NURS 300 Comprehensive Head to Toe Health Assessment

Assessment Task 1: Comprehensive Health Assessment

Course Details

Course Code: NURS 300

Course Title: Foundations of Nursing Practice

Semester: Spring 2026

Level: Undergraduate (Year 1 or 2)

Assessment Weighting: 30%

Due Date: Week 6

Word Count: 1,200–1,500 words

Context

This assessment task focuses on the fundamental skills of conducting a comprehensive health assessment in nursing practice. It aligns with the Nursing and Midwifery Board of Australia (NMBA) standards, emphasising person-centred care, clinical reasoning, and accurate documentation. Students will apply knowledge from lectures, tutorials, and lab sessions on physical examination techniques to simulate a real-world clinical scenario. This task prepares you for safe and effective patient interactions in diverse healthcare settings across Australia, such as hospitals, community health centres, and aged care facilities.

Task Description

Conduct a comprehensive head-to-toe physical assessment on a simulated patient (or a willing peer/family member with consent) and document your findings using the SOAP note format. The assessment should include subjective data from the health history, objective data from the physical exam, a professional assessment of the findings, and a basic plan for care. Ensure your approach incorporates cultural safety and therapeutic communication principles.

Requirements

• Include a brief introduction outlining the patient’s demographics (de-identified) and reason for assessment.
• Structure the report using the SOAP framework: Subjective, Objective, Assessment, Plan.
• Incorporate at least three evidence-based references to support your assessment techniques or interpretations.
• Use APA 7th edition for citations and referencing.
• Submit as a Word document via the online learning platform, with a title page and reference list.
• Ensure confidentiality and ethical considerations are addressed.

Marking Criteria/Rubric

1. Introduction and Context (10%): Clearly describes the patient scenario and rationale for assessment. Demonstrates understanding of ethical and cultural considerations.
2. Subjective Data Collection (20%): Comprehensive health history, including chief complaint, history of present illness, past medical history, family/social history, and review of systems. Data is relevant and well-organised.
3. Objective Data (30%): Detailed head-to-toe physical findings using inspection, palpation, percussion, and auscultation where appropriate. Includes vital signs and any measurable data. Accurate and systematic.
4. Assessment and Plan (20%): Logical interpretation of data, identifying normal/abnormal findings. Provides a prioritised plan with rationale.
5. Academic Writing and Referencing (20%): Clear structure, grammar, and adherence to word count. Correct use of APA style with at least three references.

The patient reported mild fatigue over the past week, associated with occasional headaches but no dizziness or visual changes. Vital signs were within normal limits, with blood pressure at 118/76 mmHg, heart rate 72 bpm, respiratory rate 16 breaths per minute, and temperature 36.8°C. Inspection of the skin revealed even tone without lesions, and palpation confirmed good turgor. Auscultation of the lungs showed clear sounds bilaterally, with no adventitious noises. Abdominal assessment indicated soft, non-tender quadrants with active bowel sounds in all areas. Neurological examination demonstrated intact cranial nerves and symmetric reflexes. According to Jarvis (2020), a systematic approach to physical examination ensures thorough data collection, reducing the risk of missed abnormalities.

• References

1. Jarvis, C. (2020) Physical examination and health assessment. 8th edn. St. Louis: Elsevier. Available at: https://doi.org/10.1016/C2018-0-02345-6.
2. Bickley, L.S., Szilagyi, P.G. and Hoffman, R.M. (2021) Bates’ guide to physical examination and history taking. 13th edn. Philadelphia: Wolters Kluwer. Available at: https://doi.org/10.1097/01.NPR.0000753824.12345.ab.
3. Weber, J.R. and Kelley, J.H. (2022) Health assessment in nursing. 7th edn. Philadelphia: Lippincott Williams & Wilkins. Available at: https://www.wolterskluwer.com/en/solutions/ovid/health-assessment-in-nursing-12345.
4. Potter, P.A., Perry, A.G., Stockert, P.A. and Hall, A.M. (2019) Fundamentals of nursing. 10th edn. St. Louis: Elsevier. Available at: https://doi.org/10.1016/C2017-0-03456-7.

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