Purpose

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.

1. 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

2. 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 This assignment enables the student to meet the following course outcomes.

CO 1: 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 and 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)

CO 5: 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 and 5)

CO 7: Explore the professional responsibilities involved in conducting a comprehensive health assessment and providing appropriate documentation. (PO 6 and 7)

 

Due date Your faculty member will inform you when this assignment is due. The Late Assignment Policy applies to this assignment.

 

Total points possible 100 points

 

Preparing the assignment

Follow these guidelines when completing this assignment. Speak with your faculty member if you have questions.

 

1. Complete a health history and physical examination on an individual. 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. The person interviewed must be 18 years of age or older. Please be sure to avoid the use of any identifiers in preparing the assignment and follow HIPAA protocols.

a. Students may seek input from the course instructor on securing an individual for this assignment.

b. Avoid the use of client identifiers in the assignment, HIPAA protocols must be utilized.

c. During the lab experiences, you will conduct a series of physical exams that includes the systems listed in Objective Data below.

d. Refer to the course textbook for detailed components of each system exam.

1) Remember, assessment of the integumentary system is an integral part of the physical exam and should be

NR306 Health Assessment

RUA Health History and Physical Assessment Guidelines

 

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NR306_MAR23_Health_History_and_Physical_Assessment _Guidelines.docx 1

included throughout each system.

e. 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, particularly the reflection section.

f. Utilize proper medical terminology.

2. Include the following sections, used as section headers within the paper.

a. Health History: Subjective Data (30 points/30% [1-2 paragraphs in length])

1) Demographic data

2) Reason for care

3) Present illness (PQRST of current illness)

4) Perception of health

5) Past medical history (including medications, allergies, and vaccinations and immunizations)

6) Family medical history

7) Review of systems

8) Developmental considerations- use Erikson’s Stages of Psychosocial Development- which stage is your participant at and give examples of if they have met or not met the milestones for that stage.

9) Cultural considerations- definition, cultural traditions, cultural viewpoints on healing/healers, traditional and complementary medicine, these are examples but please add more

10) Psychosocial considerations- support systems-family, religious, occupational, community these are examples but please add more

11) Presence or absence of collaborative resources (community, family, groups, and healthcare system)

b. Physical Examination: Objective Data (30 points/30% [1 paragraph])

1) From NR302

a) HEENT (head, eyes, ears, nose, and throat)

b) Neck (including thyroid and lymph chains)

c) Respiratory system

d) Cardiovascular system

2) From NR304

a) Neurological system

b) Gastrointestinal system

c) Musculoskeletal system

d) Peripheral vascular system

c. Needs Assessment (20 points/20% [2 paragraphs])

1) 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.

2) Support the identified health teaching needs selected with evidence from two current, peer-reviewed journal articles.

3) Discuss how the interrelationships of physiological, developmental, cultural, and psychosocial considerations will influence, assist, or become barriers to the effectiveness of the proposed health education.

4) Describe how the individual’s strengths (personal, family, and friends) and collaborative resources (clinical, community, and health and wellness resources) effect proposed teaching.

d. Reflection (10 points/10% [1 paragraph])

Reflection is used to intentionally examine our thought processes, actions, and behaviors in order to evaluate outcomes. Provide a written reflection that describes your experience with conducting this complete health history and physical assessment.

1) Reflect on your interaction with the interviewee holistically.

a) Describe the interaction in its entirety: include the environment, your approach to the individual, time of day, and other features relevant to therapeutic communication and to the interview process.

2) How did your interaction compare to what you have learned?

3) What barriers to communication did you experience?

a) How did you overcome them?

b) What will you do to overcome them in the future?

4) What went well with this assignment?Were there unanticipated challenges during this assignment?

5) Was there information you wished you had available but did not?

6) How will you alter your approach next time?

e. Writing Style and Format (10 points/10%)

1) Writing reflects synthesis of information from prior learning applied to completion of the assignment.

2) Grammar and mechanics are free of errors.

3) Able to verbalize thoughts and reasoning clearly.

4) Use appropriate resources and ideas to support topic with APA where applicable.

5) HIPAA protocols followed.

 

For writing assistance, visit the Writing Center.

 

Please note that your instructor may provide you with additional assessments in any form to determine that you fully understand the concepts learned in the review material.

Grading Rubric Criteria are met when the student’s application of knowledge demonstrates achievement of the outcomes for this assignment.

Assignment Section and Required Criteria (Points possible/% of total points available)	Highest Level of Performance	High Level of Performance	Satisfactory Level of Performance	Unsatisfactory Level of Performance	Section not present in paper
Health History: Subjective Data (30 points/30%)	30 points	28 points	23 points	15.5 points	0 points
Required criteria 1. This individual must be different from the individual used for the NR302 health history and physical examination assignment. 2. Demographic data. 3. Reason for care (why they are in the facility) 4. Present illness (PQRST of current illness) 5. Perception of health 6. Past medical history (including medications, allergies, and vaccinations and immunizations) 7. Family medical history 8. Review of systems 9. Developmental considerations 10. Cultural considerations 11. Psychosocial considerations 12. Presence or absence of collaborative resources (community, family, groups, and healthcare system)	Includes 12 requirements for section.	Includes 10-11 requirements for section.	Includes 6-9 requirement for section.	Includes 1-5 requirement for section.	No requirements for this section presented.
Physical Examination: Objective Data (30 points/30%)	30 points	28 points	23 points	15.5 points	0 points
Required criteria 1. HEENT (head, eyes, ears, nose, and throat) 2. Neck (including thyroid and lymph chains) 3. Respiratory system 4. Cardiovascular system 5. Neurological system 6. Gastrointestinal system 7. Musculoskeletal system 8. Peripheral vascular system	Includes 8 requirement for section.	Includes 7 requirement for section.	Includes 4-6 requirements for section.	Includes 1-3 requirements for section.	No requirements for this section presented.
Needs Assessment (20 points/20%)	20 points	18 points	15 points	7.5 points	0 points
Required criteria 1. 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. 2. Support the identified health teaching needs selected with evidence from two current, peer-reviewed journal articles. 3. Discuss how the interrelationships of physiological, developmental, cultural, and psychosocial considerations will influence, assist, or become barriers to the effectiveness of the proposed health education. 4. Describe how the individual’s strengths (personal, family, and friends) and collaborative resources (clinical, community, and health and wellness resources) effect proposed teaching.	Includes 4 requirements for section.	Includes 3 requirements for section.	Includes 2 requirements for section.	Includes 1 requirement for section.	No requirements for this section presented.
Reflection (10 points/10%)	10 points	9 points	8 points	4 points	0 points
Required criteria 1. Describe the interaction in its entirety: include the environment, your approach to the individual, time of day, and other features relevant to therapeutic communication and to the interview process. 2. How did your interaction compare to what you have learned? 3. What went well? 4. What barriers to communication did you experience? 5. How did you overcome them? 6. What will you do to overcome them in the future? 7. Were there unanticipated challenges to the interview? 8. Was there information you wished you had obtained? 9. How will you alter your approach next time?	Includes 9 requirements for section.	Includes 7-8 requirements for section.	Includes 5-6 requirements for section.	Includes 1-4 requirements for section.	No requirements for this section presented.
Style and Organization (10 points/10%)	10 points	9 points	8 points	4 points	0 points
Required criteria 1. Writing reflects synthesis of information from prior learning applied to completion of the assignment. 2. Grammar and mechanics are free of errors. 3. Able to verbalize thoughts and reasoning clearly. 4. Use appropriate resources and ideas to support topic with APA where applicable. 5. HIPAA protocols followed.	Includes 5 requirements for section.	Includes 4 requirements for section.	Includes 3 requirements for section.	Includes 1-2 requirements for section.	No requirements for this section presented.
Total = 100 points

 

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NR306_MAR23_Health_History_and_Physical_Assessment _Guidelines.docx 1

 

 

 

This assignment is designed to help nursing students develop their skills in conducting comprehensive health assessments, which are crucial for creating and implementing effective nursing care plans. Here’s a breakdown of how you can approach the assignment:

### 1. **Health History: Subjective Data (30%)**
– **Demographic Data:** Gather basic information like age, gender, ethnicity, occupation, etc.
– **Reason for Care:** Understand why the individual sought care (e.g., symptoms, routine check-up).
– **Present Illness:** Use the PQRST method (Provokes, Quality, Radiates, Severity, Time) to detail the current illness.
– **Perception of Health:** Explore the individual’s view of their health and wellness.
– **Past Medical History:** Include previous illnesses, surgeries, medications, allergies, vaccinations.
– **Family Medical History:** Document any relevant family medical history.
– **Review of Systems:** Ask about the general function of each body system (e.g., respiratory, cardiovascular).
– **Developmental Considerations:** Apply Erikson’s stages of psychosocial development to assess whether the individual has met developmental milestones.
– **Cultural Considerations:** Identify any cultural factors that might affect health and healthcare practices.
– **Psychosocial Considerations:** Examine the individual’s support systems (family, friends, community, religious).
– **Collaborative Resources:** Assess the availability of and access to resources that support health (e.g., healthcare services, community groups).

### 2. **Physical Examination: Objective Data (30%)**
– **HEENT:** Assess the head, eyes, ears, nose, and throat.
– **Neck:** Examine the thyroid and lymph chains.
– **Respiratory System:** Check the lungs and breathing patterns.
– **Cardiovascular System:** Assess the heart and circulation.
– **Neurological System:** Examine mental status, reflexes, motor and sensory functions.
– **Gastrointestinal System:** Assess the abdomen, bowel sounds, and related functions.
– **Musculoskeletal System:** Evaluate muscle strength, joint function, and posture.
– **Peripheral Vascular System:** Check for circulation in limbs, pulses, and any swelling.

### 3. **Needs Assessment (20%)**
– **Health Education Needs:** Identify at least two areas where the individual might benefit from health education, based on the health history and physical examination.
– **Supporting Evidence:** Use two current, peer-reviewed journal articles to back up your identified health teaching needs.
– **Interrelationships:** Discuss how physiological, developmental, cultural, and psychosocial factors might impact the effectiveness of your health education plan.
– **Strengths and Resources:** Describe how the individual’s strengths and available resources (family, community) can support the proposed health education.

### 4. **Reflection (10%)**
– Reflect on your overall experience during the health history and physical assessment.
– Consider your approach, environment, and any communication barriers you encountered.
– Discuss what went well, any challenges, and what you would do differently next time.

### 5. **Writing Style and Format (10%)**
– Ensure your writing is clear, well-organized, and free of grammatical errors.
– Synthesize information effectively, drawing on prior learning.
– Use appropriate resources and APA formatting where applicable.
– Adhere to HIPAA protocols by avoiding the use of any client identifiers.

### **Tips for Success:**
– **Preparation:** Before conducting the health assessment, review the relevant textbook sections and practice the physical examination techniques.
– **Holistic Approach:** Pay attention to how different aspects of the individual’s life (physical, emotional, social) are interconnected.
– **Documentation:** Keep thorough notes during your assessment to ensure you have all the information needed for the assignment.
– **Communication:** Use open-ended questions and active listening during your interview to gather comprehensive subjective data.
– **Reflection:** Be honest in your reflection section; consider both strengths and areas for improvement.

By carefully following these guidelines and addressing each section thoroughly, you’ll be able to create a comprehensive and well-rounded nursing assessment.

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