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Achilles +1The University of Texas at AustinSchool of NursingN224 Health Assessment SkillsFall 2008Documentation of a Complete Physical Assessment General ...

N224 Fall 2008



    The University of Texas at Austin

    School of Nursing

    N224 Health Assessment Skills

    Fall 2008

Course Credit: 2 credit hours; 1 hour of lecture and 1.5 hours of practicum

     Laboratory group assignments and performance exams

Course Prerequisite: Admitted to the School of Nursing

Course Co-Facilitator: Maureen Davis, MSN, RN-BC

     Office: NUR 5.121

     Phones: 232-9262 (O); 913-6942 (C)


Course Co-Facilitator: Gerri Sue Hoffman, MSN, RN, AH-CNS

     Office: NUR 5.186

     Phones: 475-7481 (O); 833-8055 (H); 740-8368 (C)


Course Faculty: Christine W. Abbyad, PhD, RN, WHNP

     Office: NUR 5.169

     Phone: 232-4705 (O); 694-5592 (C)


Course Faculty: Marta Anderson, MSN, RN

     Office: NUR 5.163

     Phone: 232-4706


Course Faculty: Nola Cottom, MSN, RNC

     Office: NUR 5.172

     Phones: 471-7953


Course Faculty: Mary Podmolik King, PhD, RN, CPNP-PC

     Office: NUR 5.169

     Phone: 232-4705 (O); 512/947-5128 (C)


Sim-Lab Guru: Heather Keizman, RN, MSN, WHNP-BC

     Office: NUR 4.145

     Phone: 471-3494



N224 Fall 2008

Office Hours: TBA


N224 Fall 2008

    Course Description:

Discussion, application, and documentation of health assessment skills needed to provide data

    for health promotion and nursing interventions.

Course Objectives: At the conclusion of this course, the student should be able to:

1. Demonstrate knowledge of purpose, procedure, and rationale of varied health assessment


2. Identify techniques used in developing a data base for health needs of clients, e.g.

    interviews, health histories, and physical assessments.

3. Demonstrate beginning level skills in health assessment techniques.

4. Record nursing observations using appropriate terminology.

5. Select and integrate appropriate research findings in the study of health assessment.


    N224 Fall 2008

    The University of Texas at Austin

    School of Nursing

    N224 Health Assessment Skills

    Fall 2008

    Class Schedule

    Week Dates Class Topic(s)

    Introduction to Course & Syllabus

    Aug. 28-29 1 Unit 1-Assessment of the Whole Person: Critical Thinking, The

    Interview *

    Sept. 4-5 Complete Health History, Mental Status and Nutritional Assessment 2

    Sept. 11-12 Assessment Techniques, General Survey, Measurement, VS 3

    Sept. 18-19 Heart and Great Vessels 4

    Sept. 25-26 Thorax and Lungs 5

    Oct. 2 6 Written Exam 1 Thursday - 8:00 AM For All Sections Oct. 9-10 Skin, Hair & Nails, PVS & Lymphatic System, Abdomen 7

    Oct. 16-17 Head, Neck, Nose, Mouth and Throat; Eyes & Ears 8

    Performance Exam 1: Head, Neck, Nose, Mouth and Throat;

    Oct. 23-24 9 Eyes & Ears; Heart, Thorax & Lungs; Skin, Hair & Nails,

    PVS & Lymphatic System, Abdomen & Documentation Oct. 31 10 Written Exam 2 Friday 8:00 AM For All Sections Nov. 6-7 Musculoskeletal, Neurological Systems 11

    Nov. 13-14 Male & Female Breast, Genitourinary Systems, Anus & Rectum 12

    Nov. 20-21 13 Final Performance Exam: Head to Toe & Documentation Nov. 27-28 14 Thanksgiving Holiday

    Dec. 4 15 Written Exam 3 - Thursday 8:00 AM For All Sections

    Note: * Check all homework assignments in syllabus each week.


    N224 Fall 2008

    The University of Texas at Austin

    School of Nursing

    N224 Health Assessment Skills

    Fall 2008

    Methods of Evaluation:

    1. Knowledge. Evidence of knowledge will be scores from three written examinations,

    homework assignments completed and weekly quizzes.

     a. The three written exams will be approximately 80-125 multiple choice, matching,

    and labeling questions. Emphasis will be on anatomy and assessment techniques.

    Exam 1 will cover the material from beginning of course and exam 2 will cover

    material after Exam 1. Written Exam 3 will cover the male and female

    genitourinary systems, the anus and rectum, and the complete history and physical.

     b. Weekly quizzes, comprising of a combination of 10-20 questions which may

    include multiple choice, listing and labeling, will test student preparation of the

    material to be covered that day. Quizzes will be given promptly at the beginning

    of each class period. There will be no make-up, and people who are late will not

    be given extra time to finish. For those scoring at least an 80%, extra credit

    point(s) will be added at the end to the semester grade. This scale is: # of quizzes

    greater than 80%: Possible points = 2 points for 3 quizzes greater than 80%. 3

    points for 5 quizzes greater than 80%. 4 points for all 7 quizzes greater than 80%.

    This could make a difference of a letter grade.

    2. Attitude. Professional behavior is expected from all nursing students. The basis of

    professional behavior is competence, responsibility, consideration for others and

    accountability for behavior and decisions made. Mid semester failing notices will be sent

    to students for the following evidence of unprofessional behavior:

? Tardiness

    ? Unable to pass the weekly quizzes

    ? Grade average at midterm is <80

    ? An unexcused absence

    ? Sleeping in class

    ? Late submission of required skills lab documentation

    ? Late submission of homework

    ? Not participating actively in the skills lab

Students who miss either the lecture or skills lab practice session (excused or unexcused)

    will also be required to make up any assignments missed in the skills lab within the

    week plus an additional requirement which will be at the discretion of their instructor. It

    is the responsibility of the student to call and schedule this appointment with Kathy

    Hansen in the Skills Lab office NUR 4.114 at times other than scheduled open labs.


    N224 Fall 2008

    3. Skills. Students will perform required skills (history and physical assessment skills) and

    document accordingly. An instructor (or teaching assistant) will make comments on the

    "Performance Exam Checklist" of skills demonstrated and documentation received.

    Students will be given feedback on technique and documentation.

Evidence of progress will be the following:

a. Two skills performance examinations will be given. These examinations will

    consist of student performance of learned skills, required reading, discussion and

    information given in films or other media. Students not prepared or unable to

    perform the required skills will be retested, at the faculty's convenience, until

    skills are established. The highest grade that can be achieved on a repeat

    performance exam will be 70%.

b. A "Skills Lab Prescription" will be given to students needing further practice

    and/or failing a performance exam. The failed performance exam must be

    practiced in the skills lab and demonstrated to a skills lab consultant within

    one week of the failed performance. It is the responsibility of the student to

    inform their clinical N325P instructor before clinical if they have failed any of

    their performance exams in N224.

    4. Expected Student Behaviors. Certain behaviors are consistent with the role of a professional person and are expected of you as a student. The faculty view the behaviors

    exhibited by the student to be indicative of the student's behavior when they begin

    employment as a professional.

Physical Assessments - Students in this course practice physical assessment skills with

    their classmates. You will be asked to demonstrate on a partner each of the assessment

    skills as listed in the course syllabus and to allow a student to demonstrate assessment

    skills on you. A fully professional attitude and demeanor are expected of all students at

    all times. If you have any concerns about this, please discuss them with your instructor

    early in the semester so that appropriate accommodations can be made.

The behaviors outlined below are those defined by faculty as unacceptable behaviors for

    students. If a student persistently exhibits any of these behaviors, the clinical instructor

    will schedule a conference with the student to discuss possible strategies to enable the

    student to modify those behaviors. The student and instructor will agree on the action to

    be taken by the student. If the student does not comply with the agreed on action, the

    student will fail this course.

    Unexcused Absences - Failure of proper notification or unacceptable reasons for missing lab.


N224 Fall 2008

    Make-Up - Activities for missed labs, class absences, lack of preparation for lab, or late

    arrival to lab:

    ? ―Physical Assessment CD ROM Disc‖

    ? Skills Lab Check Off

    ? Video Report

    ? Internet Search

    ? Other as professor deems necessary

5. Evaluation criteria are weighted as follows:


     Exam 1 25%

     Exam 2 25%

     Exam 3 25%

     Please note that your exam day may be moved to accommodate the total group.


    Skill Performance Examinations 15%

     Weekly Lab & Homework Assignments (Timely and Complete) 4%

     Skills Practice Documentation (Timely and Complete) 2%

     Present for All Skills Labs (Engagement Evident) 2%

     Professional Demeanor and Technique 2%

     Use of On-line Readings and Preparation Lectures Credit

    A minimum course grade of 75%, satisfactory performance of all skill performance

    examinations, and completion of homework assignments, documentation assignments

    and skills checklist are necessary to receive a passing grade for this course. A class "bar"

    may be imposed until all required homework is submitted.

Student Responsibilities: Learning Professional Behavior

(Also refer to Student Responsibilities outlined in the current School of Nursing catalogue.)

1. Part of professional responsibility is to comply with legal requirements to practice to

    protect yourself and your patients. For example, students are to complete the HIPAA

    (Health Insurance Portability and Accountability Act of 1996 (HIPAA) (effective April 14,

    2000) training prior to beginning clinical work in the agencies. However, during our

    skills lab sessions, the privacy of your practice partner needs to be protected as well. Here

    is a brief overview of HIPAA:


    The regulations protect medical records and other individually identifiable health

    information, whether it is on paper, in computers or communicated orally. Key provisions

    of these new standards include:


    N224 Fall 2008

    * Access To Medical Records. Patients generally should be able to see and obtain copies of their medical records and request corrections if they identify errors and mistakes.

    Health plans, doctors, hospitals, clinics, nursing homes and other covered entities

    generally should provide access to these records within 30 days and may charge patients

    for the cost of copying and sending the records.

* Limits on Use of Personal Medical Information. The privacy rule sets limits on how

    health plans and covered providers may use individually identifiable health information.

    To promote the best quality care for patients, the rule does not restrict the ability of

    doctors, nurses and other providers to share information needed to treat their patients. In

    other situations, though, personal health information generally may not be used for

    purposes not related to health care, and covered entities may use or share only the

    minimum amount of protected information needed for a particular purpose.

    2. Preparation and Practice Every Week. Learn time management. The content of this

    class is new and requires different language, thinking and skills sets. Procrastination will

    not work in this class. Much of the class has to be memorized and internalized. The

    workbook will help students learn content in different ways. Students are expected to do

    all the exercises in their lab workbooks. Those who are diligent and disciplined are more

    likely to retain the material, succeed in nursing school, enjoy the experience and pass

    board exams.

     Practice, Practice, Practice. Take every opportunity to hone your skills. Students are encouraged to buddy up and practice physical examination skills with their classmates or

    willing friends and family. All equipment used in class is available for checkout from the

    Learning Center. When practicing, students are encouraged to concentrate on one skill on

    as many different ―clients‖ as possible. Kathy Hansen from Skills Lab will post the

    availability of clinical teaching assistants who can help answer questions and provide

    additional practice and make-up for missed labs or lectures. Open Lab: Wednesdays

    1:00-3:00 PM, Fridays 10:30-3:00 PM.

    3. Critical Thinking Skills. There is an art and a science of nursing. Nursing is a holistic profession wherein the physical, psychological, social, spiritual, political and financial

    aspects impact nursing care. Students new to the profession may, at first, be

    uncomfortable, but with the expectations, preparation and practice, it gets easier. This

    class enables you to begin your professional skills of assessment which is the basis of the

    nursing process and practice. Sometimes, life or death and relief or suffering are based on

    the nurse's ability to assess and employ the necessary skills to gather the data, identify the

    problem, and intervene. Good nursing intervention is based on good assessment.

    4. Trust and Consideration for Others. In the event that special circumstances make it impossible for the student to be present at a class, skills lab or an exam, the student must

    notify the professor and make arrangements with the professor in advance. All faculty

    have voice mail.


N224 Fall 2008

    Name Badges - The faculty request that each student wear his/her name badge to each class.

    This will enable the faculty to more quickly learn the name of each student. Also, please

    wear your lab coat for each performance exam. For your weekly practice sessions, please

    wear your scrubs or loose fitting clothing appropriate for the examination of the

    system being covered that day, e.g., sports bra, swim shorts, etc.

5. Consequences. In the event that a student is absent from an exam without having made

    prior arrangements with the professor, he/she might not be permitted to take the exam

    and a score of zero may be recorded for the missed exam. If for unusual reasons the

    student is permitted to take the exam, a 10% penalty may be incurred on the exam score.

    6. Using Technology Effectively. A component of this course was designed to orient

    students to computer technology and to lay some groundwork for participation in a web-

    based learning environment. Blackboard Information Site: ITS HELP DESK for Faculty, Staff, and

    Student support for Blackboard 475-9400

     Browser requirements for Blackboard: Internet Explorer 5.0 or higher, Netscape

    Navigator 4.76 or higher

    UT Direct - On-Line Grades Submission:

    Grades will be submitted using the Blackboard grade book. All final grades will be

    submitted to e-gradebook. See the Learning Center for assistance in accessing your


    CD ROM - Head to Toe - in your book

Punctuality & Late or Missed Work Policy:

    Faculty are responsible for implementing a Punctuality & Late or Missed Work Policy.

Student Conduct Policy:

    Students and faculty in The School of Nursing each have responsibility for maintaining an

    appropriate learning environment. Faculty have the professional responsibility to treat students

    with understanding, dignity and respect and to guide the teaching/learning process. Students are

    expected to refrain from verbal and nonverbal behaviors in the classroom and clinical that may

    be distracting to others, such as, but not limited to: arriving late or leaving early, side

    conversations, text messaging, note passing, surfing the internet or answering e-mail on laptops,

    and answering cell phone or pager. Students who persistently engage in behaviors that are

    disruptive to the teaching/learning process may be required to leave the setting. For further

    information refer to General Information, Institutional Rules on Student Services and Activities,

    Chapter 11: Student Discipline and Conduct.


N224 Fall 2008

    Honor Code: The profession of nursing has a legacy of public respect and trust. We provide specialized care for the health needs of individuals and the community with integrity, honesty, compassion, and state of the art knowledge and skills. Learning and practicing responsible and ethical professional behavior is a vital part of professional education. The Institutional Rules on Student Services and Activities given in the General Information Catalog (Chapter 11) and The University of Texas at Austin’s Honor Code apply to all nursing students:

    The core values of The University of Texas at Austin are learning, discovery, freedom, leadership, individual opportunity, and responsibility. Each member of the University is expected to uphold these values through integrity, honesty, trust, fairness, and respect toward peers and community.

Additionally, the School of Nursing has its own honor code:

    As a student in The University of Texas at Austin’s School of Nursing, I pledge myself to be honest in all of my student activities including, but not limited to, all of my scholastic work and interactions with patients, members of the community, faculty, and peers. Furthermore, I will not use any substance prior to or during my interaction with patients that could alter my judgment or ability to render safe care: this includes but is not limited to any use of alcohol, illegal drugs, and prescription or over-the counter drugs that may impair my mental and/or physical abilities required to perform safe patient care. I will disclose to my instructor any violations of the above standards of conduct.

Scholastic Dishonesty Policy and Professional Integrity:

    Refer to the General Information for information on the Scholastic Dishonesty Policy Sec. 11-802. Scholastic dishonesty includes, but is not limited to cheating, plagiarism, collusion, falsifying academic records, and misrepresenting facts. The Dean of Students Office records acts of dishonesty and notifies the School of Nursing of each incident. In addition to all of the University statements and policies relative to academic dishonesty, the School of Nursing recognizes the strong link between honesty in academic work and professional integrity. Any act of academic dishonesty, including fabrication of reports or records of interactions with clients, is considered incompatible with ethical standards of nursing practice. The School of Nursing does not admit students who have a record of violations to the professional sequence. Students who engage in scholastic dishonesty may be subject to dismissal and may jeopardize their eligibility for licensure as a registered nurse.

Academic and Program Accommodations for Students with Disabilities:

    Refer to the General Information for information on Academic and Program Accommodations for Students with Disabilities or contact the Services for Students with Disabilities office in the Office of the Dean of Students at 471-6259. The School of Nursing works to ensure that students who have disabilities have equal access to the University’s programs and services.

    If you have any questions about services or accommodations for students with disabilities, please talk with the faculty member, the Assistant Dean for Undergraduate Programs, or the Assistant Dean for Student and Clinical Affairs or directly call the Office of the Dean of Students, Services for Students with Disabilities, 471-6259.


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