Adult Health Assessment Study Guide

Adult Health Assessment Lab Information

General Information

  • Purpose: Adult health assessment finals.

  • Instructions: Students have 15 minutes for the system assessment but will receive 30 minutes to prepare and set up.

  • Each student will complete a system assessment on their partner as outlined in the rubric. Different systems will be assessed by each partner.

  • Schedule: One week prior to the testing week, students will sign up with their partner and will be randomly assigned to testing week 1 or week 2.

  • If both NF2 (Nursing Fundamentals 2) and AHA (Adult Health Assessment) assessments are scheduled on the same day, note that BVC allows for two assessments in one day. Plan accordingly.

Assessment Guidelines

  • Assessments must be conducted on bare skin (e.g., heart sounds, skin temperature, pulses, edema); assessments cannot be accurately performed over clothing.

  • Patients do not need to remove all clothing; they must wear appropriate covering to maintain modesty during assessments.

  • Draping: Nurses must ensure patient privacy by applying appropriate draping during the assessment.

  • Stethoscope Usage: Must have skin contact and should not be placed over clothing. Assessments include exposed areas such as arms (shoulders to hands), legs (knees to feet), chest, and back, but some areas do not need to be viewed by the evaluator or camera.

Required Nurse Attire and Supplies

  • Uniform: Nurses must wear the BVC uniform complete with:
       - BVC ID
       - Pen
       - Stethoscope
       - Penlight

  • If a nurse lacks appropriate equipment (e.g., stethoscope), they should reach out to an evaluator for borrowing arrangements.

  • Bring sufficient alcohol swabs for cleaning equipment and conducting the assessment.

  • Hand sanitizer will be provided.

Patient Instructions

  • Testing Duration: Expect to be present in the testing area for up to 1 hour. This includes 30 minutes for each partner's assessment and role changes.

  • Participate in an instructor-facilitated practice lab when not in an assessment.

  • Disposition Discussion: Students should talk with their partner about expectations for the assessment day including attire, role order, and baseline findings.

  • Room Set-up: Plan the arrangement of the room and camera. Discuss where the assessment will be conducted (bed, chair, standing) and complete a timed dry run to gauge the process and duration.

Dress Code

  • Patient Attire: Dress comfortably in clothing suitable for the assessment. Suggested clothing includes tank tops/short sleeves and shorts/capris.

  • Alternatives include:
       - Shorts or loose pants
       - Tight or loose T-shirts, tank tops, long-sleeved shirts, or sports bras
       - Optional: a towel, small blanket, or robe for privacy during assessments.

Patient Participation

  • Patients should be actively engaged and cooperative during assessments.

  • Avoid cueing the nurse on task completion; this is considered academic dishonesty and can affect grading and program placement.

  • Patients should arrive hydrated and well-rested.

  • Identification: Patients must provide their first and last name along with a learner ID but are not required to disclose personal health information (e.g., date of birth or health history). Patients are expected to only answer questions as asked.

BVC ID Card Requirements

  • Card Necessity: Patients must present a BVC student ID card with their name and ID number, accompanied by a photo. If not available, visit the registrar's office for issuance.

  • For clinical placements, a plastic BVC ID is required; some facilities may issue specific IDs as well.

Adult Health Assessment Grading Rubric

Cardiovascular and Peripheral Vascular System Assessment

  • Resources: Grading is based on the following components of assessment:
      - History Questions: Ask 2 relevant cardiac or peripheral vascular health history questions.
      - Peripheral Vascular Assessment:
        - Compare upper extremities bilaterally for temperature (dorsal hand aspect).
        - Compare lower extremities bilaterally for temperature (dorsal hand aspect).
        - Assess capillary refill on fingers and toes bilaterally.
        - Palpate for edema on upper and lower extremities bilaterally.
        - Assess radial pulses bilaterally and verbalize findings concerning equality, force, and rhythm.
        - Assess brachial pulses bilaterally with verbalized findings.
        - Assess posterior tibialis pulses and verbalize corresponding findings.
        - Assess dorsalis pedis pulses and verbalize findings.
        - Assess and gently palpate precordium for signs of cardiac implants, thrills, heaves, lifts, or pulsations.

Cardiovascular Heart Assessment

  • Heart Valves and Auscultation:
        - Verbalize names of aortic, pulmonic, tricuspid, and mitral valves and palpate landmarks accurately for auscultation.
        - Auscultate heart sounds S1 and S2 at each valve using the diaphragm of the stethoscope.
        - Summarize findings from auscultation regarding presence or absence of S1, S2, S3, and S4.
        - Use the bell of the stethoscope to auscultate for murmurs at each valve and verbalize findings.

Respiratory System and Integumentary Assessment

  • Respiratory History Questions: Ask 2 relevant respiratory health questions.

  • Respiratory Inspection:
      - Assess symmetry, chest shape, and configuration, ensuring assessment occurs on bare skin.
      - Assess the anterior/posterior (AP) diameter to transverse diameter ratio and breathing quality.
      - Inspect for cyanosis, pallor, and check nail beds for clubbing.

Respiratory Palpation and Auscultation

  • Palpation: Assess chest expansion anteriorly and posteriorly while verbalizing findings.

  • Auscultation:
       - Anterior: Auscultate in minimum of 5 locations bilaterally, from supraclavicular down to the 6th rib during full inspiration/expiration.
       - Posterior: Total of 7 locations bilaterally, from C7 down to T10, comparing bilaterally during full inspiration/expiration.
       - Lateral: Assess lateral bare chest bilaterally in 4 locations (2 on each side).

Integumentary Assessment

  • Health History: Ask 2 relevant integumentary history questions.

  • Inspection: Assess for skin abnormalities, uniformity of skin tone, and check bony prominences for pressure points, redness, or breakdown.

Neurological and Musculoskeletal System Assessment

  • Neurological History Questions: Ask 2 relevant neurological health history questions.

  • Assess mood, speech patterns, level of consciousness (LOC), orientation (Person, Place, Time), short-term memory, and long-term memory.

  • Pupil Assessment: Check shape, size in mm, equality, reaction to light using a penlight, and accommodation.

Neuro Motor/Sensory Assessment

  • Assess upper and lower extremities for motor functions and sensory functions (dull/sharp).

Musculoskeletal (MSK) Assessment

  • History Questions: Ask 2 relevant musculoskeletal health history questions.

  • Gait: Assess and comment on gait and perform the Romberg test.

  • Passive Range of Motion (ROM): Move one joint bilaterally through full ROM.

  • Strength Testing: Assess strength of both upper and lower muscle groups, ensuring bilateral assessment during active ROM.

Gastrointestinal and Genitourinary System Assessment

  • Gastrointestinal History Questions: Ask 2 relevant questions including bowel movement characteristics and recent changes.

  • Inspection: Assess oral mucosa, skin turgor, abdominal contour and symmetry, ensuring eye-level assessment occurs on bare skin.

  • Auscultation: Auscultate bowel sounds in all four quadrants before palpation and check for vascular sounds.

  • Palpation: Lightly palpate all four quadrants of the abdomen.

  • Genitourinary History Questions: Ask 2 relevant questions about urinary characteristics and patterns.

  • GU Palpation: Palpate the bladder and ask gender-specific reproductive health questions (e.g., history of STIs, menstrual periods, etc.).

Conclusion

  • Total Points for Each Assessment: 37 points.

  • Benchmark to Pass Each Test: 27.5 points.