NR304 Health Assessment II

NR304 Health Assessment II

Learning Plan

Purpose

This learning plan expands upon the key concepts identified for the course and guide faculty teaching the prelicensure BSN curriculum in all locations. Readings and assignments contained within the newly aligned course shells support learners mastery of this content and the course outcomes.

Note: The lessons are the same in both campus and online course shells.

NCLEX TEST PLAN
Integrated Processes: Nursing Process, Caring, Communication & Documentation, Teaching/Learning, and Culture & Spirituality
1 / Safe and Effective Care Environment - (Management of Care, Safety and Infection Control)
2 / Health Promotion and Maintenance
3 / Psychosocial Integrity
4 / Physiological Integrity - (Basic Care and Comfort, Pharmacological & Parenteral Therapies, Reduction of Risk Potential, Physiological Adaptation)

Content Outline

Unit 1 / Peripheral Vascular System (Associated Lymphatic System) and Abdominal Assessment Part I / Application of Chamberlain Care
Upon completion of this unit, the student will be able to:
1.  Relate the impact of physical and psychosocial risk factors on peripheral vascular system assessment findings. (CO 3/ NCLEX-2, 3, 4-Reduction of Risk Potential, Physiological Adaptation)
2.  Describe the impact of developmental changes on peripheral vascular assessment findings across the lifespan. (COs 1 and 3/NCLEX-1, 2, 3, 4-Basic care and Comfort, Reduction of Risk Potential, Physiological Adaptation)
3.  Identify educational opportunities based on peripheral vascular system assessment findings to be incorporated into patient-centered care. (COs 4 and 6/NCLEX-1,2,3,4-Basic Care and Comfort, Reduction of Risk Potential, Physiological Adaptation)
4.  Perform the basic physical assessment techniques for the peripheral vascular system. (Cos 1 and 5/NCLEX-1,2)
5.  Differentiate between normal and abnormal peripheral vascular system assessment findings. (COs 1, 2, and 5/NCLEX-2)
6.  Relate the impact of physical and psychosocial risk factors on abdominal assessment findings. (CO 3/NCLEX-2, 3, 4-Reduction of Risk Potential, Physiological Adaptation)
7.  Describe the impact of developmental changes on abdominal assessment findings across the lifespan. (COs 1 and 3/NCLEX-1, 2, 3, 4-Basic care and Comfort, Reduction of Risk Potential, Physiological Adaptation)
8.  Identify educational opportunities based on abdominal assessment findings to be incorporated into patient-centered care. (COs 4 and 6/ NCLEX-1,2,3,4-Basic Care and Comfort, Reduction of Risk Potential, Physiological Adaptation) / PVS and Associated Lymphatic System:
NCLEX Nursing Assessment – Physiological data, psychosocial, sociocultural, spiritual, economic, and life style factors
A.  Structure and Function
a.  PVS
b.  Lymphatics
c.  Related organs
i.  Spleen, Tonsils, Thymus, Immune related organs
B.  Peripheral pulses
a.  Assessment
i.  Inspection
ii.  Palpation
iii.  Auscultation
b.  Normal and Abnormal findings
i.  Arterial Insufficiency
·  PAD
o  Ankle-Brachial Index
ii.  Venous Insufficiency
·  DVT
c.  Special tests
i.  Trendelenburg Test
ii.  Allen’s Test
C.  Influences
d.  Health History Data
e.  Risk Factors
i.  Psychosocial
ii.  Genetics
iii.  Culture
f.  Environmental
D.  Analysis of Findings
g.  Health History
h.  Physical Assessment
i.  Health Conditions Common to Abnormal Findings
E.  Lifespan differences
F.  Documentation
j.  Terminology
k.  Educational Opportunities
NCLEX Integrated Process of Nursing Process, Caring, Communication and Documentation, Teaching/Learning, and Culture and Spirituality
Abdominal Assessment Part I:
NCLEX Nursing Assessment – Physiological data, psychosocial, sociocultural, spiritual, economic, and life style factors
A.  Life span considerations
B.  Cultural considerations
C.  Special tests
a.  Psoas Test
b.  Murphy’s Test
c.  Blumberg’s Test
d.  McBurney’s point
D.  Analysis of findings
a.  Health history
b.  Physical assessment
c.  Associated health conditions
E.  Documentation
a.  Terminology
b.  Educational Opportunities
NCLEX Integrated Process of Nursing Process, Caring, Communication and Documentation, Teaching/Learning, and Culture and Spirituality / Chamberlain Care provides a framework for student learning by addressing:
Professional Identity Formation:
Ensures privacy and safeguards confidentiality when learning about the role of the nurse in physical assessment.
Person-Centered:
Performs physical assessment techniques of the peripheral vascular system (associated lymphatic system) with a focus on the individualized needs of the patient.
Person-Centered:
Performs physical assessment techniques of the abdomen with a focus on the individualized needs of the patient.
Care Focused:
Commits to being an engaged learner and following the Chamberlain Care Student Success Model.
NANDA-Nursing Diagnosis:
NANDA Domain 1: Health Promotion
Class 2-Health management
·  Ineffective health management
·  Readiness for enhanced health management
NANDA Domain 2: Nutrition
Class 1-Ingestion
·  Readiness for enhanced nutrition
·  Obesity
·  Risk for Overweight
Class 5-Hydration
·  Risk for deficient fluid volume
Class 4-Metabolism
NANDA Domain 12: Comfort
Class 1-Physical Comfort
·  Acute pain
·  Impaired comfort
Nursing Diagnosis R/T PAD:
·  Activity Intolerance related to poor blood flow to lower extremities
·  Ineffective Health Maintenance related to smoking and lack of information about disease management
·  Risk for Impaired Skin Integrity related to ischemic tissues of legs and feet
·  Risk for Peripheral Neurovascular Dysfunction related to impaired peripheral blood flow to lower extremities
Nursing Diagnosis R/T Appendicitis
·  Acute pain
·  Risk for deficient fluid volume
·  Risk for infection
·  Deficient knowledge
Nursing Diagnosis R/T Choleslithiasis
·  Risk for deficient fluid volume
·  Acute pain
·  Risk for imbalanced nutrition: Less than body requirements
·  Deficient knowledge
Nursing Diagnosis R/T Peritonitis
·  Risk for infection
·  Deficient fluid volume
·  Acute pain
·  Risk for imbalanced nutrition: Less than body requirements
·  Anxiety/fear
·  Deficient knowledge
Unit 2 / Abdominal Assessment Part II / Application of Chamberlain Care
Upon completion of this unit, the student will be able to:
1.  Perform the basic physical assessment techniques for the abdomen. (COs 1 and 5/NCLEX-1,2)
2.  Differentiate between normal and abnormal abdominal assessment findings. (COs 1, 2, and 5/NCLEX-2) / Abdominal Assessment- Part II:
NCLEX Nursing Assessment – Physiological data, psychosocial, sociocultural, spiritual, economic, and life style factors
A.  Inspection
a.  Landmarks
b.  Distention
B.  Auscultation
a.  Bowel sounds
b.  Bruits
C.  Palpation
a.  Light palpation
b.  Deep palpation
D.  Percussion
a.  Liver tenderness
b.  Splenic tenderness
E.  Normal vs. Abnormal Findings
F.  Documentation
a.  Terminology
b.  Educational Opportunities
NCLEX Integrated Process of Nursing Process, Caring, Communication and Documentation, Teaching/Learning, and Culture and Spirituality / Chamberlain Care provides a framework for student learning by addressing:
Professional Identity Formation:
Ensures privacy and safeguards confidentiality when learning about the role of the nurse in physical assessment.
Person-Centered:
Performs physical assessment techniques of the abdominal system with a focus on the individualized needs of the patient.
Care Focused:
Commits to being an engaged learner and following the Chamberlain Care Student Success Model.
NANDA-Nursing Diagnosis:
NANDA Domain 1: Health Promotion
Class 2-Health management
·  Ineffective health management
·  Readiness for enhanced health management
NANDA Domain 2: Nutrition
Class 1-Ingestion
·  Readiness for enhanced nutrition
·  Obesity
·  Risk for Overweight
Class 4-Metabolism
NANDA Domain 12: Comfort
Class 1-Physical Comfort
·  Acute pain
·  Impaired comfort
Nursing Diagnosis R/T Abdominal Aortic Aneurysm
·  Risk for fluid volume deficit r/t hemorrhage
·  Acute pain
·  Decreased cardiac output r/t changes in intravascular volume, increased systemic vascular resistance, third-space fluid shift
·  Ineffective breathing pattern
Unit 3 / Neurological System / Application of Chamberlain Care
Upon completion of this unit, the student will be able to:
1.  Relate the impact of physical and psychosocial risk factors on neurological system assessment findings. (CO 3/ NCLEX-2, 3, 4-Reduction of Risk Potential, Physiological Adaptation)
2.  Describe the impact of developmental changes on neurological system assessment findings across the lifespan. (COs 1 and 3/ NCLEX-1, 2, 3, 4-Basic care and Comfort, Reduction of Risk Potential, Physiological Adaptation)
3.  Identify educational opportunities based on neurological assessment findings to be incorporated into patient-centered care. (COs 4 and 6/NCLEX-1,2,3,4-Basic Care and Comfort, Reduction of Risk Potential, Physiological Adaptation)
4.  Perform the basic physical assessment techniques for the neurological system. (COs 1 and 5/NCLEX-1,2)
5.  Differentiate between normal and abnormal neurological assessment findings. (COs 1, 2, and 5/NCLEX-2) / Neurological System:
NCLEX Nursing Assessment – Physiological data, psychosocial, sociocultural, spiritual, economic, and life style factors
A.  Introduction
B.  Risk Factors
a.  Psychosocial
b.  Genetics
c.  Culture
C.  Developmental Considerations
D.  Assessment
a. Cranial Nerves
i.  Sensory
ii.  Motor
b. Reflexes
c. Mental Status
d. Mood/Emotions
e. Level of Consciousness
i.  Glasgow Coma Scale
f.  Balance and Gait
E.  Analysis of Findings
a. Normal vs. Abnormal Findings
F.  Educational Opportunities
a. Decrease risk of neurological diseases
i.  Stroke
ii.  Screenings
iii.  Pregnancy
iv.  Seizures
v.  Safety
vi.  vaccinations
G.  Documentation
a. Terminology
b. Educational Opportunities
NCLEX Integrated Process of Nursing Process, Caring, Communication and Documentation, Teaching/Learning, and Culture and Spirituality / Chamberlain Care provides a framework for student learning by addressing:
Professional Identity Formation:
Ensures privacy and safeguards confidentiality when learning about the role of the nurse in physical assessment.
Person-Centered:
Performs physical assessment techniques of the nervous system with a focus on the individualized needs of the patient.
Care Focused:
Commits to being an engaged learner and following the Chamberlain Care Student Success Model.
NANDA-Nursing Diagnosis:
NANDA Domain 1: Health Promotion
Class 2-Health management
·  Ineffective health management
·  Readiness for enhanced health management
Nursing Diagnosis R/T Stroke
·  Ineffective Cerebral Tissue Perfusion
·  Impaired Physical Mobility
·  Impaired verbal Communication
·  Disturbed Sensory Perception
·  Ineffective Coping
Nursing Diagnosis R/T Epilepsy
·  Ineffective breathing pattern related to neuromuscular impairment secondary to prolonged tonic phase of seizure or during postictal period as evidenced by abnormal respiratory rate, rhythm, and or depth
·  Ineffective Tissue Perfusion (cerebral) related to seizure activity.
·  Risk for Injury related to seizure activity
·  Ineffective Coping related to psychosocial and economic consequences of epilepsy
Unit 4 / Musculoskeletal System / Application of Chamberlain Care
Upon completion of this unit, the student will be able to:
1. Relate the impact of physical and psychosocial risk factors on musculoskeletal system assessment findings. (CO 3/ NCLEX-2, 3, 4-Reduction of Risk Potential, Physiological Adaptation)
2. Describe the impact of
developmental changes on
Musculoskeletal system assessment findings across the lifespan. (COs 1 and 3/NCLEX-1, 2, 3, 4-Basic care and Comfort, Reduction of Risk Potential, Physiological Adaptation)
3. Identify educational
opportunities based on musculoskeletal assessment findings to be incorporated into patient-centered care. (COs 4 and 6/NCLEX-1,2,3,4-Basic Care and Comfort, Reduction of Risk Potential, Physiological Adaptation)
4. Perform the basic physical
assessment techniques for the musculoskeletal system. (COs 1 and 5/NCLEX-1,2)
5. Differentiate between normal
and abnormal musculoskeletal
assessment findings. (COs 1, 2,
and 5/NCLEX-2) / Musculoskeletal System:
NCLEX Nursing Assessment – Physiological data, psychosocial, sociocultural, spiritual, economic, and life style factors
A.  Introduction
B.  Risk Factors
a.  Psychosocial
b.  Genetics
c.  Culture
C.  Developmental Considerations
D.  Assessment
a.  Inspect and Palpation
b.  Range of Motion and Strength
c.  Inflammation and Edema
d.  Deformity
e.  Posture
E.  Analysis of Findings
a. Health History
i.  Usual Activity Level
ii.  Limitations
b.  Physical Assessment
c.  Associated Health Conditions
d.  Safety Considerations
F. Educational Opportunities
G. Documentation
a.  Terminology
b.  Educational Opportunities
NCLEX Integrated Process of Nursing Process, Caring, Communication and Documentation, Teaching/Learning, and Culture and Spirituality / Chamberlain Care provides a framework for student learning by addressing:
Professional Identity Formation:
Ensures privacy and safeguards confidentiality when learning about the role of the nurse in physical assessment.
Person-Centered:
Performs physical assessment techniques of the musculoskeletal system with a focus on the individualized needs of the patient.
Care Focused:
Commits to being an engaged learner and following the Chamberlain Care Student Success Model.
NANDA-Nursing Diagnosis:
NANDA Domain 1: Health Promotion
Class 2-Health management
·  Ineffective health management
·  Readiness for enhanced health management
NANDA Domain 4: Activity/rest
Class 1-Sleep/rest
·  Disturbed sleep pattern
Class 2-Activity/rest
·  Impaired physical mobility
Class 3-Energy balance
·  Fatigue
NANDA Domain 6: Self-Perception
Class 2-Self-esteem
·  Chronic low self-esteem
NANDA Domain 9: Coping/stress tolerance
Class 2-Coping responses
·  Impaired adaptation
Musculoskeletal Disorders (MSD) describe a variety of conditions that affect the muscles, bones, and joints.
Example-Nursing Diagnosis R/T Fibromyalgia
·  Chronic Pain
·  Impaired sleep pattern
·  Fatigue
·  Anxiety
·  Impaired adaptation
·  Chronic low self esteem
Unit 5 / Reproductive System / Application of Chamberlain Care
Upon completion of this unit, the student will be able to:
1.  Relate the impact of physical and psychosocial risk factors on reproductive system assessment findings. (CO 3/ NCLEX-2, 3, 4-Reduction of Risk Potential, Physiological Adaptation)
2.  Describe the impact of developmental changes on system reproductive assessment findings across the lifespan. (COs 1 and 3/NCLEX-1, 2, 3, 4-Basic care and Comfort, Reduction of Risk Potential, Physiological Adaptation)
3.  Identify educational opportunities based on reproductive assessment findings to be incorporated into patient-centered care. (COs 4 and 6/NCLEX-1,2,3,4-Basic Care and Comfort, Reduction of Risk Potential, Physiological Adaptation)
4.  Perform the basic physical assessment techniques for the reproductive system. (COs 1 and 5/NCLEX-1,2)
5. Differentiate between normal and abnormal reproductive, breasts and regional lymphatic assessment findings. (COs 1, 2, and 5/NCLEX-2) / Reproductive System Including the Breasts and Lymphatics:
NCLEX Nursing Assessment – Physiological data, psychosocial, sociocultural, spiritual, economic, and life style factors
A.  Introduction
B.  Risk Factors
a.  Psychosocial
b.  Genetics
c.  Culture
C.  Developmental Considerations
D.  Assessment
a.  Female
i.  Inspection
1.  Genitalia
2.  Breasts
ii. Palpation
iii.  Analysis of findings
1.  Health History
2.  Risk Factors
3.  Physical Assessment
4.  Associated Health Conditions
iv.  Lifespan Considerations
v. Other Influences
1.  Lifestyle
2.  Environmental
3.  Cultural
4.  Psychosocial and Emotional
5.  Peers
b. Male
i.  Inspection
1.  Genitalia
2.  Breast
ii.  Palpation
iii.  Analysis of Findings
1.  Health History
2.  Risk Factors
3.  Physical Assessment
4.  Associated Health Conditions
iv.  Lifespan Considerations
v.  Other Influences
1.  Peers
2.  Culture
3.  Psychosocial and Emotional
4.  Lifestyle
E. Safety and Privacy Issues
F. Ethical and Legal Concerns
G. Documentation
a.  Terminology
b.  Educational Opportunities
c.  Health Promotion
i.  Self-Breast Exam
ii.  Testicular Exam
iii.  Mammogram
iv.  Other Screenings
v.  Cancer Genetic
NCLEX Integrated Process of Nursing Process, Caring, Communication and Documentation, Teaching/Learning, and Culture and Spirituality / Chamberlain Care provides a framework for student learning by addressing: