College of Nursing
UNIVERSITY OF WISCONSIN-MILWAUKEE
COLLEGE OF NURSING
Graduate Course Syllabus
Fall 2014
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 is a graduate
level 3-credit course. The lecture portion of the course is 2 credits, and the co-requisite 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 802 or 803.
Faculty:
Dr. 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 Instructors:
Diane Schadewald, DNP, MSN, RN, FNP-BC, WHNP-BC
Email: schadewa@uwm.edu
UWM Ph# (414) 229-6860
Office Cunningham Hall 691
Carol G. Klingbeil, MS, RN, CPNP-PC
Clinical Instructor
University of Wisconsin - Milwaukee
College of Nursing, Room 522
1921 E. Hartford Ave.
Milwaukee, WI 53201
klingbei@uwm.edu
Mobile: 262-385-0187
Fax: 414-229-6474
College of Nursing
Program Director :
Dr. Julie Darmody, Ph.D., RN, ACNS-BS
Email: darmodyj@uwm.edu
Office: (414) 229-5558
Cunningham Hall 691
Class meetings times and location:
Lecture: Meets 1:00 – 2:50 PM Wed 09/03/14 – 12/10/14, CUN G40
LAB: 801: Meets 3:00 – 4:50 PM Wed 09/03/14 – 12/10/14, CUN NLRC
802: Meets 3:00 – 4:50 PM Wed 09/03/14 – 12/10/14, CUN NLRC
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.
College of Nursing
* Shadow Healthcare Digital Clinical Experience Program Information.
Digital Clinical Experience [Computer software]. Gainesville, FL: Shadow Health.
Student Account Setup
Students can create their accounts by visiting http://app.shadowhealth.com/and enroll with this
course-specific PIN: August2014-5924-2233-9321-5746
* For registration and purchase, follow the guide at
https://shadow.desk.com/customer/portal/articles/980991-how-to-register-with-shadow-health. You
will need to copy and paste the unique PIN above to register in your fall course.
* Shadow Health recommends using headphones to access the concept labs in which you will
practice identifying normal and abnormal sounds.
* Technical Requirements - http://bit.ly/Shadow_Requirements
* After registering, access Shadow Health assignment at app.shadowhealth.com
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 3 rd floor
NLRC. (We will discuss some of the available on-line resources in class).
Assignments and Evaluation:
1. Evaluation/Grading
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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 (20 points)
Focused health & aggregate assessment presentation (15 points)
Graded case studies & documentation (2 @ 10 points each=20 points)
Observed performance of a focused physical examination (20 points)
Shadow Health On Line Assessment Exercises (25 points)
Total Course Grade = 100 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, single-spaced, 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 Presentation
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. The laboratory
will include the following activities:
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
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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. Bockeloh to determine if they should continue in
the advanced assessment course.
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 two 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+).
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.
Practical final assessment. Near the end of the semester, students will schedule a 20-minute time
slot with their lab instructor for their lab final physical exam. 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. This exam utilizes professional patient
models, with whom the student will interact and examine. 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.
Shadow Health Care On Line Digital Clinical Experience (DCE). The Shadow Health™ Digital
Clinical Experience™ (DCE) provides a dynamic, immersive experience designed to improve your
skills and clinical reasoning through the examination of digital standardized patients. Although these
patients are digital, each one breathes, speaks, and has a complex medical and psychosocial
history. We will be completing Shadow Health assignments throughout the course.
You can explore concept labs for the Respiratory, Cardiovascular, and Abdominal systems. We will
be using these concept labs you students to review the anatomy of each system and practice
identifying normal and abnormal sounds. You will complete these assignments after reviewing
course content, reading the course textbook, and attending lecture.
With Tina Jones, you can practice taking a detailed health history and performing physical
assessments in system-by-system assignments. All of these assignments take place during a single
visit for Tina that begins at 8 a.m. We will be using these assignments to practice relevant skills and
apply content knowledge prior to our hands-on practice sessions or lab. You will complete these
assignments after reviewing course content, reading the course textbook, attending lecture, and
completing the concept lab if applicable.
College of Nursing
The focused exams allow you to respond to patients’ chief complaints. You will perform focused
exams in which you will demonstrate a mastery of skills relevant to multiple body systems and
professional communication. The Shadow Health DCE is worth 15 points of the final course grade.
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, Sep 3:
Lecture: Overview of class, Assessment of Individuals, Aggregates & Communities; Data
Resources
Lab: Intro to lab, Basic PE review/practice.
Pre-Class Prep: Read assessment text & Goolsby chapters re: assessment/clinical decision
making and documentation.
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Week 2, Sep 10:
Lecture: Clinical Decision-Making, Diagnostics and Documentation; Focused assessment
presentation topics will be assigned in class
Lab: Basic PE Check Offs
Pre-Class Prep: Review relevant text chapters.
Week 3, Sep 17:
Lecture: Dermatologic, HEENT
Lab: Interview, History & Documentation practice, basic PE check-offs
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, Sep 24:
Lecture: Chest (Breast, Respiratory & Cardiovascular) Clinic; Turn in Adult Screening
History write-up (Drop Box)
Lab: Dermatologic, HEENT, Basic PE Checkoff
Pre-Class Prep: Review relevant text chapters. Case Study #1 Due.
Week 5, Oct 1:
Lecture: Musculoskeletal Assessment
Lab: Chest (Breast, Respiratory & Cardiovascular) Clinic
Pre-Class Prep: Review relevant text chapters.
Week 6, Oct 8:
Lab: Musculoskeletal Assessment
Lecture: Neurological Clinic; Focused Assessment Presentations
Pre-Class Prep: Review relevant text chapters.
Week 7, Oct 15:
Lab: Neurological Clinic
Lecture: GI Assessment
Pre-Class Prep: Review relevant text chapters.
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Week 8, Oct 22:
Lab: GI Assessment
Lecture: GU/GYN, Reproductive Clinic
Pre-Class Prep: Review relevant text chapters. Case Study #2 Due.
Week 9, Oct 29:
Lab: GU/GYN, Reproductive Clinic
Lecture: Abdominal, GU/GYN, Reproductive Assessment & Documentation
Pre-Class Prep: Review relevant text chapters
Week 10, Nov 5:
Lab: GU/GYN Assessment, Professional Models
Lecture: Mental Health Clinic
Pre-Class Prep: Review relevant text chapters, GU/GYN exam videos
Week 11, Nov 12:
Lab: GU/GYN Assessment, Professional Models
Due: Group Focused-Assessment Presentation and Reference materials
posted on D2L Discussion area.
Lecture: Spiritual Health Assessment; Focused Assessment Presentations
Pre-Class Prep: Review relevant text chapters
Week 12, Nov 19:
Lab: Focused Assessment Practice
Lecture: Focused-Assessment Presentations
Pre-Class Prep: Review relevant text chapters
THANKSGIVING BREAK NOV 26-30, NO CLASSES
Week 13, Dec 3:
Lab: Focused-Assessment Check Offs
Lecture: Focused-Assessment Presentations
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Pre-Class Prep: Review relevant text chapters
Week 14, Dec 10:
Lab: Focused-Assessment Check Offs, PE Kit Turn In
Lecture: Course Evaluations, Semester Wrap-Up
Pre-Class Prep: Material as needed
Shadow Healthcare DCE Assignment Time Estimates (Can be completed at any time during
the semester).
Assignment
Approximate Time
Digital Clinical Experience™ (DCE) Orientation
10 - 15 minutes
Health History (Tina Jones)
75 minutes - 115 minutes
HEENT (Tina Jones)
90 minutes - 145 minutes
Respiratory Concept Lab
25 minutes
Respiratory (Tina Jones)
50 minutes - 125 minutes
Cardiovascular Concept Lab
Cardiovascular (Tina Jones)
25 minutes
45 minutes - 125 minutes
Abdominal Concept Lab
Abdominal (Tina Jones)
25 minutes
35 minutes - 120 minutes
Musculoskeletal (Tina Jones)
Neurological (Tina Jones)
Psychological (Tina Jones)
Clinical Decision Making (Tina Jones)
50 minutes - 105 minutes
50 minutes - 105 minutes
30 minutes - 100 minutes
60 minutes
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
College of Nursing
University Policies:
http://www.uwm.edu/Dept/SecU/SyllabusLinks.pdf
There are a few 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. Audio Recordings: Should you wish to audio record a lecture, it is a professional courtesy to
request permission from the lecturer.
5. Course Time: This course consists of one 2 hour lecture and one 2 hour lab session per
week. To prepare for this class time, the student should plan for at least 3-4 hours per class
hour, for a total of approximately 16-18 hours per week.
College of Nursing
Lab Guide for
NURS 754
College of Nursing
Advanced History Taking
Upon completion of this unit the student will be able to:
Understand the components of a comprehensive health history and physical examination.
Discuss culturally competent approaches to taking a health history and performing a physical
examination.
Identify how to assess a patient problem by proper application of symptom analysis and review of
systems.
Define the components used in recording a comprehensive health history and physical examination.
Advanced Assessment of the Skin, Hair, and Nails
Advanced Assessment of the Head, Eyes, Ears Nose and Throat (HEENT)
Advanced Assessment of the Chest
Advanced Gastrointestinal Assessment
Advanced Assessment of the Musculoskeletal System
Advanced assessment of the Neurological System
Assessing Men’s and Women’s Genitourinary Health
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.
College of Nursing
Scoring Guides
for NURS 754
College of Nursing
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
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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
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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)
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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)
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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.
College of Nursing
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.
Past Medical History
Yes…..No
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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
Yes......No
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 changes, work
conditions and hours, physical or mental strain, duration of employment,
Yes...No
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present and past exposure to heat and cold, chemicals, industrial toxins,
asbestos, radioactive material, protective devices required or used
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?”
Review of Systems
General constitutional symptoms: fever, chills, malaise, easily fatigued, night
sweats, weight (average, preferred, present, change)
Yes......No
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Yes......No
Diet: appetite, likes and dislikes, restrictions (because of religion, allergy, or
other disease), vitamins and other supplements, caffeine-containing 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.
Breasts: pain, tenderness, discharge, lumps, galactorrhea, mammograms
(screening or diagnostic), frequency of breast self-examination
Yes...No…N/A
Yes......No
College of Nursing
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
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
Yes......No
Yes......No
Yes......No
Score: _____ (# yes/
total # items
Total
Score______/20
College of Nursing
College of Nursing
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
College of Nursing
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 at least two weeks prior to the scheduled presentation date.
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!
College of Nursing
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
College of Nursing
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
College of Nursing
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
/3
2. Selected appropriate physical examination based on CC & Hx
/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
College of Nursing