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Bachelor of Nursing

Transition to Registered Nurse PracticeBNTR701

Health Assessment of an Adult

Semester 2, 2018

Copyright Ara Institute of Canterbury

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Contents

Course Descriptor 1

Health Assessment of an Adult Summative Assignment 2-15

Resources 3

Case Study 4

Criteria 5

Case Study Marking Guide 6-7

Contract for Health Assessment Interview, Examination and Assignment 8

Health Data base/Record History 9-10

Review of Systems:

Subjective Data 11

Objective Data 12-14

Summary 14

Problem List 14

Action Plan 14

Mental Status Examination 15


Te Hoe OraAra Institute of Canterbury Department of Nursing, Midwifery & Allied Health

document.docx 1 Copyright Ara Institute of Canterbury


Bachelor of Nursing BNTR701

HEALTH ASSESSMENT OF AN ADULT SUMMATIVE ASSIGNMENT

This assignment is designed to give you the opportunity to build upon and integrate all previous work on health assessment in the programme. You will be able to carry out a full screening health assessment with a view to identifying client strengths as well as potential risks to health. You will also be able to use this experience to identify potential areas for the client to change, if desired, and to look at the actions required to implement this. This booklet contains information about the assignment and the criteria, client information and consent forms and a health data base record.

Please read through the health database/record prior to the arranged review session. This will enable you to bring any questions you may have about this document and how to use it to structure the interview and physical examination with your chosen “client”.

There are three parts to this experience:

A Attending a lecture and practice session to re-familiarise yourself with a variety of physical assessment skills and learn some new skills, i.e., JVP assessment. Wear clothing comfortable for practising physical assessments, i.e., shirt that opens down the front.

B Selecting and explaining to your client what this assessment involves and gaining their written consent to participate. Your client should be a “well adult” and cannot be a student of nursing. You will then interview the client to gather a full health history before bringing them to NMIT for a top to toe physical assessment (excluding genitalia). NMIT provides a clinical environment for this assessment, with a Registered Nurse who can advise on any abnormal findings.

On the day of the client assessment at NMIT wear your nursing uniform and name badge.

C Writing up your client assessment case study and submitting this in hard copy on the second floor of the library. Assessment box.

Important Dates: Thursday & Friday 21st & 22nd June: Client Physical Assessment

Thursday, 5th July, 1200 hours: Health Assessment Due



RESOURCES

Between attending the class and practice session and bringing the client to NMIT for their physical assessment you can access the following resources to assist you to further develop your health assessment skills and confidence in putting it all together.

Within this booklet there are prompt pages to help you with your assessment. You will find sections of the mental health assessment from your work in BNKN601, and also the physical assessment skills that you will have learned in Year 1. These are for your reference and to help you when completing the skills.

Books/Journals:

Lewis, P., Foley, D., Weber, J., & Kelley, J. (2012). Health assessment in nursing. Broadway, New South Wales, Australia: Lippincott, Williams & Wilkins.

Internet: there are many excellent internet based resources available. Try key words like “auscultation” or “stethoscope”.

Recommended screening guidelines for New Zealanders: www.nzgg.org.nz

Other websites:www.ana.org.nzwww.healthed.govt.nzwww.heartfoundation.org.nz

Clinical Practice Unit: is available for practice if it is not booked by a class. If you need extra equipment you can book this through the Health Simulation Technician.

Practise on willing family and friends.




Summative Assessment

Case Study

Screening assessment of a client

For this piece of assessment, you will need to find a well adult who is willing to have a full screening health interview and physical examination. It will take you approximately 1-1½ hours to carry out and you are required to hand in the written documentation of the health assessment.

You will need to:

1 Obtain written consent from your client to participate in the health assessment. Please include this in your final submitted written document.

2 Your client must be aged 16 years or more, as they need to be able to provide informed consent.

3 Interview your client, taking a complete health history including a complete subjective systems review.

4 Carry out a full screening physical examination excluding examination of the peri-anal area and genitalia.

5 Document data from interview and examination fully and accurately utilising the health history framework within this booklet. All pertinent negatives must be included in written work and terminology should be appropriate to a clinical setting.

6 Summarise the clients’ health history and physical examination findings accurately and succinctly. Include both positive health attributes as well as risks to health.

7 Create a list of all identified client problems. Include active problems as well as potential health risks identified during history and physical examination. Consider all health promotion aspects.

8 Create an action plan outlining each identified active and potential problem the appropriate nursing intervention or referral(s) for further specific investigation.

Indicate the urgency of these identified active and potential problems. Demonstrating partnership with your client, describe the health promotion and/or activities

that you have discussed with the client. Justify your nursing interventions and health promotion activities to evidence based

practice and include evidence of discussing these problems with your client.

9 Provide references for your action plan.



Pass Criteria

Health history data fully documented and includes all major sections of health history.

Confidentiality is maintained: Initials or a pseudonym is used, no DOB, no identifying place or names, hospitals, schools, workplaces used in presented work.

Physical examination data is documented in an accurate manner using terminology suitable for clinical setting. All systems are documented fully. All major problems are identified.

Terms such as normal, fine, ok, and good are not appropriate.

Follow up of problems identified in history taking is evident in physical examination section.

Summary is succinct and accurately recognises the health problems and health risks identified during history taking and physical examination as well as highlighting positive health attributes.

Problem list is inclusive of all the active and potential health risks identified during history taking and physical examination.

Action plan created addresses all health problems/risks identified and provides appropriate and relevant evidence based nurse intervention and/or health promotion and indicates appropriate referral, including timing.

Action plan is referenced indicating nursing actions are evidence-based.

Action plan includes evidence of client-nurse partnership.

Case study demonstrates analysis and critical evaluation throughout.

Consent included.

Meets guidelines re presentation (1½ spacing) and APA referencing.

Abbreviations suitable to clinical setting should be utilised.

Reference page included.

o References must demonstrate critical thinking and are appropriate to the New Zealand context.

o References must be recognised as ‘scholarly work’, e.g., peer reviewed, best practice guidelines.

o Links to limited websites (e.g., Dr.com are NOT appropriate).



ASSIGNMENT COVER SHEETStudent to complete all sections:

Lecturer Name:

Course Code and/or Title:

Due Date:

Student ID Number:

Word Count: (if required)

Declaration: Please indicate:

☐I declare that this assignment is all my own original work.

Note:Penalties for dishonest academic practice are outlined in the Ara Institute of Canterbury Student Handbook and the Plagiarism, Cheating or other Dishonest Practices Policy available via the Ara website (www.ara.ac.nz/about-us/policies). If in doubt, please consult your Tutor/Lecturer or Programme Leader.

Initialed:

Dated:

Students are advised to retain an electronic copy of work submitted.


http://www.ara.ac.nz/about-us/policies



Attach to front of work before handing in, please.

Case Study Marking Guide

Presenting Information: Demographic data, pertinent major life influencing conditions or circumstances, and reason for assessment, maintaining confidentiality.

Past Health

Note: Mental Health history must be included here if appropriate to your client.

Family Health (genogram and summary of risk analysis).

Personal/Social History: Demographic data, past development, current life situation.

Occupational History - risks and precautions addressed.

Health Habits/functional assessment. Dietary assessment undertaken and analysis made (referenced instrument). Presented in table format showing comparison to referenced tool.



Case Study Marking Guide

Review of Systems: Brief symptom analysis of positive and negative responses, any treatment and their sequel as noted by the client. Pertinent negatives in all body systems covered.

Physical Examination: Coherent, succinct description of all examination findings including relevant pertinent negatives.

Summary: Major pertinent information from all sections of the history and examination summarised.

Problem List: All active and inactive major problems listed (medical, social, and psychological). All problems numbered and listed in chronological order. Date of onset for each problem included.

Action Plan: All problems linked to appropriate nursing action, e.g., referral, nurse education.Health promotion and partnership with client evident.Supporting evidence sources/references included.

Critical analysis of the risks identified through subjective and objective data evident in action plan and health promotion planning.

Presentation of assignment as per guidelines. References must demonstrate critical thinking and

include peer reviewed sources.

General comments: ___________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

Pass Resit

______________________________________________________________________________________

______________________________________________________________________________________

Resubmit by: ___________________________________



Contract for Health Assessment Interview, Examination and Assignment

(Please attach to assignment)

The student from the Bachelor of Nursing programme at NMIT, who is being assessed, has explained that

they will ask me health related questions and perform the following physical examination skills on me:

neurological assessments; ear assessment, including otoscope examination; eye assessment; lymph node

assessment, abdominal or posterior chest assessment; cardiovascular assessment; musculoskeletal

assessment; and peripheral vascular assessment to the lower limbs. I am willing to take part in this

interview and physical examination carried out by the student.

I understand that I have the right to refuse to answer any questions or undergo any part of the examination

unacceptable to me. I understand that a supervising nursing lecturer will be available in the room during

the course of the physical examination.

I understand that any information discussed or physical examination findings will only be available to the

student, the supervising lecturer and the marker of the assignment. Any advice given during this

assessment is on the understanding that the client will seek further assistance from a General Practitioner

(GP) or other appropriate health care provider.

I retain the right to terminate this agreement at any time.

Client Signature: ______________________________

Date: ____________________

Student No: __________________________________




HEALTH ASSESSMENT OF ADULTSHEALTH DATA BASE/RECORD

HISTORYSubjective DataDate and timeLocation of AssessmentName/initials:Descriptive demographic data: age, race, gender, marital status, employment status, life-influencing circumstances and/or diagnoses, dependants, ethnicity.

Past Health a) Childhood Illnesses (birth-15 years)

1 Injuries and illnesses requiring health care and/or persisting over a long period;2 Surgeries - presence or absence of sequellae.

b) Adulthood illnesses (16 and older) Include date, and any continuing problems1 Medical illnesses.2 Occupational illness/injuries; disability.3 Surgical procedures.4 Psychiatric illnesses.

*If your client has experienced present/previous concerns regarding their mental health, you must complete a mental health assessment.

5 Major accidental trauma.6 Sports injuries.7 Obstetric history.

For each ongoing Past Health Problem (such as hypertension, diabetes, alcohol abuse, chronic anxiety/depression) write a brief description to include:

1 Date(s) of onset and diagnosis.2 Interventions and progress to date.3 Where client sought care and by whom.4 General course of the condition, including response to treatment, complications.5 Current source of care for this problem. 6 Functional status in relation to problem.7 Psychological impact of the problem.

Present Health Additional risk factors from known health history.1 Medication use - prescribed, over-the-counter, vitamins.2 Allergies and sensitivities - describe reactions.3 Immunisations (include dates).

Family History A Diagram (genogram) of family tree.

For each member - show age, whether alive (and state of health) or dead (and cause of death). Include parents, grandparents and siblings, if possible.

B Identify the major health risks from the genogram for your client. Include the wider family group in this section if significant risk factors for the client, e.g., cancer, disease, cardiovascular.



Health Behaviours 1 Nutrition – Record the last 24 hour menu and compare with “usual” diet. Assess for: quantity; food group

balance; fibre, salt, cholesterol, minerals and vitamins, fluids. Compare to a reference for healthy nutritional intake. Include information in a ‘table’ format in your write-up.

2 Alcohol - kind, amount, frequency.3 Tobacco - packs per day, number of years.4 Sleep - quality, pattern.5 Exercise - frequency, type, duration.6 Social activities/hobbies - frequency, kind. Group involvement, e.g., church.7 Medical care - where, by whom, how often.8 Dental care - where, how often; hygiene: flossing, brushing.9 Sun protection - skin, eyes10 Screening tests - pap smears, mammograms, urinalyses, cholesterol levels, E.C.G, blood screens.

Personal/Social History Brief description of patient's past and present lifestyle organised under three headings.

a) Demographic:1 Place and year of birth.

b) Past Development:1 Early family - social: relationship with parents and siblings, friends; parents' relationship to each

other; client's reactions and feelings about significant events.2 School experience: attitude, involvement, achievement.

c) Current Life Situation: 1 Coping and Stress Management.2 Religious and/or Spiritual Considerations.3 Place of residence - Family at home.4 Present life relationships: significant relationships with family members and friends, satisfactions,

dissatisfactions.5 Housing, type? Adequate? Satisfied?6 Household responsibilities, usual tasks? Pets?7 Activities of daily life. Ability to function - Help needed? 8 Financial status? Adequate? Satisfied?9 Safety in home environment. Emotional - physical. Security systems.10 Method for dealing with life stresses. What are current stressors?11 Future goals or plans.

Occupational History a) Current Employment (if currently employed):

1 Occupation, length of employment.2 Hours, tasks, responsibilities.3 Exposures.4 Protective equipment. Provided? Used?

b) Past employment(s):1 Title, nature, and duration of work; exposures - chemical, physical, biological.



REVIEW OF SYSTEMS

Subjective DataIn an organised manner screen each system for additional pathology or risks. Review health promotion behaviours. Document all positive and all negative responses to establish a known baseline. Follow up on new symptoms.

General - State of Health : Client's perception of health status. Any symptoms or concerns related to, weight changes, fatigue, fever, malaise, chills, night sweats.

Mental State: Change in memory - concentration, reaction time, mood. Refer to Mental Status Examination questioning framework if further information needed.

Skin, Hair, Nails: Colour or texture changes, pruritus, rashes, growths, changes in hair or nails.

Head: Severe or frequent headaches, dizziness.

Eyes: Local problems - dryness, itching, pain, burning, discharge, lacrimation, inflammation. Visual disturbances - diplopia, blurring spots, halos, flashes of light; temporary blindness, cataracts, glaucoma/date of tonometry; glasses/date of last eye examination.

Ears: Local problems - excessive cerumen, discharge, infections, pain, blockage. Auditory disturbances - hearing loss, tinnitus, vertigo. Use of headphones/continuous loud noise exposure.

Nose, Sinus: Epistaxis, congestion, discharge, sinus discomfort, frequent colds.

Mouth, Throat: Pain - bleeding gums, sores, toothache, abscesses, extractions, last dental visit, dentures. Throat - hoarseness, frequent URTI's, sore throats, altered taste.

Neck: Lumps, swellings, goitre, pain or stiffness.

Breasts: Change in contour or nipple, lumps, pain, discharge, bleeding. Breast self-examination.

Respiratory: Cough, sputum production, hemoptysis; dyspnea, wheezing, pleurisy, asthma, last x-ray.

Cardiovascular: Heart - chest pain, palpitations, dizziness dyspnea, orthopnea, PND. Peripheral/vascular - claudication, varicosities, phlebitis, oedema, colour/temperature changes, varicose veins.

Gastrointestinal: Changes in appetite, eructation, dysphagia, heartburn, indigestion, nausea, vomiting, hematemesis, abdominal pain, diarrhea, constipation, flatulence, bowel movements (frequency, consistency, colour, shape, use of laxatives, pain, recent changes), bleeding, jaundice.

Urinary Tract: Dysuria, haematuria, frequency, urgency, change in stream, hesitancy, incontinency, nocturia, stones.

Genital Tract, Male: Urethral discharge, penile or scrotal lesions; testicular pain or swelling; impotence; sexual activity, sexual health.

Genital Tract, Female: Discharge, itching, infections, dyspareunia. Menopause: age, night sweats, hot flushes, irritability, mood changes. Sexual health; last Pap smear (date and result).

Musculoskeletal: Pain, swelling, stiffness; sprains, fractures, deformities, weakness, co-ordination difficulties.

Nervous: Syncope, seizures, vertigo, speech difficulties, gait problems, changes in balance and coordination, tremor, muscle weakness, tingling, numbness, headache.

Endocrine: Tremor, heat or cold intolerance, excessive sweating, change in hair, nails, or voice. Polydipsia, polyphagia, polyuria.

Hematopoietic: Anaemia; spontaneous or excessive bleeding, easy bruising.



PHYSICAL EXAMINATIONObjective DataIn an organised manner, search for physical changes or risks.

a) General Inspection:Posture, colouring, mannerisms, dress, facial expression.

b) 1 Vital signs: Weight, height, BMI/WHR, blood pressure (sitting & standing), distance and near vision, urinalysis.

2 Offer tests appropriate to client situation, e.g., peak flow, blood glucose.

c) Skin, Hair, Nails: 1 Skin - general description: pigmentation, texture, temperature, moisture, lesions (locations, size,

shape, type, colour, distribution) scars.2 Hair - distribution, quality.3 Nails - colour, texture.

d) Head:1 Skull - size, shape, masses, scars, tenderness, TMJ movement.2 Face - scars, symmetry, tenderness, oedema.

e) Eyes: 1 Lids - oedema, ptosis, lid lag, lesions, ectropian, entropian.2 Sclera - jaundice, haemorrhage.3 Conjunctivae - pallor, erythema, discharge.4 Cornea - scars, ulcerations, arcus.5 Pupils - size, shape, equality, reaction to light and accommodation (PERRLA).6 EOM - equality of movement, nystagmus.7 Vision - acuity.

f) Ears:1 External - shape, tophi, discharge.2 Otoscopic - tympanic membrane: light reflex, bony landmarks, scars, perforation.3 Auditory Acuity - whisper.

g) Nose and Sinuses:1 Mucous membranes - colour, discharge, lesions.2 Septum - deviation, perforation.3 Frontal and maxillary sinuses - tenderness

h) Mouth and Pharynx:1 Lips - colour, lesions.2 Tongue - colour, coating, lesions.3 Teeth and gums - dentures, broken teeth, obvious decay, gingivitis, bleeding.4 Buccal mucosa - colour, lesions, bleeding5 Pharynx, tonsils - size, exudates, lesions.

i) Neck:1 Range of motion, tenderness, masses.2 Trachea - position.3 Salivary glands - (parotid and submaxillary) size, tenderness

j) Lymphatic - all head and neck lymph nodes evaluating enlargement, size and texture, tender vs. painless, moveable vs. fixed.



k) Thorax and Lungs:1 General inspection - shape of bony thorax, scars, masses, use of accessory muscles.2 Palpation - tactile fremitus, tenderness of skin, muscles, ribs, sternum, expansion.3 Percussion - lung fields.4 Auscultation - character and intensity of breath sounds, adventitious sounds (crackles, wheeze,

rubs).

l) Cardiovascular:1 Heart

a) Inspection - point of maximal impulse, abnormal pulsations.b) Palpation - apical impulse, thrills, heaves.c) Auscultation:

i Heart rate, regularity.ii Heart sounds S1, S2 intensity, splitting, S3, S4.iii Murmurs - locations, quality.

2 Peripheral Vascular Systema) Neck - jugular vein distension, pulsations, carotid arteries: rate, rhythm, volume, bruits.b) Abdomen - venous pattern, bruits.c) Extremities - oedema, colour, clubbing, varicosities, loss of sensation, ulcerations, calf

tenderness, hair distribution.d) Nails: capillary refill and clubbinge) Peripheral pulses:

Grades: 0 = absent2 plus = normal4 plus = full and bounding

C R F DP PT

R

L

m) Breasts: 1 Inspection - symmetry, skin or nipple changes, discharge.2 Palpation- masses, tenderness, secretions, axillary adenopathy

n) Abdomen:1 Inspection - contour, scars.2 Auscultation - bowel sounds.3 Percussion - tympany, liver span4 Palpation:

a) General - tone, tenderness.b) Organs - liver, gall bladder, spleen.c) Masses - location, size, consistency, contour, mobility, pulsations.d) Hernias - location, size, tenderness, reducibility, bowel sounds.

r) Musculoskeletal (neck, back, hip upper and lower extremities) 1 Symmetry, range of motion; point tenderness, pain with movement; crepitation, warmth, swelling,

deformities, nodules, tophi.2 Gait - flexibility, coordination.3 Motor system - muscle symmetry, tenderness, strength, tone, fasciculations.



s) Neurological:1 Mental status (if appropriate) – cognitive function, thought processes and perceptions.2 Cranial nerves - II through XII.3 Cerebellar - coordination, balance (F-N, H-S, RAM, Romberg).4 Reflexes – bracchioradialis, triceps, biceps, patellar, Achilles, plantar.5 Sensory system - touch, temperature, pain, vibration, position

2+ 2+

2+ 2+

3+ 3+

0 1+

SUMMARY

Brief description of pertinent and significant findings from history ROS and physical examination (positive attributes and risks to health).

Where there is an additional presenting concern, summarise your findings from history, ROS and physical examination for this also.

PROBLEM LIST

List of active and potential problems/issues experienced by client, as recorded in the history or found in examination.

Nursing diagnosis format can be used.

ACTION PLAN

For each problem/issue listed: Outline the actions you would initiate Outline the nursing measures you would undertake Include referrals to other health professionals Include aspects of health promotion Link to literature/resources


Key:0 = No response1+ = Diminished, low normal2+ = Brisk, average (normal)3+ = Brisker than average, may indicate disease4+ = Very brisk, hyperactive with clonus


Hinengaro/Mental Status Examination(For reference and use if appropriate to client.)

Behaviour / AppearanceAge, gender, race/ethnic background, buildHairstyle and colour, apparent health, level of hygiene, mode of dress, physical abnormalities, eye contact, cooperativeness, motor activity, abnormal movements, expressive gestures

Emotion (Mood, Affect)Mood (subjective); affect (objective) e.g., elevated, depressed, labile, angry, irritable, blunted, flattened, euphoric, incongruent, anxious; range and intensity, stability, appropriateness and congruity

Thought FormAmount or speed of thought; poverty of ideas, pressure of speech; latency; continuity of ideas, e.g., tangential, circumstantial; disturbances in language, e.g., neologisms, word salad

Thought ContentDelusionsOther; phobia, obsessions/compulsions, overvalued ideas

PerceptionHallucinations; auditory, visual, olfactory; gustatory; tactile, depersonalisation; derealisation and illusions

Cognition (orientation, memory, concentration)Level of consciousness/alertness; memory, orientation (time, place, person) concentration

InsightCapacity to organise and understand problem, symptoms or illness; knowledge of medication; amenable to and adherence with treatment.

JudgementCan demonstrate rational thinking if asked, e.g., what would you do if your smoke detector goes off?

Risk AssessmentBased on relevant risk tool; what level of risk does this person pose to self, others, environment?


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