NR306 Health Assessment RUA Health History and Physical Assessment Solution

NR306 Health Assessment

RUA Health History and Physical Assessment Guidelines

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
2. To reflect on the interactive process that takes place between the nurse and an individual while conducting a health assessment and a physical

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); Health History and Physical Assessment

CO 3: Recognize the influence that developmental stages have on physical, psychosocial, cultural, and spiritual functioning. (PO 1): Health History and Physical Assessment

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. (POs 6 and 7)

Due date: Your faculty member will inform you when this assignment is due. The Late Assignment Policy applies to this assignment; Health History and Physical Assessment

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 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.
   1. Students may seek input from the course instructor on securing an individual for this
   2. Avoid the use of client identifiers in the assignment, HIPAA protocols must be
   3. During the lab experiences, you will conduct a series of physical exams that include the systems listed in Objective Data
   4. Refer to the course textbook for detailed components of each

Remember, assessment of the integumentary system is an integral part of the physical exam and should be included throughout each system.

1. 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
2. Utilize proper medical

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

1. Health History: Subjective Data (30 points/30% [1-2 paragraphs inlength])
   • Demographic data
   • Reason for care
   • 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)
2. Physical Examination: Objective Data (30 points/30% [1paragraph])
   • HEENT (head, eyes, ears, nose, and throat)
   • Neck (including thyroid and lymph chains)
   • Respiratory system
   • Cardiovascular system
   • Neurological system
   • Gastrointestinal system
   • Musculoskeletal system
3. Needs Assessment (20 points/20% [2 paragraphs])
   • Based on the health history and physical examination findings, determine at least two health education needs for the Remember, you may identify an educational topic that is focused on wellness.
   • Support the identified health teaching needs selected with evidence from two current, peer- reviewed journal
   • Discuss how the interrelationships of physiological, developmental, cultural, and psychosocial considerations will influence, assist, or become barriers to the effectiveness of the proposed health
   • Describe how the individual’s strengths (personal, family, and friends) and collaborative resources (clinical, community, and health and wellness resources) effect proposed
4. 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.

• Reflect on your interaction with the interviewee
  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
• How did your interaction compare to what you have learned?
• What barriers to communication did you experience?
  1. How did you overcome them?
  2. What will you do to overcome them in the future?
• What went well with this assignment?
• Were there unanticipated challenges during this assignment?
• Was there information you wished you had available but did not?
• How will you alter your approach next time?

1. Writing Style and Format (10 points/10%)
   • Writing reflects synthesis of information from prior learning applied to completion of the
   • Grammar and mechanics are free of
   • Able to verbalize thoughts and
   • Use appropriate resources and ideas to support topic with APA where applicable.
   • HIPAA protocols

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.

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

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RUA Health History and Physical Assessment