NURS 3020 – Health Assessment

NURS 3020 – Health Assessment

Through this course, students have the opportunity to gain the knowledge and skills required to collect data related to assessment of individual health status. They learn the physical examination skills of inspection, palpation, percussion, and auscultation used to assess major body systems across the lifespan. They gain practical experience using interviewing techniques and communication skills for taking patient histories, and they discuss the psychological, social, and cultural aspects of clinical assessment. Additionally, students consider the integration of data to guide the nursing process and ethical guidelines. Engaging in interactive simulations, students apply knowledge and demonstrate understanding of conducting health assessments.

  • HA3001 Cultural and Genetic Influences on Health
    Identify population health, cultural influences, and genetic and genomic information as it relates to conducting a health history and physical assessment.
  • HA3002 Ethical Issues in Health Assessment
    Articulate ethical issues related to obtaining a health history and physical exam.
  • HA3003 Biopsychosocial Factors
    Evaluate the impact of biopsychosocial factors on a patient during a health assessment.
  • HA3004 Comprehensive Health History
    Conduct and document a comprehensive health history.
  • HA3005 Comprehensive Physical Assessment
    Conduct and document a comprehensive physical assessment.

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This course focuses on the knowledge and skills required to collect data related to assessment of individual health status. Physical examination skills of inspection, palpation, percussion, and auscultation are used to assess major body systems across the lifespan. Interviewing skills and history taking are included, as well as the psychological, social, and cultural aspects of clinical assessment. Attention is given to the integration of data to guide the nursing process, requisite communication skills, and ethical guidelines. Interactive simulations provide an opportunity for students to apply knowledge.

Week 4 Video: Health History
My name is Jenna Wampler and this is my government issued ID. Here is a scan of the room I
am conducting the interview in with no papers or notes.
Knock…Good morning, my name is Jenna I am a masters of nursing education student at
Walden University and I will be conducting your exam today. Before we get started are there any
language or hearing impairments I should be aware of?
Ryan: No.
Ok great. Can I have you verify your name and DOB?
Ryan Franks. June 10, 1988.
Ok and how would you classify your ethnicity?
Ryan: white or Caucasian
Ok and can you state how old you are?
Ryan: 30
And are you married?
Ryan: Yes, for almost a year
That’s great! OK thank you. I want to assure you that anything we discuss is confidential do you
have any questions about that? Wash hands
Tell me what brings you in today Ryan?
Ryan: I have a sore throat
Ok and when did that start?
Ryan: like 3-4 days ago
Ok and did you notice is happened suddenly when you woke up or has it gradually gotten wors
Ryan: I woke up with it and it keeps me up during the night because I keep swallowing
Okay and I saw on your computer chart you work at Country Companies, has anyone you work
with or live with been sick?
Ryan: No
Okay any other pain in your head, the back of your neck, or jaw?
Ryan: No
Can you describe the pain in your throat? Does it feel swollen or scratchy?
Ryan: Sore, it feels scratchy and itchy
On a scale of 1-10 if 10 is the worst sore throat you’ve had and 1 is no pain or uncomfortability
what would you rate your pain?
Ryan: a 5
You mentioned it keeps you up at night does it hurt to swallow
Ryan: ya it hurts really bad when I swallow
Okay so swallowing makes it worse, is there anything else you’ve noticed that makes it worse?
Ryan: not really
Ok does anything make it better or have you taken anything for it?
Ryan: no, I’ve tried cough drops at work and that’s about it
Ok so no cold medicines or gargling salt water?
Ryan: I tried 2 or 3 times but it didn’t really do anything
Ok so no other symptoms than the sore throat…no fever, stomach pain, or nausea
Ryan: no and no fever that I know of
Ok because this is your first visit at our clinic we want to get a history of your overall health and
go through each body system to ensure we cover everything and so I am going to ask you a
bunch of questions and then we can move on to addressing your sore throat and get you feeling
better
Ryan: ok sounds good
If at anytime you have any questions, concerns, or need clarification please stop me and we can
go over that ok?
Ryan: Ok
Alright so you mentioned you haven’t tried any medications for your sore throat, are there
meds you take daily by prescription or over the counter like Claritin or advil?
Ryan: No
Any vitamins or supplements?
Ryan: oh ya I take a multivitamin
OK very good. Are you allergic to any medications?
Ryan: not that I know of
Any food allergies?
Ryan: No
Any environmental allergies like pollen or cat hair?
Ryan: No
I saw that we scanned your immunizations into your electronic chart and everything is up to
date there? Do you get a flu shot every year?
Ryan: Yes
OK great. When was your last exam?
Ryan: I do a work physical every year but the last time I was at the doctor was probably in
college
Ok and did they do any testing or have concerns about any conditions?
Ryan: no they said my bp was good and I was pretty healthy
Do you go to the eye doctor and dentist regularly?
Ryan: Yes
Good. How would describe your overall health?
Ryan: pretty healthy I like to be active
What kinds of activities do you do to be active?
I know you said at your work check-up your blood pressure was good, Is there anything you’ve
been diagnosed with as an adult, cancer, diabetes, thyroid or kidney problems?
Ryan: No
Okay how about any sexually transmitted diseases?
Ryan: Ive never been tested
Any hospitalizations or surgeries?
Ryan: No
Have you ever had a blood transfusion?
Ryan: No
And do you consider yourself to have any disability?
Ryan: No
Alright sounds pretty healthy overall!
Ryan: Yea I think so
Do you currently or have you ever used any tobacco products?
Ryan: No
Do you drink alcohol?
Ryan: occasionally, like maybe one beer or glass of wine during the week and then once a day
on the weekend.
Okay so about 3-5 drinks in a week of just wine and beer?
Ryan: yea that’s about right
Have you ever used illegal drugs?
Ryan: no
So no marijuana or anything?
Ryan: No
Okay have you ever used prescription drugs that were or were not prescribed to you?
Ryan: No
You mentioned working at country companies what do you do there?
Ryan: I am a financial analyst
Ok and any environmental hazards you’re exposed to or any work related concerns?
Ryan: no
Any history of current feelings of depression?
Ryan: no
Do you wear your seatbelt?
Ryan: yes
Do you see a dentist and eye doctor at least every year?
Ryan: yes and the dentist every 6 months
Have you noticed any visual changes?
No
What do you do for fun?
Ryan: I like being outside and hiking, running, riding my bike, and golfing
Very good sounds active. Do you live with anyone else?
Ryan: Yes my wife and I rent a house
Okay good, and how would you describe your living condition?
Ryan: its great we love our house, its in a safe neighborhood, and clean
Great, how old is your wife?
Ryan: She’s 26
Do you have any children together or from previous relationships?
Ryan: No
OK, have you ever served in the military?
Ryan: no
Ok, now we are going to move on to family history so Ill ask you questions about your parents,
paternal, and maternal grandparents and if any members are deceased if you could let me know
roughly what age they passed away
Ryan: Ok
Ok let’s start with your mother
Ryan: She is still living
OK and does she have diabetes, heart disease, high blood pressure, cancer, or stroke?
Ryan: No
TB, CF, epilepsy, thyroid problems?
Ok and how about your dad?
Ryan: he has high blood pressure
Ok and do you know if he takes medication for that?
Ryan: I think so but I don’t know what
Do you know about what age he was diagnosed?
No
Ok and do you have any siblings?
Ryan: No I am an only child
OK, let’s move on to your maternal grandparents.
Ryan: all of my grandparents passed away around 75…my moms parents had heart disease. My
dads mom had a stroke, and my dads dad had diabetes.
I’m sorry to hear that, Ill make sure we keep this history in your chart and if any new conditions
develop with your parents we will be sure to update it
Ryan: Ok
I know you’ve answered a lot of questions today I have just a few more and these will be
specific to each body system and after that I will address your sore throat and we can proceed
with testing or prescribe medication ok?
Ryan: sounds good
You mentioned your sore throat wakes you at night, how do you feel you sleep normally?
Ryan: good I don’t really have any problems
Ok, any skin changes or rashes that you’ve noticed?
Ryan: No not at all
Are you having any headaches or sinus pain?
Ryan: no, I haven’t
Have you had any sneezing, runny nose, or stuffy nose?
Ryan: no
I know you mentioned no childhood asthma, do you have pain or trouble breathing?
Ryan: no
Have you been coughing at all?
Ryan: no
Any mucous production?
Ryan: no
Any chest pain or heart palpitations like your heart is racing fast?
Ryan: no
Any difficulty exercising?
Ryan: no I’m pretty active
Ok good. Have you noticed any swelling in your ankles, hands, feet?
Ryan: no
Has your sore throat impacted your appetite at all?
Ryan: no
How is your appetite regularly?
Ryan: its good
Can you recall what you ate yesterday starting with bfast
Any heartburn, vomiting, or nausea?
Ryan: no
Any changes in bowel movements?
Ryan: No
Any trouble urinating or do you notice dark or discolored urine?
Ryan: no
Are you having any body aches, joint stiffness, or pains?
Ryan: no
Any dizziness or confusion?
Ryan: no
Have you ever had a seizure?
Ryan: no
Any tenderness in your lymph node area?
Ryan: yea actually I do
Ok do they feel swollen?
Ryan: Ya
Any recent bleeding or bruising?
Ryan: No
Any unexplained weight loss or weight gain?
Ryan: no
Any feelings of depression, anxiety, mood swings, or trouble concentrating?
Ryan: no
Ok is there anything else you want to share about what’s going on or your health history?
Ryan: no
Ok and what problems concern you most today?
Ryan: just my throat
All right let’s move on to the exam and we’ll see what’s going on!
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