The Nursing History and Physical Exam

 

The comprehensive nursing history and physical is the first step and foundation of the nursing process. The collection of resident data helps you identify the individual’s needs, strengths, risk factors, and limitations. This, in turn, will assist in developing an individualized, person-centered plan of care. Additionally, the data collected provides a benchmark for comparison of future resident data, which will help identify changes in the individual’s health status. In this course, you will learn the basic principles and guidelines for completing the comprehensive health history and physical exam. In addition, you will learn about the other types of screenings you may need to perform for a thorough picture of the resident.

$22.50

Hours: 1.50
REL-SRC-0-NHPE

Certificates

Certificates provided by accrediting body (7 Match)

California Board of Registered Nursing

1.5 HOURS


Provider approved by the California Board of Registered Nursing, CEP# 13791

Nurses will receive 1.50 contact hours for participating in this course.

District of Columbia Board of Nursing

1.5 HOURS


DC-RN -- District of Columbia Board of Nursing Approved Continuing Education program (CE Provider #50-290).

Nurses will receive 1.50 contact hours for participating in this course.

Florida Board of Nursing CE

1.5 HOURS


Florida Board of Nursing CE Provider #: 50-290

Nurses will receive 1.50 contact hours for participating in this course.

American Nurses Credentialing Center

1.5 HOURS


Relias, LLC is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.

Nurses will receive 1.50 contact hours for participating in this course.

Georgia Board of Nursing

1.5 HOURS


Georgia Board of Nursing CE Provider #: 50-290

Nurses will receive 1.50 contact hours for participating in this course.

South Carolina Board of Nursing

1.5 HOURS


This program was approved by the South Carolina Board of Nursing Approved Continuing Education Program (CE provider #50-290) CE Broker Course # 20-[Custom_Code]

West Virginia Board of Registered Nursing

1.5 HOURS


Course Details

Course Code: REL-SRC-0-NHPE
Hours: 1.5
Type: Online Course
Content Expiration Date: 2/28/2021
Learning Objectives:
Summarize the basic principles and guidelines for completing a comprehensive nursing assessment.
Explain how to complete a comprehensive health history.
Illustrate how to complete a comprehensive physical exam.
Identify the other types of assessments and screenings that may need to be completed.

Outline:

Section 1: Introduction




  1. About This Course

  2. Learning Objectives



Section 2: The Basics of the Assessment




  1. Importance of the Assessment

  2. Subjective vs. Objective Data

  3. Basic Techniques

  4. General Guidelines

  5. Review

  6. Summary



Section 3: The Health History




  1. Factors Affecting the Interview

  2. Demographic Information

  3. Social and Family History

  4. Past and Current Health Status

  5. Review of Systems

  6. Mental Status

  7. Medications

  8. Preparing for the Exam

  9. Review

  10. Summary



Section 4: The Physical Exam – Head and Neck




  1. Basic Assessment Data

  2. Skin Assessment

  3. Head and Neck

  4. Eyes

  5. Ears

  6. Nose and Sinuses

  7. Mouth and Pharynx

  8. Water Swallow Test

  9. Review

  10. Summary



Section 5: The Rest of the Physical Exam




  1. Thorax

  2. Lung Auscultation

  3. Heart Auscultation

  4. Abdomen

  5. Reproductive Organs

  6. The Extremities

  7. Cerebellar Function

  8. Review

  9. Summary



Section 6: Other Assessments and Screenings




  1. Functional Assessment

  2. Cognitive Impairment Screening

  3. Depression Screening

  4. Pressure Ulcer Risk Assessment

  5. Fall Risk Assessment

  6. Elopement Risk Assessment

  7. Elder Abuse

  8. Other Screenings

  9. Review

  10. Summary



Section 7: Conclusion




  1. Summary

  2. Course Contributors

  3. Resources

  4. References

  5. Congratulations!


Staff Writer: Jennifer Moore, RN-BC, DNS-CT, CDP
Jennifer Moore, RN-BC, DNS-CT, CDP started working in the senior care industry in 2000. She is a certified Gerontological Nurse, a Director of Nursing Services – Certified, and a Certified Dementia Practitioner. She has held positions including MDS Coordinator, Director of Nursing, Medicare Nurse Coordinator, Nurse Consultant, Area Manager, and Director of Quality Assurance. Her overall responsibility within each of these positions was to ensure residents received the highest quality of care. This included active participation in quality improvement initiatives, review of clinical records to identify areas of weakness, corroboration with the medical director to institute policies and procedures for resident care, and staff education/training. Additionally, she was responsible for maintaining an effective compliance program under a Quality of Care Corporate Integrity Agreement with the Office of Inspector General for a period of five years. She currently serves as the manager of curriculum design for post-acute care for Relias. Within this position, her responsibility is to oversee the development of online training modules for the post-acute care industry. She has served as the subject matter expert for courses on re-hospitalization, clinical skill reviews, and various OSHA and regulatory compliance topics. In addition, she has presented at various state conferences on mandatory compliance, quality assessment and assurance (QA&A), and quality assurance and performance improvement (QAPI). Disclosure: Jennifer Moore, RN-BC, DNS-CT, CDP has declared that no conflict of interest, Relevant Financial Relationship or Relevant Non-Financial Relationship exists.
Expert Reviewer: Elizabeth Kellerman, MSN, RN
Elizabeth Kellerman MSN, RN started in nursing in 2007 after graduating from Samuel Merritt University in Oakland, California. While working in a critical care unit at Sutter Mills-Peninsula Hospital she earned her CCRN and TNCC. Her experience and knowledge led her to nursing education where she taught at a community college while working to receive her Master's in Nurse Education at Western Carolina University. As a nursing instructor, she spent time in many types of care settings including medical-surgical inpatient and community living centers. Her passion for education and training has most recently led her to a position as subject matter expert and content writer for Relias. Disclosure: Elizabeth Kellerman, MSN, RN has declared that no conflict of interest, Relevant Financial Relationship or Relevant Non-Financial Relationship exists.
Target Audience:
The target audience for this course is: entry level Nurses; in the following settings: Post-Acute Care.
G Tags:
G512, G514
Relias will be transparent in disclosing if any commercial support, sponsorship or co-providership is present prior to the learner completing the course.
Course Delivery Method and Format
Asynchronous/Online Distance Learning; please see certificate details for specifics on delivery format.
Relias has a grievance policy in place to facilitate reports of dissatisfaction. Relias will make every effort to resolve each grievance in a mutually satisfactory manner. In order to report a complaint or grievance please contact Relias.
If you require special accommodations to complete this module, please contact Relias Support by completing the web form (https://www.relias.com/help) or by using the chat functionality.
All courses offered by Relias, LLC are developed from a foundation of diversity, inclusiveness, and a multicultural perspective. Knowledge, values and awareness related to cultural competency are infused throughout the course content.
Reference herein to any specific commercial product, process, or service by trade name, trademark, service mark, manufacturer or otherwise does not constitute or imply any endorsement, recommendation, or favoring of, or affiliation with, Relias, LLC.
All characteristics and organizations referenced in the following training are fictional. Any resemblance to any actual organizations or persons living or dead, is purely coincidental.
To earn continuing education credit for this course you must achieve a passing score of 80% on the post-test and complete the course evaluation.
Accommodations
If you require special accommodations to complete this module, please contact Relias Customer Support here.