THE HEALTH HISTORY AND PHYSICAL EXAMINATION
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
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 4 Revised 11/05/18 EL/css
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