Obtaining a History and Physical Exam for Nurses

Course Code: REL-PAC-0-OHPEX

Hours: 1.75

Type: Online Course

Content Expiration Date: 12/31/2024

Learning Objectives:
Describe the steps in completing a comprehensive health history.
Identify the types of assessments and screenings that may need to be completed.
Explain how to complete a comprehensive physical exam.
Discuss the basic principles and guidelines for completing a comprehensive nursing assessment.

Outline:

Section 1: Introduction

About This Course

Learning Objectives

Section 2: The Basics of the Assessment

The Initial Nursing Assessment

Importance of the Assessment

Subjective vs. Objective Data

Basic Physical Assessment Techniques

General Assessment Guidelines

Review

Summary

Section 3: The Health History

Factors Affecting the Interview

Demographic Information

Social and Family History

Past and Current Health Status

Review of Systems

Mental Status

Medications

Preparing for the Exam

Review

Summary

Section 4: The Physical Exam: Head and Neck

Basic Assessment Data

Skin Assessment

Head and Neck

Eyes

Ears

Nose and Sinuses

Mouth and Pharynx

Yale Swallow Protocol (YSP)

Review

Summary

Section 5: The Rest of the Physical Exam

Thorax

Lung Auscultation

Heart Auscultation

Abdomen

Reproductive Organs

The Extremities

Cerebellar Function

Review

Summary

Section 6: Other Assessments and Screenings

Functional Assessment

Cognitive Impairment Screening

Depression Screening

Pressure Injury Risk Assessment

Fall Risk Assessment

Wandering and Elopement Risk Assessment

Other Screenings

Review

Elder Abuse

Summary

Section 7: Conclusion

Course Summary

Course Contributor

References

Instructor: Edward Bartels, RN, BSN, MICN

Ed has 30 plus years of nursing experience with clinical roles in trauma, emergency, critical care, skilled nursing, behavioral health, occupational health, home care, and is a certified clinical nursing instructor in North Carolina. Ed served as Director of Nursing for rural emergency services and physician practices. Ed earned his Bachelor of Science in Nursing from the University of North Carolina, Greensboro. Ed retired from the U.S. Coast Guard with 34 years served.

Target Audience:
The target audience for this course is: Nurses; in the following settings: Post-Acute Care.

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All courses offered by Relias Learning, 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.

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.

Course Delivery Method and Format
Asynchronous Distance Learning with interactivity which includes quizzes with questions/answers, and posttests.