Health History and Physical Examination

PURPOSE
As you learned in NR302, before any nursing plan of care or intervention can be implemented or
evaluated, the nurse conducts an assessment, collecting subjective and objective data from an
individual. The data collected are used to determine areas of need or problems to be addressed by the
nursing care plan. This assignment will focus on collecting both subjective and objective data,
synthesizing the data, and identifying health and wellness priorities for the person. The purpose of the
assignment is twofold.
• To recognize the interrelationships of subjective data (physiological, psychosocial, cultural and
spiritual values, and developmental) and objective data (physical examination findings) in
planning and implementing nursing care
• To reflect on the interactive process that takes place between the nurse and an individual while
conducting a health assessment and a physical examination
COURSE OUTCOMES
CO1: CO1. Explain expected client behaviors while differentiating between normal findings,
variations and abnormalities. (PO1)
CO 2: Utilize prior knowledge of theories and principles of nursing and related disciplines to
integrate clinical judgment in professional decision-making and implementation of
nursing process while obtaining a physical assessment. (POs 4, 8)
CO 3: Recognize the influence that developmental stages have on physical, psychosocial,
cultural, and spiritual functioning. (PO 1)
CO 4: Utilize effective communication when performing a health assessment. (PO 3)
CO5: Demonstrate beginning skill in performing a complete physical examination using the techniques of
inspection, palpation, percussion, and auscultation. (PO 2
CO 6: Identify teaching/learning needs from the health history of an individual. (POs 2, 5)
CO 7: Explore the professional responsibilities involved in conducting a comprehensive health assessment
and providing appropriate documentation. (PO 6, 7)
DUE DATE
Please see the Course Calendar.
TOTAL POINTS POSSIBLE 100 points
PREPARING THE ASSIGNMENT
There are four graded parts to this assignment: (1) Obtain a health history and conduct a physical
examination on an individual of your choosing (not a patient), (2) compile a health education needs
assessment, (3) self-reflection, and (4) writing style and format.
Instructions for each part follow.
NR 304 RUA Grading Rubric and Grading Criteria V2.docx 10_16 SMa Revised 11/05/18 EL/css 4
Health History Assessment and Physical Assessment (50 points)
 Using the following subjective and objective components, as well as your textbook for explicit
details about each category, complete a health history and physical examination on an
individual. You may choose to complete portions of this assignment as you obtain the health
history and perform the physical examination associated with the body systems covered
NR304. Please be sure to avoid the use of any identifiers in preparing the assignment. Students
may seek input from the course instructor on securing an individual for this assignment. Keep
notes on each part of the health history and physical examination as you complete them so that
you can refer to the notes as you write the paper.

1. Subjective Data—Health History Components to Be Included
   • Demographic data
   • Reason for care (why they are in the facility)
   • Present illness (PQRST of current illness)
   • Perception of health
   • Past medical history (including medications, allergies, and vaccinations and
   immunizations)
   • Family medical history
   • Review of systems
   • Developmental considerations
   • Cultural considerations
   • Psychosocial considerations
   • Presence or absence of collaborative resources (community, family, groups, and
   healthcare system)
   ***REMEMBER: Make notes of the health history findings, ensuring that you have addressed all of the
   components listed here. Students are also encouraged to take notes about their experiences while
   conducting the health history for reference when creating the assignment, particularly the reflection section.
2. Objective Data—Physical Exam Components to Be Included
    During the lab experiences, you will conduct a series of physical exams that includes the
   following systems.
    Keep notes on each part of the physical exam as you complete them to reference as you write
   the paper.
    Refer to the course textbook for detailed components of each system exam. Remember,
   assessment of the integumentary system is an integral part of the physical exam and should be
   included throughout each system.
    From NR302
   o HEENT (head, eyes, ears, nose, and throat)
   o Neck (including thyroid and lymph chains)
   o Respiratory system
   o Cardiovascular system
    From NR304
   NR 304 RUA Grading Rubric and Grading Criteria V2.docx 10_16 SMa Revised 11/05/18 EL/css 4
   o Neurological system
   o Gastrointestinal system
   o Musculoskeletalsystem
   o peripheral vascular system
   ***REMEMBER: Make notes of the physical examination findings, ensuring that you have addressed all of the
   components listed on the Return Demonstration Checklist. Students are also encouraged to take notes
   about their experiences while conducting the physical examination for reference when creating the
   assignment, particularly the reflection section.
   Needs Assessment (20 points)
3. Based on the health history and physical examination findings, determine at least two health
   education needs for the individual. Remember, you may identify an educational topic that is
   focused on wellness.
4. Select two peer-reviewed journal articles that provide evidence-based support for the health
   teaching needs you have identified.
   Reflection (20 points)
   Nurses use reflection to, mindfully and intentionally, examine our thought processes, actions,
   and behaviors in order to better evaluate our patients’ outcomes. You have interviewed an
   individual, conducted a head-to-toe physical assessment, and identified at least two health
   teaching needs. You have also located within the literature evidence-based support for the
   teaching that will be used to address the individual’s health education needs. As you formulate
   your findings in writing within this assignment, it is time to turn your attention inward. The final
   element of this assignment is to write a reflection that describes your experience.
5. Be sure your reflection addresses each of the following questions.
   a. How did this assignment compare to what you’ve learned and expected?
   b. What enablers or barriers to communication did you encounter when performing a
   health history and physical exam? How could you overcome those barriers?
   c. Were there any unanticipated challenges encountered during this assignment?
   What went well with this assignment?
   d. Was there information you wished you had available but did not?
   e. How will you alter your approach to a obtaining a health history and conducting a
   physical examination the next time?
   Writing Style and Format (10 points)
   Your writing should reflect your synthesis of ideas based on prior knowledge, newly acquired
   information, and appropriate writing skills. Scoring of your written communication is based on
   proper use of grammar, spelling, and APA sixth-edition formatting, as well as how clearly your
   thoughts and reasoning are expressed in writing.
   Documentation of Findings or How to Write the Paper
   NR 304 RUA Grading Rubric and Grading Criteria V2.docx 10_16 SMa Revised 11/05/18 EL/css 4
   Using Microsoft Word, create a double-spaced document. The paper should be formatted according
   to APA sixth-edition guidelines for the title page, running head, and reference page. The use of
   headings is required for this paper. All portions of this assignment should be included within the
   paper, including the reflection.
6. Begin by writing one to two paragraphs describing the individual’s stated condition of health
   medications and allergies. Also, include any of the following information that may be pertinent:
   demographic data, perception of health, past medical history, vaccinations and immunizations,
   family medical history, review of systems, developmental considerations, cultural
   considerations, psychosocial considerations, and the presence or absence of resources from the
   community, family, groups, or the healthcare system.
7. Write one paragraph describing the physical assessment findings, ensuring proper terminology
   is used to describe any abnormal or unusual findings.
8. Write one paragraph discussing (1) the rationale for the selection of the health teaching topics
   and (2) how the findings in the scholarly articles (identified in the needs assessment portion of
   the assignment and properly cited) were used to develop the health teaching topics to promote
   the individual’s health and wellness status.
9. Write one paragraph discussing (1) how the interrelationships of physiological, developmental,
   cultural, and psychosocial considerations will influence, assist, or become barriers to the
   effectiveness of the proposed health education and (2) a description of the impact of the
   individual’s strengths (personal, family, and friends) and collaborative resources (clinical,
   community, and health and wellness resources) on the proposed teaching.
10. Write one paragraph describing your reflection of this assignment from a holistic point of view.
    Consider the following areas: Include the environment, your approach to the individual, time of
    day, and other features relevant to therapeutic communication and to the interview process.
    You may find your textbook helpful in providing a description of therapeutic communication and
    of the interview process. Be certain to address the questions listed above in the reflection
    instructions.