Comprehensive Physical Assessment
Comprehensive Physical Assessment
This Comprehensive Assessment activity provides the opportunity to plan and conduct a full health assessment on a patient in a single clinic visit. Students spend, on average, three hours on this activity.
Before entering the clinic room you will complete the Plan My Exam activity to organize the exam procedures you will use into a sequence that moves smoothly from head to toe by mapping them to the region of the body where you will perform them. After you have planned your exam, you will enter the clinic room and conduct a Comprehensive Assessment by interviewing and examining your Digital Standardized Patient.
These prompts help you think more deeply about your performance in the activity. Reflective writing develops your clinical reasoning skills as you grow and improve as a clinician and gives your instructor insight into your learning process. The more detail and depth you provide in your responses, the more you will benefit from this activity.
- Read Chapters 4-11 in Jarvis, C. (2015). Physical examination and health assessment (7th ed.). St. Louis, MO: Saunders.
- Read Chapters 12-17 in Jarvis, C. (2015). Physical examination and health assessment (7th ed.). St. Louis, MO: Saunders.
- Read Chapters 4, 18 & 31 In Jarvis, C. (2015). Physical examination and health assessment (7th ed.). St. Louis, MO: Saunders.
- Read Chapters 19-20 In Jarvis, C. (2015). Physical examination and health assessment (7th ed.). St. Louis, MO: Saunders.
- Optional Resource: Map the Human Heart
Map of the Human Heart — NOVA | PBS
See exactly how your heart pumps blood throughout your body and learn astounding facts about the human heart.
- Read Chapters 21 and 24-26 in Jarvis, C. (2015). Physical examination and health assessment (7th ed.). St. Louis, MO: Elsevier.
- Read Chapters 22-23 In Jarvis, C. (2015). Physical examination and health assessment (7th ed.). St. Louis, MO: Elsevier.
- Read Chapters 28 in Jarvis, C. (2015). Physical examination and health assessment (7th ed.). St. Louis, MO: Elsevier.
Additional Instructions:
- All submissions should have a title page and reference page.
- Utilize a minimum of two scholarly resources.
- Adhere to grammar, spelling and punctuation criteria.
- Adhere to APA compliance guidelines.
- Adhere to the chosen Submission Option for Delivery of Activity guidelines.
Submission Option:
Instruction
Paper
- 2 to 3-page paper. Include title and reference pages.
Baccalaureate Generalist- Comprehensive Physical Assessment
Description: The baccalaureate-graduate nurse cares for patients, including individuals,
families, groups, communities, and populations across the lifespan and across the continuum
of healthcare environments, perform comprehensive and focused developmental and physical
assessments.
Course Competencies: 1) Perform assessments of individuals throughout the lifespan and
include spiritual, social, cultural, psychological and physical components. 3) Analyze data to
determine risk potential for individuals. 4) Synthesize assessment findings using the Digital
Clinical Experience (DCE) and in written format using standardized terminology. 5)
Demonstrate effective communication with individuals, families and interdisciplinary team
members.
QSEN Competencies: 1) Patient-Centered Care 3) Evidenced-Based Practice
BSN Essential IX
Area Gold
Mastery
Silver
Proficient
Bronze
Acceptable
Acceptable
Mastery not
Demonstrated
Digital Clinical
Experience
Score
Fully discusses
Clinical
Experience score
results and how it
relates to your
clinical practice
Describes
Clinical
Experience score
results and how
it relates to your
clinical practice
Superficially
discusses
Clinical
Experience score
results and how
it relates to your
clinical practice
Does not use
appropriate
developmental
approaches.
Student
Performance
Index
Fully discusses
results from the
Performance
Index and how
score results and
how it relates to
your clinical
practice
Describes results
from the
Performance
Index and how
score results and
how it relates to
your clinical
practice
Superficially
discusses results
from the
Performance
Index and how
score results and
how it relates to
your clinical
practice
Does not use
appropriate
physical
assessment
skills.
Subjective Data
Collection
Fully discusses
results from the
Subjective Data
Collection and
how score results
and how it relates
to your clinical
practice
Describes results
from the
Subjective Data
Collection and
how score
results and how
it relates to your
clinical practice
Superficially
discusses results
from the
Subjective Data
Collection and
how score
results and how
it relates to your
clinical practice
Does not use
appropriate
physical
assessment
skills.
Objective Data
Collection
Fully discusses
results from the
Objective Data
Collection and
how score results
Describes results
from the
Objective Data
Collection and
how score
Superficially
discusses results
from the
Objective Data
Collection and
Does not use
appropriate
physical
assessment
skills.
and how it relates
to your clinical
practice
results and how
it relates to your
clinical practice
how score
results and how
it relates to your
clinical practice
Care Plan Fully discusses a
care plan that
contains one
NANDA DX with
three NICs and
three NICs
Describes care
plan that
contains one
NANDA DX
with three NICs
and three NICs
Superficially
discusses a care
plan. Does not
use NANDA,
NIC, and NOC
Does not use
appropriate
physical
assessment
skills.
Time:
Interaction with
Patient
Post-exam
activities
Fully discusses
the time spent
and what
changes you
would make
and/or how can
the time be
better spent?
Describes the
time spent and
what changes
you would make
and/or how can
the time be
better spent?
Superficially
discusses the
time spent and
what changes
you would make
and/or how can
the time be
better spent?
Does not use
appropriate
physical
assessment
skills.
Self-reflection
Fully discusses a
self-reflection
from the
Comprehensive
Experience
exercise. How did
the experience
relate to your
clinical practice
describes a self-
reflection from
the
Comprehensive
Experience
exercise. How
did the
experience relate
to your clinical
practice
Superficially
discusses a self-
reflection from
the
Comprehensive
Experience
exercise. How
did the
experience relate
to your clinical
practice
Does not provide
a detailed
reflection of the
comprehensive
Experience
exercise
APA, Grammar,
Spelling, and
Punctuation
No errors in
APA, Spelling,
and Punctuation.
One to three
errors in APA,
Spelling, and
Punctuation.
Four to six
errors in APA,
Spelling, and
Punctuation.
Seven or more
errors in APA,
Spelling, and
Punctuation.
References Provides two or
more references.
Provides two
references.
Provides one
references.
Provides no
references.
Comprehensive physical Assessment
HAIR NAILS, SKIN
SUBJECTIVE: Reports improved acne due to oral contraceptives. Skin on neck has stopped darkening and facial and body hair has improved. She reports a few moles but no other hair or nail changes.
OBJECTIVE: Scattered pustules on face and facial hair on upper lip, acanthosis nigricans on posterior neck.
NEUROLOGICAL
SUBJECTIVE: Reports no dizziness, light-headedness, tingling, loss of coordination or sensation, seizures, or sense of disequilibrium.
OBJECTIVE: strength 5/5 bilateral upper and lower extremities. Normal graphesthesia, stereognosis, and rapid alternating movements bilaterally. Tests of cerebellar function normal. DTRs 2+ and equal bilaterally in upper and lower extremities. Decreased sensation to monofilament in bilateral plantar surfaces.
MUSCULO
SUBJECTIVE: Reports no muscle pain, joint pain, muscle weakness, or swelling.
OBJECTIVE: Bilateral upper and lower extremities without swelling, masses, or deformity and with full range of motion. No pain with movement.
ABDOMINAL
SUBJECTIVE: Gastrointestinal: Reports no nausea, vomiting, pain, constipation, diarrhea, or excessive flatulence. No food intolerances. Genitourinary: Reports no dysuria, nocturia, polyuria, hematuria, flank pain, vaginal discharge or itching.
OBJECTIVE: Abdomen protuberant, symmetric, no visible masses, scars, or lesions, coarse hair from pubis to umbilicus. Bowel sounds are normoactive in all four quadrants. Tympanic throughout to percussion. No tenderness or guarding to palpation. No organomegaly. No CVA tenderness.
CARDIOVASCULO
Subjective: Reports no palpitations, tachycardia, easy bruising, or edema. OBJECTIVE: Heart rate is regular, S1, S2, without murmurs, gallops, or rubs. Bilateral carotids equal bilaterally without bruit. PMI at the midclavicular line, 5th intercostal space, no heaves or lifts. Bilateral peripheral pulses equal bilaterally, capillary refill less than 3 second
s. No peripheral edema.
RESPIRATORY.
SUBJECTIVE :Reports no shortness of breath, wheezing, chest pain, dyspnea, or cough.
OBJECTIVE: Chest is symmetric with respiration, clear to auscultation bilaterally without cough or wheeze. Resonant to percussion throughout. In office spirometry: FVC 3.91 L, FEV1/FVC ratio 80.56%.
HEENT
SUBJECTIVE: Reports no current headache and no history of head injury or acute visual changes. Reports no eye pain, itchy eyes, redness, or dry eyes. Wears corrective lenses. Last visit to optometrist 3 months ago. Reports no general ear problems, no change in hearing, ear pain, or discharge. Reports no change in sense of smell, sneezing, epistaxis, sinus pain or pressure, or rhinorrhea. Reports no general mouth problems, changes in taste, dry mouth, pain, sores, issues with gum, tongue, or jaw. No current dental concerns, last dental visit was 5 months ago. Reports no difficulty swallowing, sore throat, voice changes, or swollen nodes.
Reports no current headache and no history of head injury or acute visual changes. Reports no eye pain, itchy eyes, redness, or dry eyes. Wears corrective lenses. Last visit to optometrist 3 months ago. Reports no general ear problems, no change in hearing, ear pain, or discharge. Reports…
