WVNCC | West Virginia Northern Community College



WVNCC | West Virginia Northern Community College

West Virginia Northern Community College
Master Course Guide

Course Number: NURS 133

Course Title: Health Assessment and Diagnostics I


Course Description: This course is designed to introduce the nursing student to the knowledge and skills required to perform a health assessment across the lifespan and to document appropriate findings. The nursing student will be introduced to normal lab values and basic diagnostic procedures.



Prerequisites: Admission to nursing program

Prerequisites/Corequisites: A&P 1

Corequisites: Introduction to Nursing Concepts, Drug Dosage and Calculation I

Credit Hours: 2 Lecture: 1 Lab: 1 Contact: 4

Expanded Description / Course Focus: The course is designed to assist students to develop skills in history taking, psychosocial assessment, and physical assessment. Content focuses on assessment of individuals throughout the lifespan. This course teaches basic laboratory studies, normal and abnormal values, lab studies specific to body systems and basic diagnostic procedures. Emphasis is placed on detailed health history taking, differentiation, interpretation, and documentation of normal and abnormal findings. The course includes lecture, discussion, and demonstration of history taking and an integrated physical assessment.


Text Information Available in Bookstore

Required Equipment for Course Black Pen
Tablet Watch with second hand
E-Book Uniform
Stethoscope Nursing Student ID
Sphygmomanometer Other as designated
Course Student Learning Outcomes: The following list of student learning outcomes will be achieved at the successful completion of the course.

Human Flourishing: Advocate for patients and families in ways that promote their self-determination, integrity, and ongoing growth as human beings. (Diversity, holism, patient-centeredness, caring)
• Perform an integrated comprehensive health assessment

Nursing Judgment: Make judgments in practice, substantiated with evidence, that integrate nursing science in the provision of safe, quality care and that promote the health of patients within a family and community context. (Patient-centeredness, holism, ethics)
• Critically analyze findings from the collection of subjective and objective data and to distinguish to between consistent with health and the data which indicates alteration in health

Professional Identity: Implement one’s role as a nurse in ways that reflect integrity, responsibility, ethical practices, and an evolving identity as a nurse committed to evidence-based practice, caring, advocacy, and safe, quality care for diverse patients within a family and community context. (Ethics, Caring, Integrity, Patient-centeredness, excellence)
• Integrate teaching/learning principles into patient interviews and physical assessments

Spirit of Inquiry: Examine the evidence that underlies clinical nursing practice to challenge the status quo, question underlying assumptions, and offer new insights to improve the quality of care for patients, families, and communities. (Excellence)
• Demonstrate knowledge of preparation and post-procedure care for patients undergoing lab and diagnostic tests

Student Learning Outcomes: The following list of student learning performance objectives will be addressed in the course.

1. Importance of Health Assessment
a. Define the term assessment in the context of the nursing process.
b. Explain the importance of the health assessment process.
c. Describe the components of a health assessment.
d. Distinguish between objective and subjective data.
e. Identify situations in which the appropriateness of the chosen health assessment approach varies.
f. Discuss the purpose of maintaining a written medical record.
g. Differentiate between health promotion and health protection.
h. Describe the three levels of health promotion.
2. Interview Techniques
a. State the purposes of a health history.
b. Distinguish the purposes of comprehensive and focused health assessments.
c. Describe when to use open-ended, closed-ended, and directive questioning.
d. Articulate the scope of the health history.
e. Delineate types of data that belong under each of the following sections of a health history:
 Biographic data
 Reason for seeking care
 Present health status
 Past health history
 Family history
 Review of systems
 Psychosocial status
 Environmental health
f. Describe the health history format based on functional health patterns.
g. Describe age-related and situational variations in the health history.
h. Describe components of activities of daily living (ADL) assessment.
i. Demonstrate use of open-ended, closed-ended, and directive questioning.
j. Demonstrate communication enhancement and communication diminishment techniques.
3. Techniques and Equipment
a. Describe the use of inspection, palpation, percussion, and auscultation in physical assessment.
b. Identify the positions used for examination of the patient.
c. Discuss the importance of draping the patient during a physical examination.
d. Describe the equipment used during a physical examination:
e. Define Standard Precautions.
f. Identify the rationale for using personal protective equipment during a physical examination.
g. Demonstrate techniques of inspection, palpation, percussion, and auscultation.
h. Demonstrate correct use of specific equipment used in a physical examination.

4. General Inspection/Vital Signs
a. Identify the components of a general inspection.
b. Discuss variables that influence a nurse’s impressions of the patient during general inspection.
c. Compare methods used to measure body temperature.
d. Describe the purpose of and methods for measuring heart rate.
e. Discuss techniques used for measurement of respiratory rate.
f. Describe the purpose of and methods for measuring blood pressure.
g. Describe the technique for measurement of oxygen saturation.
h. Review the normal ranges of vital signs across age groups.
i. Discuss variables that affect the measurement of vital signs.
j. Discuss techniques used for and variables that affect the measurement of height and weight across the life span.
k. Complete a general inspection and document findings.
l. Perform techniques for measurement of vital signs, height, and weight.
5. Ethic, Cultural, and Spiritual Considerations
a. Identify the importance that cultural considerations play in shaping nursing care.
b. Describe ways to increase cultural sensitivity.
c. Cite facts in the following areas for four major cultural minority groups (African Americans, Hispanics/Mexicans, Asians/Pacific Islanders, American Indians/Alaskan Natives):
 Demographic trends
 Education and employment
 Health care utilization
 General health status
 Health beliefs
 Health practices
 Family relationships
 Communication
 Religious experiences/special rituals
 Dietary practices
d. Recognize that cultural diversity exists.
e. Demonstrate awareness of one’s own cultural beliefs.
f. Demonstrate awareness of one’s own stereotypes and prejudices toward those who are different from self.
6. Pain Assessment
a. Review the anatomy and physiology of pain.
b. Differentiate among the different types of pain.
c. Relate the relevant data that are included in a comprehensive health history for pain.
d. Distinguish specific age-related and cultural data that are included in a comprehensive health history for pain.
e. Identify screening tools and scales that may be used for the assessment of pain.
f. Describe appropriate inspection techniques used in the assessment of pain.
g. Describe expected findings derived from the assessment of pain.
h. Describe variations related to age, race, culture, and gender that are expected on assessment of pain.
i. Demonstrate history-taking and examination techniques appropriate for the assessment of pain.
j. Use screening tools during the assessment of pain.
7. Nutritional Assessment
a. Discuss the various approaches used in anthropometric assessment.
b. Identify types of biochemical/lab tests that aid nutritional assessment.
c. Describe the components of a nutritional clinical examination.
d. Distinguish different methods for obtaining a diet history.
e. Review the recommended daily intake guidelines for healthy eating.
f. Discuss how nutritional assessments are adapted for various age groups.
g. Review clinical signs and laboratory findings indicative of malnourishment.
 Albumin
 Pre-albumin
 Hemoglobin and Hematocrit
 Blood Glucose
 Lipid Profile
 Urine specific gravity
h. Identify indicators for nutritional supplementation.
i. Discuss “red flags” and associated assessment findings for nutritional inadequacy across the life span.
j. Describe common problems and conditions associated with nutrition.
k. Compute body mass index.
8. Developmental Assessment
a. Describe three major aspects of development.
b. Discuss selected theories of psychosocial and cognitive development.
c. Classify expected developmental tasks across the life span.
d. Describe developmental tasks of the family.
e. Identify purpose of developmental assessment.
9. Mental Status Assessment
a. Identify screening tools appropriate for a mental health assessment.
b. Describe appropriate observation and interview techniques used in mental health assessment.
c. Describe expected findings derived from the mental health assessment.
d. Describe minor variations that may be found during a mental health assessment.
e. Describe variations related to age, race, culture, gender, and selected situations that are expected during a mental health assessment
10. Skin, Hair and Nails
a. Review anatomy of the skin, hair, and nails.
b. Review physiology of the skin, hair, and nails that is relevant to their assessment.
c. Delineate age-related, cultural, and situational variations in anatomy and physiology that can be expected to affect assessment of the skin, hair, and nails.
d. Relate the relevant data that are included in a comprehensive health history of the skin, hair, and nails.
e. Identify equipment appropriate to the examination of the skin, hair, and nails.
f. Identify common problems and conditions of the skin, hair, and nails.
g. Discuss health promotion practices that are pertinent to the skin, hair, and nails.
h. Demonstrate history-taking and examination techniques appropriate for the skin, hair, and nails.
i. Review clinical signs and laboratory findings
 Electrolytes
 Wound cultures
 Allergy Testing
j. Review equipment needed in the assessment of the skin, hair, and nails.
11. Head, Eyes, Ears. Nose and Throat
a. Review anatomy of the head, eyes, ears, nose, and throat that is pertinent in assessment of that system.
b. Review physiology of the head, eyes, ears, nose, and throat that is relevant to assessment of that system.
c. Relate the relevant data that are included in a comprehensive health history of the head, eyes, ears, nose, and throat.
d. Distinguish specific age-related, cultural, and situational data that are included in a comprehensive health history of the head, eyes, ears, nose, and throat.
e. Identify equipment appropriate to the examination of the head, eyes, ears, nose, and throat.
f. Describe appropriate inspection, palpation, and positioning techniques used in the examination of the head, eyes, ears, nose, and throat.
g. Describe expected findings derived from the examination of the head, eyes, ears, nose, and throat.
h. Describe minor variations that may be found on examination of the head, eyes, ears, nose, and throat.
i. Describe variations related to age, race, culture, gender, and selected situations that are expected on examination of the head, eyes, ears, nose, and throat.
j. Describe abnormal findings that may be identified by examination of the head, eyes, ears, nose, and throat.
k. Identify common problems and conditions of the head, eyes, ears, nose, and throat.
l. Demonstrate history-taking and examination techniques appropriate for the head, eyes, ears, nose, and throat.
12. Lungs
a. Review anatomy of the lungs and respiratory system that is pertinent in assessment of that system.
b. Review physiology of the lungs and respiratory system that is relevant to assessment of that system.
c. Relate the relevant data that are included in a comprehensive health history of the lungs and respiratory system.
d. Describe appropriate inspection, auscultation, palpation, percussion, and positioning techniques used in the examination of the lungs and respiratory system.
e. Describe expected findings derived from the examination of the lungs and respiratory system.
f. Describe variations related to age, race, gender, and selected situations that are expected on examination of the lungs and respiratory system.
g. Describe abnormal findings related to examination of the lungs and respiratory system.
h. Review laboratory findings and diagnostic testing relevant to assessment of the lungs and respiratory system
 ABGs
 CBC
 Sputum examination
 Skin Tests
 X-ray
 CT scan
 VQ scan
 PFTs
 Bronchoscopy
i. Identify common problems and conditions of the lungs and respiratory system.
j. Demonstrate history-taking and examination techniques appropriate for the lungs and respiratory system.
k. Review equipment needed in the assessment of the lungs and respiratory system.
13. Heart and Peripheral Vascular
a. Review anatomy of the heart and peripheral vascular system that is pertinent in assessment of that system.
b. Review physiology of the heart and peripheral vascular system that is relevant to assessment of that system.
c. Relate the relevant data that are included in a comprehensive health history of the heart and peripheral vascular system.
d. Describe appropriate inspection, auscultation, palpation, percussion, and positioning techniques used in the examination of the heart and peripheral vascular system.
e. Describe expected findings derived from the examination of the heart and peripheral vascular system.
f. Describe variations related to age, race, gender, and selected situations that are expected on examination of the heart and peripheral vascular system.
g. Describe abnormal findings related to examination of the heart and peripheral vascular system.
h. Review laboratory findings and diagnostic testing relevant to assessment of the heart and peripheral vascular system.
 Enzymes and markers
 Lipid profile
 Electrocardiogram
 Stress test
 X-rays
 Ultrasound
 Arteriogram
i. Identify common problems and conditions of the heart and peripheral vascular system.
j. Demonstrate history-taking and examination techniques appropriate for the heart and peripheral vascular system.
k. Review equipment needed in the assessment of the heart and peripheral vascular system.
14. Abdomen and GI
a. Review anatomy of the abdomen and gastrointestinal system that is pertinent in assessment of that system.
b. Review physiology of the abdomen and gastrointestinal system that is relevant to assessment of that system.
c. Relate the relevant data that are included in a comprehensive health history of the abdomen and gastrointestinal system.
d. Cite pertinent rationale for collection of relevant data.
e. Describe appropriate inspection, auscultation, palpation, percussion, and positioning techniques used in the examination of the abdomen and gastrointestinal system.
f. Describe expected findings derived from the examination of the abdomen and gastrointestinal system.
g. Describe variations related to age, race, gender, and selected situations that are expected on examination of the abdomen and gastrointestinal system.
h. Describe abnormal findings related to examination of the abdomen and gastrointestinal system.
i. Review laboratory findings and diagnostic testing relevant to assessment of the abdomen and gastrointestinal system.
 Urinalysis
 Renal function tests
 Liver function tests
 BUN/Creatinine
 Urine culture
 Stool for occult blood
 Biopsy
 X-ray
 Ultrasound
 CT Scan
 Direct observation tests
j. Identify common problems and conditions of the abdomen and gastrointestinal system.
k. Demonstrate history-taking and examination techniques appropriate for the abdomen and gastrointestinal system.
l. Review equipment needed in the assessment of the abdomen and gastrointestinal system.
15. Musculoskeletal
a. Review anatomy of the musculoskeletal system that is pertinent in assessment of that system.
b. Review physiology of the musculoskeletal system that is relevant to assessment of that system.
c. Relate the relevant data that are included in a comprehensive health history of the musculoskeletal system.
d. Describe appropriate inspection, palpation, percussion, and positioning techniques used in the examination of the musculoskeletal system.
e. Describe expected findings derived from the examination of the musculoskeletal system.
f. Describe variations related to age, race, gender, and selected situations that are expected on examination of the musculoskeletal system.
g. Review laboratory findings and diagnostic testing relevant to assessment of the musculoskeletal system.
 Alkaline Phosphatase
 Calcium
 Uric Acid
 Creatine kinase
 BUN
 Biopsy
 Radiographic diagnostics (x-ray, CT scan, MRI)
 Bone density
 Arthroscopy
 Electromyography
h. Describe abnormal findings related to examination of the musculoskeletal system.
i. Identify common problems and conditions of the musculoskeletal system.
j. Demonstrate history-taking and examination techniques appropriate for the musculoskeletal system.
k. Review equipment needed in the assessment of the musculoskeletal system
16. Neurologic
a. Review anatomy of the neurologic system that is pertinent in assessment of that system.
b. Review physiology of the neurologic system that is relevant to assessment of that system.
c. Relate the relevant data that are included in a comprehensive health history of the neurologic system.
d. Describe appropriate inspection, palpation, percussion, and positioning techniques used in the examination of the neurologic system.
e. Describe expected findings derived from the examination of the neurologic system.
f. Describe variations related to age, race, gender, and selected situations that are expected on examination of the neurologic system.
g. Review laboratory findings and diagnostic testing relevant to assessment of the neurologic system
 ICP/CPP
 Neuroimaging Studies
 X-rays
 Electroencephalogram
 Biopsy
 Lumbar Puncture
h. Describe abnormal findings related to examination of the neurologic system.
i. Identify common problems and conditions of the neurologic system.
j. Demonstrate history-taking and examination techniques appropriate for the neurologic system.
k. Review equipment needed in the assessment of the neurologic system.
17. Breasts and Axillae
a. Review anatomy of the breasts and axillae that is pertinent in assessment of that system.
b. Review physiology of the breasts and axillae that is relevant to assessment of that system.
c. Relate the relevant data that are included in a comprehensive health history of the breasts and axillae.
d. Describe appropriate inspection, palpation, and positioning techniques used in the examination of the breasts and axillae.
e. Describe expected findings derived from the examination of the breasts and axillae.
f. Describe variations related to age, race, gender, and selected situations that are expected on examination of the breasts and axillae.
g. Review laboratory findings and diagnostic testing relevant to assessment of the breast and axillae
 Mammogram
h. Describe abnormal findings related to examination of the breasts and axillae.
i. Identify common problems and conditions of the breasts and axillae.
j. Demonstrate history-taking and examination techniques appropriate for the breasts and axillae
18. Head-to-toe Assessment
a. Derive guidelines for use in performing a comprehensive history and physical examination that includes all body systems.
b. Analyze approach and findings from a specified comprehensive assessment.
c. Recount the sequential structure used for recording history and physical examination findings.
d. Discuss the compilation of a risk profile using findings from a health assessment.
e. Use an organized approach in performing a comprehensive history and physical examination.
19. Documenting the Assessment
a. Discuss examples for each part of the comprehensive history and examination for a well client.
b. Explain the reasons why the nurse must document the health assessment in an accurate, concise, and legible manner, without bias or opinion