The Nursing History and Physical Exam

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!

Jennifer Moore, RN-BC, CDP, WCC started working in the senior care industry in 2000. She is a certified Gerontological Nurse, a Certified Dementia Practitioner, and Wound Care Certified. 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 Director of Curriculum Design & Research for Relias. Within this position, her responsibility is to oversee the development of online training modules across the healthcare continuum. She has served as the subject matter expert for courses on re-hospitalization, clinical skill reviews, leadership, management, 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, CDP, WCC has declared that no conflict of interest, Relevant Financial Relationship or Relevant Non-Financial Relationship exists.

Elizabeth Kellerman, MSN, RN worked as a critical care nurse in an Intensive Care Unit of a community hospital and that experience provided significant training in caring for older adults. Her experience and knowledge led her to nursing education where she taught at a community college as she received 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. She is currently developing her medical writing skills through the University of California San Diego's medical writing program. Disclosure: Elizabeth Kellerman, MSN, RN has declared that no conflict of interest, Relevant Financial Relationship or Relevant Non-Financial Relationship exists.