Name: Amarachi B Akpuaka Date: _____________________________ Nursing Physical Assessment Part 1 Health Assessment is a skill that must be practiced frequently and continue throughout your nursing career. Practice your health assessment skills on someone outside of class. You may use a family member or another classmate. Do not give their name or identifying information. Use your text as well as information on the Moodle site to help. Describe each area thoroughly. Please state what you see. Please type using the following format. Upload on the Moodle class site by the due date. See Rubric on last page. Background information (this is not a complete nursing history. Only basic information that may affect be noticed during the physical assessment). ● Patient Information: initials, age, sex, race. History of chronic illness, surgeries, allergies and is the patient on any medications. Give information about medications. What are they for, dosage, time given. How long have they been on them? Any problems with the medications? Preparing and Initiating Health Assessment • Inspect Environment: safety, emergency, privacy • Assess BP, Heart Rate, Respiratory Rate, Temperature, and Pain and verbalizes findings. • Describe how you would appropriately positions patient for comfort, safety, and privacy throughout assessment General Appearance and Mental Status • Assess apparent general state of health, affect and mood—Are they smiling, unhappy appearing, do they appear anxious or angry? • Speech pace and clarity, responds appropriately? Describe • Posture-Are they able to sit erect, do they have any obvious problems with mobility? Please Describe. • Personal hygiene (odors, cleanliness) • Assess alertness, orientation to person, place, & time—ask their name, where are they and the time of day. Please do not give name or personal identifying information of the person you are examining. Use initials. CATAGORY Exemplary Competent Developing Competency Not competent Content Content demonstrates what has been learned in the course or readings. All components of the criterion are addressed in a comprehensive and thorough manner 5 pt. Content addressed but one or two areas needed more detail. Maximum 3pt. Content is superficial and not well developed. 1 pt. Did not address or very little content. 0 pt. Language Is clear, concise, and easy to understand. Uses terminology appropriately. 2 pt. Some proofreading errors or an incorrect terms 1 pt Unclear or incorrect language 0 pt.
Nursing Physical Assessment Part 1 Health Assessment is a skill that must be practiced frequently and continue
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