Name
Purdue University Globle
NU552 Advanced Health Assessment Course Module Overview
Prof. Name
Date
The NU552 Unit 6 Journal Template is designed to assess students’ ability to perform comprehensive physical and psychiatric assessments, document objective findings, apply clinical reasoning, and develop evidence-based patient care plans. The assignment typically combines written journal documentation with a Kaltura competency video. Students are expected to demonstrate appropriate assessment techniques, analyze two clinical scenarios, identify differential diagnoses, recommend diagnostic testing, and address ethical and policy considerations related to psychiatric care.
The NU552 Unit 6 Journal evaluates advanced health assessment and clinical decision-making skills. It requires students to connect patient history, physical examination findings, diagnostic information, evidence-based guidelines, and professional nursing judgment.
The written portion focuses on documenting required examinations and analyzing assigned clinical cases. The practical component requires students to demonstrate selected examination skills in a recorded Kaltura video while following competency, consent, privacy, and safety requirements.
A strong NU552 Unit 6 Journal should demonstrate that the student can:
Perform and document systematic health assessments.
Use appropriate clinical terminology.
Recognize relevant positive and negative findings.
Develop reasonable differential diagnoses.
Select appropriate diagnostic tests.
Explain the rationale for clinical decisions.
Develop an evidence-based management plan.
Apply ethical and legal principles to psychiatric care.
Before submitting the NU552 Unit 6 Journal, students should carefully review the assignment instructions and grading rubric. Completing the template alone is not enough; all required written and video components must be addressed.
Common submission requirements include:
Complete every applicable section of the Unit 6 Journal Template.
Practice the required physical examination skills before recording.
Record the competency demonstration through Kaltura.
Obtain and verbally confirm informed consent from the adult volunteer.
Maintain the volunteer’s appropriate clothing and dignity throughout the demonstration.
Copy the completed journal into the designated assignment submission area when required.
Embed the Kaltura video in the assignment submission.
Check the rubric for required skills, documentation, and clinical reasoning.
Review the final submission for completeness and accuracy.
Following the template in the order provided can help reduce the likelihood of overlooking an individual requirement.
The journal requires students to document specific objective examinations. Some assessments may be written only, while selected skills are demonstrated through the competency video.
The breast examination should be thoroughly documented in the journal but should not be performed during the competency video when the assignment specifically excludes it.
Documentation should address inspection, palpation, and relevant lymph-node assessment. Students should describe findings using objective and professional terminology rather than vague statements.
Important areas include:
Breast symmetry and contour.
Skin color and texture.
Dimpling, retraction, edema, or visible masses.
Nipple position and characteristics.
Nipple discharge or lesions.
Palpation of breast tissue using a systematic technique.
Assessment of the axillary region and relevant lymph nodes.
Normal or abnormal findings identified during the assessment.
The abdominal examination should follow the standard sequence of inspection, auscultation, percussion, and palpation.
The journal should contain objective findings and appropriate clinical terminology. Students should distinguish normal findings from abnormalities and connect significant findings with the patient’s presenting complaint when appropriate.
The genitourinary, or GU, examination should be documented in the journal and is not performed in the video when excluded by the competency instructions.
The written assessment may address:
External inspection.
Palpation of relevant structures.
Internal examination when clinically indicated.
Presence or absence of lesions, discharge, swelling, tenderness, or masses.
Appropriate infection-prevention practices.
Patient education.
Objective documentation of findings.
Because GU assessments can involve sensitive examinations, privacy, informed consent, appropriate draping, and respectful communication are essential.
A comprehensive neurological examination evaluates multiple aspects of neurological function. Documentation may include:
Mental status and level of consciousness.
Cranial nerve function.
Motor strength and movement.
Sensory function.
Deep tendon and other relevant reflexes.
Coordination.
Gait.
Balance.
Findings should be documented objectively and should identify clinically meaningful abnormalities rather than relying on general statements such as “neurological exam normal.”
A psychiatric assessment evaluates a patient’s appearance, behavior, emotional state, cognition, thought processes, and judgment.
Important components include:
Appearance and general behavior.
Mood and affect.
Speech.
Thought process.
Thought content.
Perception.
Insight.
Judgment.
Orientation and cognitive function.
Students should describe observable findings and patient statements accurately and avoid making unsupported assumptions about the patient’s mental state.
The breast assessment should be systematic and should include an explanation of what is being assessed and why each step is clinically relevant.
Positioning changes help the examiner identify differences in breast symmetry, contour, skin changes, and possible abnormalities.
Depending on the examination stage, the patient may be positioned:
Sitting upright with the arms relaxed.
With the arms raised overhead.
With the hands pressing against the hips.
Leaning forward when appropriate.
Supine with a small pillow or folded towel beneath the shoulder during palpation.
Inspection in multiple positions can make skin retraction, dimpling, asymmetry, or other visible changes easier to identify.
A systematic breast examination generally follows these steps:
Explain the examination and obtain informed consent.
Provide privacy and appropriate draping.
Inspect both breasts for symmetry, contour, skin changes, edema, dimpling, and visible masses.
Inspect the nipples for position, retraction, lesions, and discharge.
Palpate the breast tissue systematically using the finger pads.
Assess all breast quadrants and the axillary tail, also known as the tail of Spence.
Examine relevant axillary, supraclavicular, and infraclavicular lymph-node areas.
Document objective findings accurately.
The examination should be performed respectfully, with clear communication throughout the process.
A GU examination should be approached systematically while maintaining privacy, dignity, and patient comfort. Students should understand the purpose of the examination, the equipment required, and the appropriate positioning before describing the procedure.
Depending on the examination, equipment may include:
Examination gloves.
Appropriate drapes.
Lubricant.
Speculum for indicated pelvic examinations.
Adequate examination lighting.
Specimen-collection supplies when testing is required.
The equipment used depends on the patient’s symptoms, age, anatomy, clinical indication, and type of examination being performed.
Positioning varies according to the examination.
For example, a female pelvic examination may use the lithotomy position when clinically appropriate. Male GU assessments may involve standing or supine positioning depending on the structures being evaluated.
Regardless of positioning, the examiner should maintain appropriate draping and explain each step before proceeding.
A comprehensive GU assessment may include:
Explain the procedure and obtain informed consent.
Establish privacy and appropriate draping.
Perform external inspection.
Palpate relevant structures when indicated.
Conduct an internal examination when clinically necessary.
Assess for lesions, discharge, swelling, tenderness, or masses.
Obtain specimens when indicated.
Document objective findings.
Provide relevant patient education and follow-up recommendations.
The clinical reasoning portion requires students to analyze two patient scenarios, with one scenario selected from each designated group.
Students select one patient from the first group:
A 33-year-old woman presenting with lower abdominal pain.
A 15-year-old male presenting with testicular pain.
A 55-year-old woman presenting with upper abdominal pain.
Students select one patient from the second group:
A 44-year-old caregiver experiencing anhedonia, sleep disturbance, low self-esteem, and excessive guilt.
A 24-year-old college student experiencing restlessness, emotional reactivity, and declining academic performance.
A 60-year-old patient receiving buprenorphine/naloxone therapy who presents with nausea, sweating, nervousness, and paranoia.
Students should avoid simply naming a diagnosis. The purpose of the clinical scenario section is to demonstrate how the available information leads to a clinical conclusion.
Each scenario should demonstrate organized clinical reasoning. Students should move logically from the patient’s history and examination to possible diagnoses, diagnostic testing, final diagnosis, and management.
Begin by identifying historical information that could influence the differential diagnosis.
Relevant information may include:
Chief complaint and history of present illness.
Onset, location, duration, and characteristics of symptoms.
Associated symptoms.
Previous medical conditions.
Surgical history.
Current medications.
Allergies.
Family history.
Social and substance-use history when relevant.
Sexual or reproductive history when clinically appropriate.
Relevant risk factors.
The history should focus on information that helps explain the patient’s current presentation.
Clinical reasoning depends on both findings that support a diagnosis and findings that make a diagnosis less likely.
Pertinent positives are symptoms, examination findings, or test results that support a potential diagnosis.
Pertinent negatives are important findings that are absent and may help rule out or reduce the likelihood of competing diagnoses.
Students should explain why particularly important findings matter rather than simply listing them.
Each clinical scenario should include at least three differential diagnoses when required by the assignment.
For each potential diagnosis, explain:
Why the diagnosis is being considered.
Which findings support it.
Which findings argue against it.
What additional information or testing could help distinguish it from other conditions.
This approach demonstrates clinical reasoning rather than memorization.
Diagnostic testing should be selected according to the patient’s presentation and differential diagnoses. Each recommended test should have a clinical rationale.
Depending on the scenario, testing may include:
Complete blood count or other laboratory studies.
Comprehensive metabolic testing.
Urinalysis.
Pregnancy testing when clinically appropriate.
Diagnostic imaging.
Electrocardiography.
Mental health screening instruments.
Toxicology testing when clinically indicated.
Students should avoid recommending tests simply to create a longer list. Every test should help evaluate a suspected diagnosis, assess severity, identify complications, or guide management.
The final diagnosis should be supported by the patient’s overall clinical picture rather than by a single symptom.
Students should integrate:
Patient history.
Physical examination findings.
Pertinent positive and negative findings.
Diagnostic results.
Differential diagnoses.
Current evidence and clinical guidelines.
The explanation should make it clear why the selected diagnosis is more likely than the alternatives.
The management plan should address the patient’s immediate needs as well as appropriate follow-up.
A concise plan may include:
Initial treatment or intervention.
Medication considerations.
Patient education.
Monitoring requirements.
Follow-up appointments.
Referral to an appropriate specialist.
Preventive care when applicable.
Safety-net instructions or indications for urgent evaluation.
Clinical recommendations should be supported by current evidence and at least one relevant clinical practice guideline when required.
Ethical and legal considerations are an important part of psychiatric nursing because mental health care frequently involves sensitive information, questions of decision-making capacity, and potential safety concerns.
Students should consider how the following principles apply to their selected scenario:
Patients generally have the right to participate in decisions about their healthcare. Nurses should support informed decision-making by providing understandable information and respecting patient preferences within applicable legal and clinical boundaries.
Psychiatric information can be particularly sensitive. Healthcare professionals must protect patient information and follow applicable privacy requirements, including HIPAA regulations in covered healthcare settings.
Confidentiality may have legally recognized exceptions, particularly when there is a serious safety concern or another disclosure is required or permitted by law.
When a patient presents a potential risk to self or others, healthcare professionals must evaluate safety concerns and follow applicable laws, institutional policies, and professional standards.
Students should distinguish between respecting confidentiality and taking appropriate action when safety obligations apply.
Accurate documentation is essential in psychiatric care. Nurses should record relevant observations, patient statements, assessments, interventions, communications, and responses objectively.
Documentation should avoid stigmatizing or judgmental language and should accurately reflect what was observed or reported.
A systematic approach can make the NU552 Unit 6 Journal easier to complete and can help ensure that important requirements are not missed.
Students should:
Read the complete journal template before starting.
Review the grading rubric alongside the assignment instructions.
Practice required examination techniques before recording the video.
Use a consistent assessment sequence.
Document objective findings with appropriate medical terminology.
Identify clinically significant positive and negative findings.
Provide at least three supported differential diagnoses for each required scenario.
Explain the rationale for diagnostic tests.
Connect the final diagnosis to the clinical evidence.
Develop a practical, evidence-based management plan.
Include current clinical practice guidelines.
Address ethical, legal, and confidentiality considerations.
Confirm that all required video and written components are submitted.
The strongest submissions demonstrate a clear connection between assessment findings, clinical reasoning, evidence, diagnosis, and patient-centered management.
No. According to the assignment requirements provided, the breast examination is documented in the journal template but is not performed during the competency video.
No. The GU examination is documented in the journal rather than demonstrated in the recorded competency when excluded by the assignment instructions.
Students must complete two clinical scenarios, selecting one scenario from each of the two designated groups.
Each scenario should include at least three differential diagnoses, accompanied by clinical reasoning explaining why each diagnosis is being considered.
The management plan should address appropriate treatment or interventions, diagnostic considerations, patient education, follow-up, referrals, medication considerations, and monitoring. Recommendations should be supported by current evidence and relevant clinical guidelines.
Psychiatric nursing requires careful attention to patient autonomy, informed consent, confidentiality, privacy, safety, documentation, and applicable legal and institutional requirements. Addressing these areas demonstrates that students understand the professional responsibilities associated with mental health care.
Start with the patient’s history and presenting symptoms, identify pertinent positive and negative findings, develop at least three differential diagnoses, select appropriate diagnostic tests, determine the most likely diagnosis, and finish with an evidence-based management plan. This creates a logical clinical reasoning pathway.
The NU552 Unit 6 Journal Template combines physical assessment, clinical reasoning, psychiatric assessment, evidence-based practice, and professional ethics. Students can strengthen their submissions by following the template carefully, documenting objective findings, analyzing both positive and negative clinical evidence, supporting differential diagnoses with appropriate reasoning, and connecting management recommendations to current guidelines.
The competency video is equally important because it demonstrates practical assessment skills, communication, consent, and professional conduct. Careful preparation before recording can help students present their examination techniques clearly and meet the required competency standards.
American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). American Psychiatric Association Publishing. https://doi.org/10.1176/appi.books.9780890425787
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2023). Seidel’s guide to physical examination (10th ed.). Elsevier. https://www.us.elsevierhealth.com/
Bickley, L. S. (2024). Bates’ guide to physical examination and history taking (14th ed.). Wolters Kluwer. https://shop.lww.com/
Centers for Disease Control and Prevention. (2024). Mental health. https://www.cdc.gov/mentalhealth/
U.S. Department of Health & Human Services. (n.d.). Health Insurance Portability and Accountability Act of 1996 (HIPAA). https://www.hhs.gov/hipaa/index.html
U.S. Preventive Services Task Force. (2024). Recommendation topics. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics
World Health Organization. (2023). Mental health. https://www.who.int/health-topics/mental-health
