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NQCG3151 Foundations in History Taking and Physical Assessment Across the Lifespan Level 6

Module Overview

This module is designed to prepare nurses, midwives and allied healthcare practitioners with the additional skills in History Taking and Physical Examination (specifically the skills of inspection palpation and auscultation) across all major body systems. The module is appropriate for anyone who seeks to practice enhanced patient/client assessments with a higher level of autonomy. These skills are the foundation for Advanced Practitioner education for those undertaking roles such as Advanced Practitioner, Specialist Practitioner, Consultant Practitioner or Emergency Care Practitioner. They are also essential skills for anyone undertaking Non Medical Prescribing. The skills are also of value to many ward and community based nurses seeking to enhance the quality of the assessments that they undertake on patients in their care as part of their regular nursing, midwifery or allied health professional roles.

Aims and Objectives

Module Aims

To equip you with a) a deeper level of knowledge, ability and critical awareness in relation to patient/client history taking and recording, and the ability to differentiate normal vs abnormal findings. b) a foundation level of skills and critical awareness in relation to the systematic physical assessment of patients/clients across the lifespan, and the ability to differentiate normal vs abnormal findings. This will be underpinned by a deeper knowledge base in relation to relevant/applied anatomy and physiology.

Learning Outcomes

Learning Outcomes

Having successfully completed this module you will be able to:

  • Demonstrate knowledge, skill and judgement in patient/client consultation, including data gathering, data processing and communication, and be able to critically appraise the place of these skills and underpinning knowledge within the context of an holistic health assessment.
  • Demonstrate knowledge, skill and judgement in the physical assessment skills of inspection, palpation, percussion and auscultation across major body systems, and appraise the application of these skills and their underpinning knowledge in the context of care delivery across the lifespan
  • Distinguish and explain findings of ‘normality’ and ‘deviations from normality’ in the assessment process, including those influenced by genetic, ethnic, physiologic, anatomic and developmental/lifespan differences, and demonstrate the ability to seek advice and/or make credible referrals as appropriate
  • Demonstrate self awareness regarding the importance of maintaining respect for privacy, dignity and confidentiality when undertaking health assessment.
  • Articulate the contribution of the evidence base underpinning the implementation of history taking and physical assessment skills within the context of professional practice
  • Critically consider the place of the skills of history taking and physical examination within the context of contemporary clinical practice

Syllabus

This module's content is a key component of advanced practice programmes and pre-requisite for the Diagnostic Assessment and Decision Making and non-medical prescribing modules. Syllabus content is underpinned by extensive insights and feedback that has been gained since 2000 when this module was first delivered. It has also been informed by the considerable experience of the team who deliver the programme, which includes consultant practitioners, lecturer/practitioners and seconded practitioners alongside academic staff who have clinical experience from across the lifespan and across the health illness continuum from primary to critical care. The use of core texts from both the US and UK (texts widely used across the UK and many other countries) ensures national and international transferability of the skills taught. The syllabus content is as follows: • Methods of undertaking a systematic, comprehensive health history across all major body systems and with peoples of all ages, using a range of different assessment tools and formats. Includes mental health screening. • Relevant anatomy and physiology, particularly ‘surface anatomy’, pertaining to all major body systems, including variations across the lifespan, and variations occurring as a result of gender or ethnicity. • The role of the ‘general survey’; including inspection of hands, nails, hair, skin and face as a core assessment process which underpins and integrates the physical examination. • Utilisation of the physical examination skills of inspection, palpation, percussion and auscultation across all major body systems (including respiratory, cardiac, gastro-intestinal, genitor-urinary, neurological and musculo-skeletal systems, as well as inspection of eyes, ears, nose and throat) • The challenges of integration: respiratory and cardiovascular assessments, and neurological and musculoskeletal assessment. • Interpretation of assessment findings to enable the distinction between ‘normal’ and ‘abnormal’ findings, including variations of normality. • Making credible referrals in cases of proven or suspected abnormality. • Documentation of findings from all history taking and physical assessment processes • Contextualising of history taking and physical examination skills by critical analysis of different models and frameworks of health assessment. • Exploration of the place of history taking and physical assessment skills within the context of care delivery /advanced clinical practice. • Exploration of legal, professional and ethical issues pertaining to the changing/blurring of role boundaries between and within different health care professions. • Consideration of the evidence base underpinning health assessment and role extension and advanced practice. • Consideration of issues relating to privacy, dignity and confidentiality in the context of health assessment.

Special Features

In order to learn and practice the skills taught on this module, you have the opportunity to work in small groups of three to five, with an instructor working between two groups, in order to undertake supervised practice of the examination skills on each other. With consent, you can therefore expect colleagues to examine your neck, head, back, chest (females upper chest only) abdomen and limbs. Guidance re appropriate clothing (e.g. swim/sportswear) will be given. Underwear is never removed and groups are appropriately screened. Every effort is made to ensure privacy and dignity, and ground rules are set on day one. Participation in the ‘patient role’ is not compulsory, and if you have individual concerns you are invited to discuss these with the module leader.

Learning and Teaching

Teaching and learning methods

The module uses a wide variety of teaching and learning methods. The emphasis is very much on the importance of self directed learning, accompanied by a considerable emphasis on skills rehearsal. Atypically, you are encouraged to identify a core text as the basis of your learning, and to supplement this by accessing other texts, relevant journal publications and on line resources. You are also encouraged to explore and the evidence base underpinning the utilisation of these skills. Learning is also supported by your access to the on line blackboard learning environment, which includes core and supporting learning materials, and video demonstrations of the skills being taught. You are strongly encouraged to read relevant handouts and book chapters before each session, and to revisit these materials after each session, to maximise effective learning and consolidation. You are also strongly encouraged to identify mechanisms by which you can practice the skills taught, both within your professional working environment and informally. Much of the study time allocated to the programme needs to be used for skills rehearsal to ensure effective learning and execution of the skills taught. Importantly, although skills and knowledge are examined at the end of the programme, and a required standard must be reached, successful completion of the course does not confer confirmation of competence. Rather, it is acknowledged that competence is context specific, and also normally takes considerably longer to achieve than the total length of the programme. You are therefore given guidance regarding how competency can be achieved within your own practice setting after the course is completed. A wide range of teaching and learning methods will be used, and are likely to include: • Lectures • Demonstrations • Supervised skills practice on peers • Quizzes • Self directed learning (including books, journals, audio-visual resources etc.) • E-learning (including use of Blackboard and other on-line resources.) • Supervised skills rehearsal within the practice setting. (The module is not formally assessed in practice but you are encouraged to develop informal arrangements to enable you to undertake supervised skills rehearsal/development within your particular clinical practice domain.)

TypeHours
Follow-up work40
Wider reading or practice72
Lecture18
Practical classes and workshops27
Revision70
Demonstration3
Preparation for scheduled sessions20
Total study time250

Resources & Reading list

McGee,P (2017). Evidence Based Physical Diagnosis. 

Rushforth,H (2009). Assessment Made Incredibly Easy. 

Bickley,L.S. (2016). Bates’ Guide to Physical Examination and History Taking. 

Henderson,M., Tierney,L.,Smenta,G. (2012). The Patient History: An Evidence-Based Approach to Differential Diagnosis. 

Jarvis,C. (2015). Physical Examination and Health Assessment. 

Assessment

Summative

MethodPercentage contribution
Objective Structured Clinical Examination  (2 hours) 100%
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