NR304 Health Assessment II
RUA Health
History and Physical
Assessment Guidelines
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.
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, 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, 5)
CO 7: Explore
the professional responsibilities involved in conducting a comprehensive health
assessment and providing appropriate documentation. (PO
6, 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. This individual must be
different from the individual used for the NR302 health history and physical
examination assignment. 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
in NR304. 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.
2.
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
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.
3.
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?
5)
Were there unanticipated challenges during
this assignment?
6)
Was there information you wished you had available but did not?
7)
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
See rubric
next page
NR304 Health Assessment II
RUA Health
History and Physical
Assessment Guidelines
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.
From NR302
o
HEENT (head, eyes, ears,
nose, and throat)
o
Neck (including thyroid and
lymph chains)
o
Respiratory system
o
Cardiovascular system
2. From NR304
o
Neurological system
o
Gastrointestinal system
o
Musculoskeletal system
o
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.
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.
NR304 Health Assessment II
RUA Health
History and Physical
Assessment Guidelines
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.
Reflection
(10points/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
