class meetings times and location:
Lecture: Meets 7:00 PM-8:50 PM Tue 01/22/12-05/09/12, CUN G40
LAB: Meets 5:00 PM-6:50 PM Tue 01/22/12-05/09/12, CUN 608
Catalog Description: Comprehensive assessment of health in individuals and aggregates,
including measurement of health status, appraisal of needs, analysis of environmental
contexts, and development of diagnostic strategies.
Course Description: This course is designed to provide an in-depth analysis of approaches
to the assessment of health in individuals, families, and populations. Emphasis will be
placed on theories, research findings, and practice guidelines as they relate to
measurement of health status, appraisal of health needs and concerns, analysis of
environmental contexts, and clinical decision-making.
Course Objectives: Upon successful completion of the course, the student will be able to:
1.
Apply selected theories, research, and clinical practice guidelines related to health
assessment and diagnostic strategies.
2.
Evaluate the health status of individuals and populations, synthesizing data derived
through various health assessment strategies, including clinical status, cultural
beliefs and behaviors, and environmental factors.
3.
Demonstrate advanced assessment of health status of individuals across the
lifespan, using comprehensive and focused approaches.
Textbooks and Readings:
Required:
Goolsby, M., Grubbs, L. (2011). Advanced assessment: Interpreting findings and
formulating differential diagnoses. Philadelphia: F. A. Davis.
A physical assessment text. We suggest:
Seidel, H., Ball, J., Dains, J., & Benedict, G. (2011). Mosby’s guide to physical examination
(7th ed.). St. Louis: Mosby.
Recommended:
If you do not already have a current handbook for diagnostic testing, we recommend
purchasing one for this course and for your upcoming clinical experiences.
Agency for Healthcare Research and Quality. (2008). Guide to clinical preventative services.
Rockville, MD, AHRQ. Can be accessed online at:
http://www.ahrq.gov/clinic/pocketgd1011/pocketgd1011.pdf
Seidel (Ed.)(2011). Mosby's physical examination handbook (7rd ed.). St. Louis: Mosby.
Wright, W. (2008). Physical Assessment & Health History of the Adult Examination (6h ed.).
North Andover, MA: Fitzgerald Health Education Associates. (can be found at
www.FHEA.com)
There is also a wealth of assessment information and tools available online and in the
3rd floor NLRC. (We will discuss some of the available on-line resources in class).
Assignments and Evaluation:
1. Evaluation/Grading
Your course grade will be based on both lecture and laboratory evaluations. The evaluation
components will consist of the following:




Adult Screening History write-up (30 points)
Focused health & aggregate assessment presentation (20 points)
Graded case studies & documentation (3 @ 10 points each=30 points)
Observed performance of a focused physical examination (20 points)
2. Description of assignments
Adult Screening History write-up.
Students will be required to perform a screening or annual History on an adult client (age
>18) outside of class time and document it. The History should be type written, singlespaced, with appropriate double spacing between headings. The goal is to be complete, yet
succinct. Identifying information should maintain the anonymity of your patient. Course
faculty will evaluate this assignment using the Scoring Guide: Adult Screening History.
Focused Health and Aggregate Assessment
Students will be required to work in small groups (3-4 people) to research and write up a
common “focused” clinical problem. This focused assessment will include pertinent history
and physical examination findings, proposed diagnostic testing and a prioritized list of
differential diagnoses. Students will also provide pertinent background, aggregate and
epidemiological information about the problem. This assignment is preparation for the
practical final examination and will be evaluated using the Scoring Guide: Focused
Assessment. 5 points will be deducted for students who do not participate in the class
presentation activity.
Practice Component
On-campus laboratory experiences will emphasize skills necessary for assessing the most
commonly encountered health problems/conditions in clinical settings and for delivering
preventive, curative, and rehabilitative services. The packet Scoring Guides for Health
Assessment provides tools for you to use in practicing and faculty to use in evaluating
assessment skills.
Students will have opportunity to obtain feedback on their advanced health assessment
skills under the direct supervision of a faculty member during your clinical laboratory
sessions. Autotutorial media will be available weekly to facilitate cognitive and
psychomotor skills related to advanced health assessment. The laboratory will include the
following activities:
1.
Observed basic physical examination. In order to continue with the in-depth
comprehensive assessment, students must demonstrate that they can do a basic head
to toe examination within 20 minutes. This will be completed during the second lab
session. The grading tool “BASIC ADULT PHYSICAL EXAMINATION: Observed” is found
in the “Scoring Guides” portion of this packet. Students may bring one index card with
notes on one side for reference during the test if they choose. Students must
satisfactorily complete at least 83% of the components to pass. An unsatisfactory
performance (<83%) will require students to practice and repeat the PE. The student
who does not pass the examination on first attempt is responsible for his/her own
remediation, but resources are available in the NLRC. Students who are unable to
complete the basic physical examination upon the 2nd attempt will meet with Dr. Kako
to determine if they should continue in the advanced assessment course.
2.
Case studies & Documentation. This course will use multiple case studies to integrate
students’ previous clinical knowledge with Advance Practice Nurse level critical
thinking, history taking and documentation skills. Students will have multiple case
studies to choose from, work through during lab and document using SOAP format.
Although three write-ups will be graded, students are encouraged to present practice
write-ups to their lab instructor for critique of history taking and documentation skills
and recommendations for improvement (if any). Critiqued documentation may not be
submitted for a grade. Write-ups to be graded should be uploaded to the course D2L
site drop box under the lab instructor’s name by the due date. Late case studies will
receive one letter grade lower for each week they are late (A to A-; A-to B+).
3.
Gynecological-genitourinary training. A training session with professional patients will
occur during lab time towards the end of the semester in order to learn how to
perform the female gynecological examination and a male genitourinary/rectal
examination. For each examination, you will work in small groups with one course
faculty and a professional patient. You will have an opportunity to perform the
examination with the coaching and guidance of the faculty and the professional patient
and to observe 2-3 other examinations.
3.
Practical final assessment. Near the end of the semester, students will schedule a 20minute time slot with their lab instructor for their lab final. Students will be given a
scenario and be asked to perform a focused assessment, eliciting pertinent history and
completing exam components appropriate to the patient’s clinical presentation.
Students must also select diagnostic tests to be done and provide a list of differential
diagnoses in their documentation, no other treatment plans will be required.
3. Grading Scale:
95-100 A
87-90
B
79-82 C
72-74 D
93-94
A-
85-86
B-
77-78 C-
70-71 D-
91-92
B+
83-84
C+
75-76 D+
00-69 F
4. Course Attendance Policy: Because the lectures/discussions and other types of
class sessions are critical components of successfully completing the course,
attendance is required. If you will be absent from class, please notify the course
coordinator and or the lab instructor in advance as soon as possible. If you will miss
a class, it is recommended that you arrange to have a classmate take notes for you
and/or collect any handouts.
5. Course Expectations:
A.
Required Readings
Students will be expected to complete all assigned readings from the textbooks prior to
class. Students will be expected to read any additional assigned articles and online
national practice guidelines as specified as well.
B. Grading Policy
Any assignment that is submitted after the due date according to the class
schedule will be reduced by one letter grade (e.g., A- to B+) for each week, including the
first week that the assignment is late.
Content Outline and Assigned Readings
Week 1, Jan 22:
Lab: Intro to lab, Basic PE review/practice
Lecture: Overview of class, Assessment of Individuals, Aggregates &
Communities; Data Resources
Pre-Class Prep: Read assessment text & Goolsby chapters re:
assessment/clinical decision making and documentation.
Week 2, Jan 29:
Lab: Basic PE Check Offs
Lecture: Clinical Decision-Making, Diagnostics and Documentation
Pre-Class Prep: Review relevant text chapters.
Week 3, Feb 5:
Lab: Interview, History & Documentation practice, basic PE check-offs
Lecture: Dermatologic, HEENT
Pre-Class Prep: Review common lab/diagnostic tests and be prepared to
discuss. Consider bringing a diagnostic testing (lab) reference to class,
Practice basic physical exam
Week 4, Feb 12:
Lab: Dermatologic, HEENT, Basic PE Checkoff
Lecture: Chest (Breast, Respiratory & Cardiovascular) Clinic; Turn in Adult
Screening History write-up (Drop Box)
Pre-Class Prep: Review relevant text chapters. Case Study #1 Due.
Week 5, Feb 19:
Lab: Chest (Breast, Respiratory & Cardiovascular) Clinic
Lecture: Musculoskeletal Assessment
Pre-Class Prep: Review relevant text chapters.
Week 6, Feb 26:
Lab: Musculoskeletal Assessment
Lecture: Neurological Clinic; Focused assessment presentation topics will
be assigned in class
Pre-Class Prep: Review relevant text chapters.
Week 7, March 5:
Lab: Neurological Clinic
Lecture: GI Assessment
Pre-Class Prep: Review relevant text chapters.
Week 8, March 12:
Lab: GI Assessment
Lecture: GU/GYN, Reproductive Clinic
Pre-Class Prep: Review relevant text chapters. Case Study #2 Due.
Spring Break March 17-24, 2013, No Classes
Week 9, March 26:
Lab: GU/GYN, Reproductive Clinic
Lecture: Abdominal, GU/GYN, Reproductive Assessment & Documentation
Pre-Class Prep: Review relevant text chapters
Week 10, Apr 2:
Lab: GU/GYN Assessment, Professional Models
Lecture: Mental Health Clinic
Pre-Class Prep: Review relevant text chapters, GU/GYN exam videos
Week 11, April 9:
Lab: Mental Health Assessment, Interview
Lecture: Spiritual Health Assessment
Pre-Class Prep: Review relevant text chapters Due: Group FocusedAssessment Presentation and Reference materials posted on D2L
Discussion area.
Week 12, April 16:
Lab: Focused Assessment Practice
Lecture: Focused-Assessment Presentations
Pre-Class Prep: Review relevant text chapters, Case Study #3 Due
Week 13, April 23:
Lab: Focused-Assessment Check Offs
Lecture: Focused-Assessment Presentations
Pre-Class Prep: Review relevant text chapters
Week 14, April 30:
Lab: Focused-Assessment Check Offs
Lecture: Focused-Assessment Presentations
Pre-Class Prep: Review relevant text chapters
Week 15, May 7:
Lab: Focused-Assessment Check Offs, PE Kit Turn In
Lecture: Course Evaluations, Semester Wrap-Up
Pre-Class Prep: Material as needed
ACADEMIC CONDUCT
Students are expected to demonstrate academic integrity in all course activities. Academic
integrity requires honesty concerning all aspects of academic work including:



Correct procedures for citing sources of information, words, and ideas
Ways to properly credit collaborative work with project team or study group
members
Strategies for planning and preparing for examinations, papers, projects and
presentations.
Students are encouraged to consult with faculty regarding any questions about appropriate
behaviors to maintain academic integrity. Any violation of academic integrity will result in a
zero on the assignment and may result in additional sanctions consistent with university
policy
University Policies:
http://www.uwm.edu/Dept/SecU/SyllabusLinks.pdf
There are two additional policies:
1. Inclement weather: UWM student should contact the University at 229-4444 (UWParkside, 262-595-2345) or check the appropriate website to ascertain the status of
class cancellation due to inclement weather. Even when classes are canceled,
University offices and services remain available, unless the entire University is
closed by the Governor. http://www4.uwm.edu or http://www.uwp.edu
2. Safety: Safety techniques and strategies are described in College of Nursing Student
Handbooks for undergraduate and graduate students distributed to all nursing
students upon entering the program. Copies are available in the Office of Student
Affairs. Information about UWM campus safety is found at
http://www4.uwm.edu/current_students/student_services/safety.cfm
3. Technology and Social media: See student handbook
4. Tape Recordings: Should you wish to tape record a lecture, it is a professional
courtesy to request permission from the lecturer
Lab Guide for
NURS 754
Advanced History Taking
Upon completion of this unit the student will be able to:
1.
Understand the components of a comprehensive health history and physical
examination.
2.
Discuss culturally competent approaches to taking a health history and performing
a physical examination.
3.
Identify how to assess a patient problem by proper application of symptom analysis
and review of systems.
3.
Define the components used in recording a comprehensive health history and
physical examination.
Advanced Assessment of the Skin, Hair, and Nails
Upon completion of this unit the student will be able to:
1.
Identify the specific cues obtained from the client that indicate the need for a
history related to the skin, hair, or nails.
2.
Describe the appropriate analysis of a symptom for a problem related to the skin,
hair, or nails.
3.
Identify and perform the physical examination for a problem related to the skin,
hair, or nails.
4.
Identify and discuss appropriate diagnostic testing for a problem related to the
skin, hair, or nails.
5.
Describe findings from the history, physical examination, and appropriate
diagnostic testing that indicate deviation from normal skin, hair, or nails.
6.
Discuss universal precautions guidelines to be used in providing health care.
Advanced Assessment of the Head, Eyes, Ears Nose and Throat (HEENT)
Upon completion of this unit the student will be able to:
1.
Identify the specific cues obtained from the client that indicate the need for a history
related to the HEENT.
2.
Describe the appropriate analysis of a symptom for a problem related to HEENT.
3.
Identify and perform the physical examination for a problem related to HEENT.
4.
Identify and discuss appropriate diagnostic testing for a problem related to HEENT.
5.
Describe findings from the history, physical examination, and appropriate
diagnostic testing that indicate deviation from normal HEENT exam.
Physical exam book videos or Bates videotapes: Head, Eyes, and Ears; Nose, Mouth, and
Neck; Lymphatic system;
Advanced Assessment of the Chest
Upon completion of this unit the student will be able to:
1. Identify the specific cues obtained from the client that indicates the need for a
history related to the breasts, axillae, lungs or cardiovascular systems.
2. Describe the appropriate analysis of a symptom for a problem related to the
breasts, axillae, lungs or cardiovascular systems.
3. Identify and perform the physical examination for a problem related to breasts,
axillae, lungs or cardiovascular systems.
4. Identify and discuss appropriate diagnostic testing for a problem related to the
breasts, axillae, lungs or cardiovascular systems.
5. Accurately describe findings from the history, physical examination, and
appropriate diagnostic testing related to the breasts, axillae, lungs or cardiovascular
systems that indicate deviation from normal.
Physical examination book videos or Bates videotapes: Thorax and lungs. Breasts and
axillae; Neck vessels and heart, Peripheral vascular system.
Advanced Gastrointestinal Assessment
Upon completion of this unit the student will be able to:
1. Identify the specific cues obtained from the client that indicate the need for a
history related to the gastrointestinal system.
2. Describe the appropriate analysis of a symptom for a problem related to the
gastrointestinal system.
3. Identify and perform the physical examination for a problem related to the
gastrointestinal system.
4. Identify and discuss appropriate diagnostic testing for a problem related to the
gastrointestinal system.
Physical exam book videos or Bates videotapes:, Gastrointestinal system (Abdomen).
Advanced Assessment of the Musculoskeletal System
Upon completion of this unit the student will be able to:
1. Identify the specific cues obtained from the client that indicates the need for a
history related to the musculoskeletal system.
2. Describe the appropriate analysis of a symptom for a problem related to the
musculoskeletal system.
3. Identify and perform the physical examination for a problem related to the
musculoskeletal system.
4. Identify and discuss appropriate diagnostic testing for a problem related to the
musculoskeletal system.
5. Accurately describe findings from the history, physical examination, and
appropriate diagnostic testing of the musculoskeletal system that indicate deviation
from normal.
Physical exam book videos or Bates videotapes: Musculoskeletal system
Advanced assessment of the Neurological System
Upon completion of this unit the student will be able to:
1. Identify the specific cues obtained from the client that indicates the need for a
history related to the neurological system.
2. Describe the appropriate analysis of a symptom for a problem related to the
neurological system.
3. Identify and perform the physical examination for a problem related to the
neurological system.
4. Identify and discuss appropriate diagnostic testing for a problem related to the
neurological system.
5. Accurately describe findings from the history, physical examination, and
appropriate diagnostic testing of the neurological system that indicate deviation
from normal.
Physical exam book videos or Bates videotapes: Neurological system: Cranial nerves and
sensory system; Neurological system: Motor system and reflexes.
Assessing Men’s and Women’s Genitourinary Health
Upon completion of this unit the student will be able to:
1. Identify the specific cues obtained from the client that indicate the need for a history
related to the female or male genitourinary system, anus, rectum, or prostate.
2. Describe the appropriate analysis of a symptom for a problem related to the female or
male genitourinary system, anus, rectum, or prostate.
3. Identify and perform the physical examination for a problem related to the female or
male genitourinary system, anus, rectum, or prostate.
4. Identify and discuss appropriate diagnostic testing for a problem related to the female
or male genitourinary system, anus, rectum, or prostate.
5. Accurately describe findings from the history, physical examination, and appropriate
diagnostic testing related to the female or male genitourinary system, anus, rectum, or
prostate that indicate deviation from normal.
6. Synthesize findings from the history, physical examination, and appropriate diagnostic
testing to determine a differential diagnosis for selected problems related to the
female or male genitourinary system, anus, rectum, or prostate.
Physical exam book videos or Bates videotapes: Male genitalia, rectum, and hernias,
Female genitalia, anus, and rectum.
The Focused Physical Final Examination
Upon completion of this course the student will be able to:
1. Correctly identify the components of a focused physical exam based on presenting
history.
2. Perform a focused physical examination of the adult using correct technique and
sequence for all systems examined.
3. Determine a list of differential diagnoses consistent with presenting symptomology
and physical assessment findings.
4. Identify appropriate diagnostic testing based on history, PE findings and list of
differential diagnoses.
5. Accurately record a focused physical examination of the adult, including all key
information and using standard format.
Scoring Guides
for NURS 754
UNIVERSITY OF WISCONSIN-MILWAUKEE COLLEGE OF NURSING
COMPREHENSIVE HEALTH ASSESSMENT SCORING GUIDE:
EVALUATION OF BASIC PHYSICAL EXAM
Student name: _____________________________________
Evaluator: _________________________________________
S=satisfactory /U=unsatisfactory
General
Performance
1. Wash hands
S
U
2. Organize equipment & supplies
S
U
3. Maintain asepsis throughout exam
S
U
4. Maintain privacy and utilize appropriate draping
S
U
5. Maintain a safe environment
S
U
6. Uses an integrated exam sequence
S
U
7. Responses to clients verbal and behavioral cues
S
U
8. Prepares client for process
S
U
9. Provides feedback to client regarding findings & plans
S
U
10. Inspect skin, hair, nails
S
U
11. Palpate for temperature, edema
S
U
Communication Skills
Skin
Head
12. Inspect and palpate head (include scalp, hair)
S
U
13. Inspect and palpate sinus areas
S
U
14. Palpate temporomandibular joint
S
U
15. Test CN V (motor and sensory)
S
U
16. Test CN VII (motor)
S
U
17. Auscultate and palpate temporal arteries
S
U
18. Visual Acuity (Snellen, Rosenbaum, OS, OU, OD)
S
U
19. Assess alignment(corneal light reflex;cover/uncover test)
S
U
20. Assess for E.O.M.’s (CN III, IV, VI)
S
U
21. Test papillary responses (PERRLA) CN II, III
S
U
22. Inspect and palpate external structures
S
U
23. Perform ophthalmoscopic exam
S
U
24. Inspect and palpate external structures
S
U
25. Test gross hearing (watch or whisper test)
S
U
26. Perform otoscopic exam
S
U
27. Inspect and palpate external nose
S
U
28. Assess patency
S
U
29. Inspect internal structures
S
U
Eyes
Ears
Nose
Mouth
30. Inspect and palpate lips and oral cavity (gums, teeth,
Mucous membranes, sublingual area)
S
U
31. Inspect palates, tonsils
S
U
32. Test CN IX & X
S
U
33. Assess tongue (color, symmetry, strength (CN XII)
S
U
S
U
S
U
S
U
37. Inspect thorax (P,L,A)
S
U
38. Palpate thorax systematically (P,L,A)
S
U
39. Auscultate lungs (P,L,A)
S
U
40. Auscultate and palpate carotids (bruits)
S
U
41. Inspect precordium sitting and supine
S
U
42. Palpate precordium sitting or supine
S
U
Neck
34. Inspect and palpate trachea
35. Palpate lymph nodes (preauricular, postauricular,
occipital, posterior and deep cervical, supraclavicular)
36. Assess CN XI (shoulder strength)
Respiratory (posterior, lateral and anterior)
Cardiac
(5 areas and apical impulse)
43. Auscultate heart sounds
(5 areas with bell and diaphragm) supine and sitting
S
U
S
U
45. Inspect (2 positions of examiner)
S
U
46. Auscultate bowel sounds
S
U
S
U
48. Palpate inguinal nodes
S
U
49. Percussion systematically
S
U
50. Palpate systematically (light & deep)
S
U
51. Palpate liver
S
U
52. Assess CVA tenderness
S
U
S
U
S
U
55. Inspect and palpate spine
S
U
56. Assess spine (ROM, strength)
S
U
57. Assess hips and knees (inspect, palpate, ROM, strength)
S
U
44. Palpate pulses (brachial, radial, femoral, popliteal,
Posterior tibial & dorsalis pedis)
Abdomen
47. Auscultate arteries for
Bruits (aorta; renal, iliac & femoral bilaterally)
Musculoskeletal
53. Assess head and neck and shoulder
(inspect, palpate, ROM, strength)
54. Assess elbows, wrists and hands
(inspect, palpate, ROM, strength)
58. Assess ankles, feet and toes
S
U
59. Assess mental status
S
U
60. Assess sensory tactile sensation:
S
U
S
U
S
U
63. Assess gait
S
U
64. Heel to toe walking (Tandem walking)
S
U
65. Romberg
S
U
66. Assess deep tendon reflexes
S
U
(inspect, palpate, ROM, strength)
Neurological
(stereognosis, graphesthesia)
61. Assess coordination of upper extremities
(Finger to nose, RAM) (pick 1)
62. Assess coordination of lower extremities
(heel to shin, RAM) (pick 1)
(biceps, triceps, brachioradialis, patellar, Achilles)
Student score __________________
Student must successfully complete at least 83% of items (i.e. > 55/66 items) in 20 minutes
or less to pass.
UNIVERSITY OF WISCONSIN-MILWAUKEE COLLEGE OF NURSING
COMPREHENSIVE HEALTH ASSESSMENT SCORING GUIDE:
Documentation of SCREENING (Well) ADULT HISTORY
Student’s name
_____ Evaluator: ___________________
Directions:
1.
Assess and record each item on all patients unless exceptions are indicated. A
patient’s inability to cooperate or provide the necessary information should be
reflected in the recording.
2.
See Seidel course textbook and/or Wright cards for further information about
specific items.
Item Criteria
Recording
Identifying Information
The patient’s initials, sex, race/ethnicity, and date of birth.
Yes......No
Source and Reliability of Information
The historian’s identity and apparent reliability of the historian’s
information.
Yes......No
Reason for Visit
Brief description of the patient’s main reason(s) for seeking care, stated
verbatim in quotation marks.
Yes......No
Well Adult Visit
.
Usual health, date of last physical exam and reason for that exam,
health since last exam, and any health concerns.
Yes…..No
Past Medical History
Hospitalizations and/or surgery: dates, hospital, diagnosis,
complications; injuries and disabilities
Yes......No
Major childhood illnesses: measles, mumps, whooping cough,
chickenpox, smallpox, scarlet fever, rheumatic fever, diphtheria, polio
Yes......No
Adult illnesses: tuberculosis, hepatitis, diabetes mellitus, hypertension,
myocardial infarction, tropical or parasitic diseases, other infections
Yes......No
Immunizations: Date(s) of last DHHS-recommended immunization(s)
Yes......No
Screening tests: Date(s) of last DHHS-recommended screening test(s)
Yes......No
Medications: past, current, and recent medications (dosage, home
remedies, nonprescription and herbal medicines)
Yes......No
Allergies: drugs, foods, environmental allergies
Yes......No
Emotional status: mood disorders, psychiatric care or medications
Yes......No
Family Medical History
Genogram with at least 3 generations and brief summary.
Yes......No
Family history of hypertension, cancer, cardiac, respiratory, kidney,
strokes, or thyroid disorders; asthma or other allergic manifestations;
blood dyscrasias; psychiatric difficulties; tuberculosis; rheumatologic
diseases; diabetes mellitus; hepatitis; familial disorders; spontaneous
abortions and stillbirths
Personal/Social History
The information included in this section varies according to the concerns of the
patient and the influence of the health problem on the patient’s life.
Occupation: usual work and present work if different, list of job
Yes......No
changes, work conditions and hours, physical or mental strain, duration
of employment, present and past exposure to heat and cold, chemicals,
industrial toxins, asbestos, radioactive material, protective devices
required or used
Yes...No
Yes...No
Environment: home, school, work, structural barriers if handicapped,
travel and other exposure to contagious diseases, residence in tropics,
water and milk supply, other sources of infection when applicable
Yes…..No
Patterns of obtaining of health care, including resources for primary
care and emergency care.
Current health habits and/or risk factors: exercise; seat belt use;
sunscreen use/sun protection; smoking (packs per day/duration) or
other tobacco use; salt intake; obesity/weight control; 24-hour diet
recall; frequency of teeth brushing/flossing; last dental visit; alcohol
intake: beer, wine, hard liquor (amount/day), duration; CAGE score;
driving after drinking; blackouts, seizures, or DTs; drug or alcohol
treatment program or support group; recreational drugs used (e.g.,
marijuana, cocaine, heroin, LSD, PCP, etc.) and methods (injection,
sniffing, smoking, or use of shared needles); guns in home and how
stored
Yes......No
Sexual activity: Age at onset of puberty, sexarche; partners: men,
women, or both; number of current and past partners; is pregnancy
desired now?; contraceptive or barrier protection method used; past
sexually transmitted disease (syphilis, gonorrhea, chlamydia, PID,
herpes, warts, other); treatment.
Yes......No
Women: Gravidity and parity G#PTPAL (G=# of pregnancies, T=# of term
pregnancies, P=# of preterm pregnancies, A=# of
abortions/miscarriages, L=# of living children); number and duration of
each pregnancy, delivery method; complications during any pregnancy
or postpartum period
Yes...No
Amount and nature of stress in patient’s life and her/his methods of
coping, including whether s/he has sought outside help to deal with
problems (e.g., from mental health professionals, clergy).
Preface by saying: “Since violence is so common, I’ve begun to ask
about it routinely.” Then ask: “At any time, has anyone hit, kicked, or
otherwise hurt or frightened you?”
Yes......No
Review of Systems
General constitutional symptoms: fever, chills, malaise, easily fatigued,
night sweats, weight (average, preferred, present, change)
Yes......No
Diet: appetite, likes and dislikes, restrictions (because of religion,
allergy, or other disease), vitamins and other supplements, caffeinecontaining beverages (coffee, tea, cola); food diary or daily listing of
food intake as needed
Yes......No
Skin, hair, and nails: rash or eruption, itching, pigmentation or texture
change; excessive sweating, unusual nail or hair growth
Yes......No
Head and neck: frequent or unusual headaches, their location,
dizziness, syncope, severe head injuries; loss of consciousness
(momentary or prolonged)
Yes......No
Eyes: visual acuity, blurring, double vision, light sensitivity, pain, change
in appearance or vision; use of glasses/contacts, eye drops or other
medication used; history of trauma, glaucoma, or familial eye disease
Yes......No
Ears: hearing loss, pain, discharge, tinnitus, vertigo
Yes......No
Nose: sense of smell, frequency of colds, obstruction, nose bleeds,
postnasal discharge, sinus pain
Yes......No
Throat and mouth: hoarseness or change in voice; frequent sore
throats, bleeding or swelling of gums; recent tooth abscesses or
extraction; soreness of tongue or buccal mucosa, ulcers; disturbance of
taste
Yes......No
Endocrine: Thyroid enlargement or tenderness, heat or cold
intolerance, unexplained weight change, polydipsia, polyuria, changes
in facial or body hair, increased hat and glove size, skin striae
Yes......No
Yes...No…N/A
Males: erections, emissions, testicular pain, libido, infertility
Females: Last menstrual period, regularity, duration, and amount of
flow; dysmenorrhea; intermenstrual discharge or bleeding; itching;
date of last Pap smear; age at menopause; libido; frequency of
intercourse; sexual difficulties; infertility; use of oral or other
contraceptives.
Yes...No…N/A
Breasts: pain, tenderness, discharge, lumps, galactorrhea,
mammograms (screening or diagnostic), frequency of breast selfexamination
Yes......No
Chest and lungs: pain related to respiration, dyspnea, cyanosis,
wheezing, cough, sputum (color, character, quantity), hemoptysis, night
sweats, exposure to tuberculosis; last chest x-ray
Yes......No
Heart and blood vessels: chest pain or distress, precipitating causes,
timing and duration, relieving factors, palpitations, dyspnea, orthopnea
(number of pillows), edema, claudication, hypertension, previous
myocardial infarction, exercise tolerance, past cardiac tests
Yes......No
Hematologic: anemia, tendency to bruise or bleed easily, thromboses,
thrombophlebitis, any known blood cell disorder, transfusions
Yes......No
Lymphatic: enlargement, tenderness, suppuration
Yes......No
Yes......No
Gastrointestinal: appetite, digestion, intolerance of any foods,
dysphagia, heartburn, nausea, vomiting, hematemesis, bowel regularity,
constipation, diarrhea, change in stool color or contents (clay, tarry,
fresh blood, mucus, undigested food), flatulence, hemorrhoids,
hepatitis, jaundice, dark urine; history of ulcer, gallstones, polyps,
tumor; previous radiographic studies (where, when, findings)
Genitourinary: dysuria, flank or suprapubic pain, urgency, frequency,
nocturia, hematuria, polyuria, hesitancy, dribbling, loss in force of
stream, passage of stone; edema of face, stress incontinence, hernias,
sexually transmitted disease
Musculoskeletal: joint stiffness, pain, restriction of motion, swelling,
redness, heat, bony deformity
Neurologic: syncope, seizures, weakness or paralysis, problems with
sensation or coordination, tremors
Yes......No
Yes......No
Yes......No
Psychiatric: depression, mood changes, difficulty concentrating,
nervousness, tension, suicidal thoughts, irritability, sleep disturbances
Summary:
One-paragraph statement summarizing pertinent positive and negative
findings in this patient’s health history.
Yes......No
Yes......No
Score: _____ (# yes/
total # items
Total
Score______/30
University of Wisconsin-Milwaukee College of Nursing
NURS 754: Comprehensive Assessment of Health Implications for Clinical Decision Making
Scoring Guide: Case Study Documentation
Student Name___________________________________________________________
Item Criteria
1. “Elicited” an appropriate history using standard format. Requested
appropriate additional information based on patient presentation
1..2..3..4..5
Physical Examination and Diagnostic Testing
Indicate which components of the physical examination relevant to
the patient’s presenting problem would be performed:
2.
Appropriate exam chosen based on data provided
1..2..3..4..5
3.
Appropriate diagnostic testing recommended
1..2..3..4..5…N/A
Proposed ASSESSMENT
4.
Assessment and differential diagnoses appropriate given
information provided.
1..2..3..4..5
5.
1..2..3..4..5
Documentation thorough and concise. Appropriate SOAP format.
5=no errors
4=1-3 errors
3=4-6 errors
items
Raw score: _______/ #
2=7-9 errors
1=> 10 errors
Total Score: ___________/10
University of Wisconsin-Milwaukee College of Nursing
Comprehensive Assessment of Health Implications for Clinical Decision Making
Focused Health & Aggregate Assessment Write-up
Directions
Students, working in groups, will be required to research and write up a common
“focused” clinical problem based on the presenting symptoms of a case study patient. The
chief complaint you and your colleagues will be working on will reflect those used for your
practical final exam.
Each group will be given a chief complaint. Student groups should choose a diagnosis
consistent with the chief complaint and develop a presentation that explores the “typical”
presentation of a patient with that presenting symptom, including focused history, physical
exam and diagnostic testing (if appropriate) findings. Also include a prioritized list of
pertinent differential diagnoses.
Students may wish to include a chart or a paragraph or two that illustrates the major
differences in your chosen diagnosis vs. the diagnoses on your list of differentials.
To further explore the health problem, groups will be asked to provide a brief review of the
health problem, including incidence and prevalence and provide pertinent aggregate and
environmental data, including the “typical” population affected by this problem and other
epidemiological information. Please refer to the Scoring Guide: Focused Assessment
Write-up when completing this project.
You should use several resources for this project, including course texts, Uphold & Graham,
professional websites, journal articles, etc. Please upload bibliography, copy of your and
presentation (in Powerpoint) to D2L discussion area at least 24 hours before the
presentation day. Your presentation should be written up in Word or PowerPoint format
and uploaded to the discussion area on D2L by November 17. These reports can be used
to help students study for the final exam.
Please feel free to use D2L discussion board and email to discuss these cases. I will answer
any questions you may have via email or in class. Have fun!
University of Wisconsin-Milwaukee College of Nursing
NURS 754: Comprehensive Assessment of Health Implications for Clinical Decision Making
Scoring Guide: Focused Health & Aggregate Assessment Presentation
Student Names___________________________________________________________
Topic: __________________________________________________________________
Item Criteria
Individual assessment
1. Appropriate historical data included/recommended to elicit based on
chief complaint
Yes......No
Appropriate physical examination and diagnostic testing (if
appropriate) recommended based on chief complaint and historical
data
2.
Avoided selecting too many/few examination components.
Yes......No
3.
Appropriate diagnostic testing ordered or performed
4.
Prioritized differential diagnoses appropriate given data collected.
Yes...No…N/A
Yes......No
Aggregate assessment
5.
Clear and comprehensive description of the aggregate generally
affected by this health problem
6.
Presentation of data as it relates to the problem, the population.
Include incidence/prevalence
Yes......No
Yes......No
7.
Evaluated environmental issues potentially related to this health
problem
Yes......No
Professional Criteria
8.
Identification of implications, constraints and facilitating factors
for decision making for the APN/in the clinical setting
Yes......No
9.
Appropriateness of data sources
Yes......No
10.
Professional presentation
Yes......No
Comments:
Score:
/20
University of Wisconsin-Milwaukee College of Nursing
NURS 754: Comprehensive Assessment of Health Implications for Clinical Decision Making
Scoring Guide: Focused Assessment Final Examination
Student Name:____________________________________________________
Evaluator:____________________
Item Criteria
1. Elicited appropriate history. Requested appropriate additional
information based on patient presentation
2. Selected appropriate physical examination based on CC & Hx
/3
/3
/3
3. Accurately performed physical examination components.
/3
4. Appropriate diagnostic testing selected based on H&P findings
/2
5. Selected correct diagnosis:
6. Prioritized list of differential diagnoses is appropriate given
information provided.
/1
Professional Criteria
7. Encounter conducted in an efficient yet caring manner, including
nurse’s ability to relate to patient’s age, developmental stage,
educational level, mental status, and demeanor.
8. Assessment completed within 20 minutes
Comments:
/20
/3
/2