Nursing

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 istwofold.
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. (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.
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 thisassignment.
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 include the systemslisted
in Objective Data below.
d. Refer to the course textbook for detailed components of each systemexam.
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.
2. Include the following sections, used as section headers within the paper.
NR306 Health Assessment
RUA Health History and Physical Assessment Guidelines
a. Health History: Subjective Data (30 points/30% [1-2 paragraphs inlength])
1) Demographic data
2) Reason for care
3) Present illness (PQRST of currentillness)
4) Perception of health
5) Past medical history (including medications, allergies, and vaccinations and immunizations)
6) Family medical history
7) Review ofsystems
8) Developmental considerations
9) Cultural considerations
10) Psychosocial considerations
11) Presence or absence of collaborative resources(community, family, groups, and healthcare system)
b. Physical Examination: Objective Data (30 points/30% [1paragraph])
1) HEENT (head, eyes, ears, nose, andthroat)
2) Neck (including thyroid and lymph chains)
3) Respiratory system
4) Cardiovascularsystem
5) Neurologicalsystem
6) Gastrointestinalsystem
7) Musculoskeletalsystem
c. Needs Assessment (20 points/20% [2paragraphs])
1) Based on the health history and physical examination findings, determine at least two health
education needsfor the individual. Remember, you may identify an educational topic that isfocused
onwellness.
2) Support the identified health teaching needs selected with evidence from two current, peerreviewed journal articles.
3) Discuss how the interrelationships of physiological, developmental, cultural, and psychosocial
considerations will influence, assist, or become barriersto the effectiveness of the proposed health
education.
4) Describe how the individual’sstrengths(personal, family, and friends) and collaborative resources
(clinical, community, and health and wellness resources) effect proposed teaching.
d. Reflection (10 points/10% [1paragraph])
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 intervieweeholistically.
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 youexperience?
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 nexttime?
e. Writing Style and Format (10points/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 reasoningclearly.
4) Use appropriate resources and ideas to support topic with APA where applicable.
5) HIPAA protocolsfollowed.
NR306 Health Assessment
RUA Health History and Physical Assessment Guidelines
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.
NR306 Health Assessment
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. Demographic data
2. Reason for care (why they are in the facility)
3. Present illness (PQRST of currentillness)
4. Perception of health
5. Past medical history (including medications, allergies, and
vaccinations andimmunizations)
6. Family medical history
7. Review ofsystems
8. Developmental considerations
9. Cultural considerations
10. Psychosocial considerations
11. Presence or absence of collaborative resources (community,
family, groups, and healthcare system)
Includes 11
requirementsfor
section.
Includes 9-10
requirementsfor
section.
Includes 5-8
requirements
forsection.
Includes 1-4
requirementsfor
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 lymphchains)
3. Respiratory system
4. Cardiovascularsystem
5. Neurologicalsystem
6. Gastrointestinal system
7. Musculoskeletalsystem
Includes 8
requirementsfor
section.
Includes 7
requirementsfor
section.
Includes 4-6
requirements
forsection.
Includes 1-3
requirementsfor
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
Includes 4
requirementsfor
section.
Includes 3
requirementsfor
section.
Includes 2
requirements
forsection.
Includes 1
requirement for
section.
No requirements
for this section
presented.
NR306_Health_History_and_Physical_Assessment_Guidelines_V3 4
NR306 Health Assessment
RUA Health History and Physical Assessment Guidelines
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
(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 hadobtained?
9. How will you alter your approach nexttime?
Includes 9
requirementsfor
section.
Includes 7-8
requirementsfor
section.
Includes 5-6
requirements
forsection.
Includes 1-4
requirements
forsection.
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 theassignment.
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 protocolsfollowed.
Includes 5
requirementsfor
section.
Includes 4
requirementsfor
section.
Includes 3
requirements
forsection.
Includes 1-2
requirements
forsection.
No requirements
for this section
presented.
Total Points = 100
NR306_Health_History_and_Physical_Assessment_Guidelines_V3 5