NU552 Unit 6 Journal Templates

Student Name

Purdue University Globle 

NU552 Advanced Health Assessment and Diagnostic Reasoning

Prof. Name

Date

NU552 Unit 6 Journal Templates

Directly answering the assignment requirements, the NU552 Unit 6 Journal Template requires students to document comprehensive objective examinations, describe the correct techniques for breast and genitourinary (GU) assessments, analyze two clinical case scenarios using evidence-based clinical reasoning, and discuss ethical and policy considerations related to psychiatric care. Students must also submit a Kaltura video demonstrating selected examination skills while following the provided competency guidelines.

Understanding the NU552 Unit 6 Journal Template

The NU552 Unit 6 Journal evaluates students’ ability to perform advanced health assessments, demonstrate sound clinical judgment, and apply evidence-based practice. The assignment combines written documentation with a practical skills demonstration to assess competency in physical assessment, diagnostic reasoning, and psychiatric nursing principles.

Students are expected to accurately document examination findings, explain assessment procedures, evaluate patient scenarios, and justify clinical decisions using current evidence and professional guidelines.

Journal Submission Requirements

Before completing the assignment, students should ensure they meet all submission expectations.

Students must:

• Complete the Unit 6 Journal template.

• Practice examination skills before recording the demonstration.

• Record and submit a Kaltura video.

• Obtain and verbally confirm informed consent from an adult volunteer during the video.

• Keep the volunteer appropriately clothed throughout the competency demonstration, even though a clinical setting would typically involve draping and skin exposure.

• Copy the completed journal into the assignment submission text box.

• Embed the Kaltura video within the submission.

• Review the grading rubric before submitting.

Required Objective Examination Documentation

Although not every examination is demonstrated in the video, students must document each required assessment thoroughly within the journal template.

Breast Assessment

Students are required to document a complete breast examination but should not perform this assessment in the video demonstration.

Documentation should include:

• Inspection findings

• Palpation technique

• Assessment of breast symmetry

• Skin changes

• Nipple characteristics

• Axillary lymph node assessment

• Normal and abnormal findings when appropriate

Abdomen Assessment

Students should document the abdominal examination using the standard clinical sequence:

• Inspection

• Auscultation

• Percussion

• Palpation

Documentation should include objective findings and appropriate medical terminology.

Genitourinary Assessment

The genitourinary (GU) examination must be documented in the journal but is not demonstrated in the video.

Documentation should include:

• External inspection

• Internal examination when clinically indicated

• Assessment findings

• Relevant patient education

• Appropriate infection-control measures

Neurological Assessment

The neurological examination should evaluate:

• Mental status

• Cranial nerves

• Motor function

• Sensory function

• Reflexes

• Coordination

• Gait

• Balance

Psychiatric Assessment

Students should document a complete psychiatric evaluation that includes:

• Appearance

• Behavior

• Mood and affect

• Speech

• Thought process

• Thought content

• Perception

• Insight

• Judgment

• Cognitive status

Performing a Female Breast Examination

Students should explain every step of the examination while identifying the rationale behind each action.

Patient Positioning

Proper positioning improves visualization and palpation of breast tissue.

The patient should be positioned:

• Sitting upright for inspection

• Arms relaxed at the sides

• Arms raised overhead

• Hands pressing against the hips

• Leaning forward if needed

• Supine with a small pillow under the shoulder during palpation

Each position allows better visualization of asymmetry, skin retraction, dimpling, or underlying masses.

Breast Examination Procedure

A systematic breast assessment generally includes:

1. Explain the procedure and obtain consent.

2. Ensure privacy and appropriate draping.

3. Inspect both breasts for:

   • Symmetry

   • Skin color

   • Contour

   • Dimpling

   • Edema

   • Visible masses

4. Inspect the nipples for:

   • Position

   • Retraction

   • Discharge

   • Lesions

5. Palpate each breast using finger pads in a systematic pattern.

6. Assess all breast quadrants and the tail of Spence.

7. Palpate axillary, supraclavicular, and infraclavicular lymph nodes.

8. Document all findings accurately.

Performing a Genitourinary Examination

The GU examination should be described step-by-step while explaining patient positioning, required equipment, and the clinical purpose of each assessment.

Required Equipment

Equipment commonly includes:

• Examination gloves

• Drapes

• Lubricant

• Speculum (female examination)

• Adequate lighting

• Collection supplies if specimens are needed

Patient Positioning

Patient positioning depends on the examination being performed.

Examples include:

• Lithotomy position for female pelvic examinations

• Standing or supine position for male examinations

• Appropriate draping throughout the examination to maintain dignity and privacy

Examination Process

A comprehensive GU examination generally includes:

• Obtaining informed consent

• External inspection

• Palpation of relevant structures

• Internal examination when indicated

• Assessment for lesions, discharge, tenderness, swelling, or masses

• Documentation of findings

• Patient education when appropriate

Clinical Case Scenario Requirements

Students must complete two clinical scenarios, selecting one scenario from each group.

Scenario Group One

Choose one of the following patients:

• A 33-year-old female with lower abdominal pain.

• A 15-year-old male with testicular pain.

• A 55-year-old female with upper abdominal pain.

Scenario Group Two

Choose one of the following patients:

• A 44-year-old caregiver experiencing anhedonia, sleep disturbances, low self-esteem, and excessive guilt.

• A 24-year-old college student with restlessness, emotional reactivity, and declining academic performance.

• A 60-year-old patient receiving buprenorphine/naloxone therapy presenting with nausea, sweating, nervousness, and paranoia.

Demonstrating Clinical Judgment

Each clinical scenario should demonstrate advanced clinical reasoning supported by current evidence.

Relevant Patient History

Students should identify historical information that influences diagnosis, including:

• Present illness

• Past medical history

• Surgical history

• Medication use

• Allergies

• Family history

• Social history

• Risk factors

Pertinent Positives and Negatives

Students should identify examination findings that either support or rule out possible diagnoses.

Differential Diagnoses

Each scenario should include at least three differential diagnoses with a clinical rationale explaining why each condition is being considered.

Diagnostic Testing

Students should recommend appropriate diagnostic studies based on the differential diagnoses.

Examples may include:

• Laboratory testing

• Urinalysis

• Pregnancy testing

• Imaging studies

• Electrocardiography

• Mental health screening tools

• Toxicology screening

Each diagnostic recommendation should be supported by clinical reasoning.

Determining the Final Diagnosis

Students should explain how the patient’s:

• History

• Physical examination

• Diagnostic findings

• Clinical guidelines

collectively support the final diagnosis.

Management Plan

A brief evidence-based management plan should include:

• Initial treatment

• Patient education

• Follow-up recommendations

• Referrals when indicated

• Medication considerations

• Monitoring strategies

Students should support management decisions with current clinical evidence and include at least one applicable clinical practice guideline.

Ethics and Policy in Psychiatric Care

Psychiatric nursing requires heightened attention to ethics, confidentiality, and legal responsibilities.

Students should discuss:

• Patient autonomy

• Informed consent

• Confidentiality requirements

• HIPAA compliance

• Duty to protect when safety concerns exist

• Documentation standards

• Professional ethical responsibilities

• State and institutional policies governing mental health care

Understanding these principles helps protect patient rights while ensuring safe and legally compliant clinical practice.

Key Points for a Successful NU552 Unit 6 Journal

To complete the assignment successfully, students should:

• Follow every instruction in the journal template.

• Practice assessment techniques before recording the video.

• Use systematic examination procedures.

• Apply evidence-based clinical reasoning.

• Support diagnoses with appropriate diagnostic testing.

• Reference current clinical practice guidelines.

• Demonstrate accurate documentation using professional medical terminology.

• Address ethical and legal responsibilities in psychiatric care.

Accurate documentation, organized clinical reasoning, and adherence to professional assessment standards will strengthen both the written journal and the competency demonstration.

Frequently Asked Questions

Does the breast examination need to be demonstrated in the video?

No. The breast examination should be fully documented in the journal template but is not performed during the competency video.

Is the genitourinary examination performed in the recorded demonstration?

No. Like the breast examination, the GU assessment is documented in the journal but is not demonstrated in the video.

How many clinical scenarios are required?

Students must complete two scenarios—one selected from each of the two scenario groups provided in the assignment instructions.

How many differential diagnoses should each scenario include?

Each scenario should include at least three evidence-supported differential diagnoses with appropriate clinical reasoning.

What should be included in the management plan?

The management plan should summarize the proposed treatment approach, recommended diagnostic testing, patient education, referrals, follow-up care, and evidence-based interventions supported by current clinical guidelines.

Why are ethics emphasized in the psychiatric section?

Psychiatric care involves highly sensitive patient information and requires strict adherence to confidentiality, informed consent, legal standards, and ethical principles to protect patient rights and ensure safe clinical practice.

Clinical assessment assignments evaluate students’ ability to integrate patient history, objective examination findings, diagnostic reasoning, evidence-based practice, and ethical decision-making into safe and effective nursing care.

References

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.; DSM-5-TR). 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/

NU552 Unit 6 Journal Templates

Health Insurance Portability and Accountability Act of 1996 (HIPAA). https://www.hhs.gov/hipaa/index.html

U.S. Preventive Services Task Force. (2024). Recommendation statements. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics

World Health Organization. (2023). Mental health. https://www.who.int/health-topics/mental-health