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UNIVERSITY OF WISCONSIN-MILWAUKEECOLLEGE OF NURSING

Graduate Course Syllabus

Spring 2013

Title: NURS 754: COMPREHENSIVE ASSESSMENT OF HEALTH:

IMPLICATIONS FOR CLINICAL DECISION MAKING

Credits: 3 units; GComprehensive 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 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 801..

Faculty: James Bockeloh, DNP, RN, FNP-BC, APNP e-mail: [email protected] Office: Cunningham 522 UWM Ph#414 229-5556 Cell Ph# 262-880-6415Office Hours: By Appointment

Lab Instructor : Susan A. Fontana, PhD, APRN, FNP-BCAssociate Professor and Family Nurse Practitioner-Board CertifiedUniversity of Wisconsin-MilwaukeePO Box 413Milwaukee, WI 53201

Program Director : Kim Litwack PhD RN APNP FAANEmail address: [email protected] 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

mailto:[email protected]

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, 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

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 20-minute 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


Week 6, Feb 26:

Lab: Musculoskeletal Assessment

Lecture: Neurological Clinic; Focused assessment presentation topics will be assigned in class


Week 7, March 5:

Lab: Neurological Clinic

Lecture: GI Assessment


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 Focused-Assessment 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



Week 14, April 30:

Lab: Focused-Assessment Check Offs



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 (UW- Parkside, 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

http://www4.uwm.edu/current_students/student_services/safety.cfm

http://www.uwp.edu/

http://www4.uwm.edu/

http://www.uwm.edu/Dept/SecU/SyllabusLinks.pdf

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


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 theskin, 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)


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


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


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


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 themusculoskeletal 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


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


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

Communication Skills

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

Skin

10. Inspect skin, hair, nails S U

11. Palpate for temperature, edema S U

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

Eyes

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

Ears

24. Inspect and palpate external structures S U

25. Test gross hearing (watch or whisper test) S U

26. Perform otoscopic exam S U

Nose

27. Inspect and palpate external nose S U

28. Assess patency S U

29. Inspect internal structures S U

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

Neck

34. Inspect and palpate trachea S U

35. Palpate lymph nodes (preauricular, postauricular,

occipital, posterior and deep cervical, supraclavicular) S U

36. Assess CN XI (shoulder strength) S U

Respiratory (posterior, lateral and anterior)

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

Cardiac

40. Auscultate and palpate carotids (bruits) S U

41. Inspect precordium sitting and supine S U

42. Palpate precordium sitting or supine S U

(5 areas and apical impulse)

43. Auscultate heart sounds

(5 areas with bell and diaphragm) supine and sitting S U

44. Palpate pulses (brachial, radial, femoral, popliteal,

Posterior tibial & dorsalis pedis) S U

Abdomen

45. Inspect (2 positions of examiner) S U

46. Auscultate bowel sounds S U

47. Auscultate arteries for

Bruits (aorta; renal, iliac & femoral bilaterally) 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

Musculoskeletal

53. Assess head and neck and shoulder S U

(inspect, palpate, ROM, strength)

54. Assess elbows, wrists and hands 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

58. Assess ankles, feet and toes S U


Neurological

59. Assess mental status S U

60. Assess sensory tactile sensation: S U

(stereognosis, graphesthesia)

61. Assess coordination of upper extremities S U

(Finger to nose, RAM) (pick 1)

62. Assess coordination of lower extremities S U

(heel to shin, RAM) (pick 1)

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

(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

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 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

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.

Yes…..No

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.

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).

Yes...No

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, 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.

Yes...No…N/A

Breasts: pain, tenderness, discharge, lumps, galactorrhea, mammograms (screening or diagnostic), frequency of breast self-examination

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

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)

Yes......No

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

Yes......No

Musculoskeletal: joint stiffness, pain, restriction of motion, swelling, redness, heat, bony deformity

Yes......No

Neurologic: syncope, seizures, weakness or paralysis, problems with sensation or coordination, tremors

Yes......No

Psychiatric: depression, mood changes, difficulty concentrating, nervousness, tension, suicidal thoughts, irritability, sleep disturbances

Yes......No

Summary:One-paragraph statement summarizing pertinent positive and negative findings in this patient’s health history.

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. Documentation thorough and concise. Appropriate SOAP format. 1..2..3..4..5

5=no errors

4=1-3 errors

3=4-6 errors Raw score: _______/ # items

2=7-9 errors

1=> 10 errorsTotal Score: ___________/10


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!



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 Yes...No…N/A

4. Prioritized differential diagnoses appropriate given data collected.Yes......No

Aggregate assessment

5. Clear and comprehensive description of the aggregate generally affected by this health problem

Yes......No

6. Presentation of data as it relates to the problem, the population. Include incidence/prevalence

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



Scoring Guide: Focused Assessment Final Examination

Student Name:____________________________________________________ Evaluator:____________________

Item Criteria1. Elicited appropriate history. Requested appropriate additional information based on patient presentation

/3

2. Selected appropriate physical examination based on CC & Hx /3

3. Accurately performed physical examination components./3

4. Appropriate diagnostic testing selected based on H&P findings/3

5. Selected correct diagnosis:/2

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. /3

8. Assessment completed within 20 minutes /2

Comments: /20

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