THE 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

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 nursingprocess 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)

CO 6: Identify teaching/learning needs from the health history of an individual. (POs 2, 5)

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 ahealth educationneeds assessment, (3)self-reflection, and (4) writing style and format.

Instructions for each part follow.

HealthHistoryAssessmentand Physical Assessment

• 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 associatedwith the body systems covered in 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 ofphysical 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 integumentarysystem 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

o Neurological system

o Gastrointestinal system

o Musculoskeletal system

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(

1. Based on the health history and physical examination findings, determine at least twohealth education needs for the individual.Remember, you may identify an educational topic that is focused on wellness.

2. Select two peer-reviewed journal articles that provideevidence-based support for thehealth teaching needs you have identified.

Reflection

Nurses use reflection to, mindfully and intentionally, examine our thought processes, actions, and behaviors in order to betterevaluate our patients' outcomes. You have interviewed anindividual,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'shealth education needs.As you formulateyour 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.

1. 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 couldyou 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 hadavailable but did not?

e. How will you alter your approach to a obtaining a health history and conducting a physical examinationthe next time?

Writing Style and Format

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-editionformatting, as well as how clearlyyour thoughts and reasoning are expressed in writing.

Documentation of Findingsor How to Write the Paper

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.

1. Begin by writing one to two paragraphs describing the individual's stated condition of health medicationsand 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.

2. Write one paragraph describing the physical assessment findings, ensuring proper terminology is used to describe any abnormal or unusual findings.

3. 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.

4. 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.

5. Write one paragraph describing your reflectionof 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.