NURS 680B Week 5 Comprehensive Health Assessment

NURS 680B Week 5 Comprehensive Health Assessment

 

Students will select a new “patient” (friend or family member) for whom they will perform and document a complete history. This will include a complete head-to-toe review of systems (ROS) and a complete head-to-toe physical examination. This will be documented in a SOAP note format.

The patient should be an adult over the age of 18 with a chief complaint. Please do not choose the same friend or family member from previous course assignments.

Document a working diagnosis and a minimum of 3 differential diagnoses. These are based on the chief complaint (CC) an history of present illness (HPI). All 3 diagnoses Working diagnosis and differential diagnoses must include pertinent positive and negative symptoms. You may also include known diagnoses, such as obesity or hypertension. These do not need pertinent findings.

NOTE: Do not use real names or initials or otherwise identify your “patient.” Failure to maintain privacy will result in a failing score

Assignment Details

The Subjective health history and Objective physical exam must contain all required elements as outlined in Jarvis Chapter 27 (except breast and genital exams) and the attached document. The Assessment, as well as the Plan, will be focused based on CC and HPI.

Read the rubric for the Comprehensive Health Assessment assignment carefully.

The assignment submission should be a single document that contains:

A complete subjective history

A complete objective examination

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Working diagnosis with at least 3 differential diagnoses with pertinent findings for each

Plan of care that includes a discussion of the national guidelines for your diagnosis and health maintenance needs for your patient

A comprehensive health assessment gives nurses insight into a patient’s physical status through observation, the measurement of vital signs and self-reported symptoms. It includes a medical history, a general survey and a complete physical examination.

The general survey consists of a patient’s age, weight, height, build, posture, gait and hygiene. Nurses use health assessments to obtain baseline data about patients and to build a rapport with them that can ease anxiety and lead to a trusting relationship.

A comprehensive health assessment is generally conducted at the time of admission into an acute care facility or during the first visit to an outpatient clinic. When nurses perform an assessment, they may use techniques such as:

Inspection

This is the most frequently used method for assessment. Nurses look for indications of a health problem by using their eyes, ears and nose. They may inspect skin color, lesions, bruises or rashes as well as pay attention to abnormal sounds and odors.

Auscultation

Nurses listen to the sounds of the abdomen by placing the diaphragm or bell of a stethoscope on the bare skin of a patient.

Palpation

Nurses apply varying degrees of pressure on the patient with different parts of their hands. Palpation allows nurses to assess for texture, tenderness, temperature, moisture, pulsations and the presence of masses.

Percussion

Nurses firmly press on sections of a patient’s body with the distal part the middle finger on their non-dominant hand. The technique is used directly over suspected areas of tenderness to check a patient’s level of discomfort.