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 todetermine areas of need or problems to be addressed by the nursing care plan. This assignment will focuson 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, andspiritual 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 whileconducting 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 andproviding appropriate documentation. (PO 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.
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.
Avoid the use of client identifiers in the assignment, HIPAA protocols must be utilized.
1)Remember, assessment of the integumentary system is an integral part of the physical exam and shouldbe
Include the following sections, used as section headers within the paper.
Health History: Subjective Data (30 points/30% [1-2 paragraphs in length])
6)Family medical history
7)Review of systems
10)Psychosocial considerations- support systems-family, religious, occupational, community these areexamples but please add more
Physical Examination: Objective Data (30 points/30% [1 paragraph])
1)From NR302
HEENT (head, eyes, ears, nose, and throat)
Neck (including thyroid and lymph chains)
Respiratory system
Cardiovascular system
2)From NR304
Neurological system
Gastrointestinal system
Peripheral vascular system
Needs Assessment (20 points/20% [2 paragraphs])
3)What barriers to communication did you experience?
What will you do to overcome them in the future?
4)What went well with this assignment?Were there unanticipated challenges during this 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.
a.Students may seek input from the course instructor on securing an individual for this assignment.
c.During the lab experiences, you will conduct a series of physical exams that includes the systemslisted in Objective Data below.
d.Refer to the course textbook for detailed components of each system exam.
included throughout each system.
e.Keep notes on each part of the health history and physical examination as you complete them so that youcan refer to the notes as you write the paper, particularly the reflection section.
f.Utilize proper medical terminology.
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)
8)Developmental considerations- use Erikson’s Stages of Psychosocial Development- which stageis 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, traditionaland complementary medicine, these are examples but please add more
11)Presence or absence of collaborative resources (community, family, groups, and healthcare system)
c)Musculoskeletal system
1)Based on the health history and physical examination findings, determine at least two healtheducation 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 psychosocialconsiderations 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 inorder to evaluate outcomes. Provide a written reflection that describes your experience withconducting 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 interviewprocess.
2)How did your interaction compare to what you have learned?
a)How did you overcome them?
5)Was there information you wished you had available but did not?
6)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.
Expert Solution Preview
As a medical professor in charge of creating college assignments and answers for medical college students, I understand the importance of providing comprehensive educational experiences. In this assignment, students will be tasked with conducting a health history and physical examination on an individual. The purpose of this assignment is two-fold: first, to recognize the interrelationships between subjective and objective data in planning and implementing nursing care, and second, to reflect on the interactive process between the nurse and the individual during a health assessment and physical examination.
The assignment guidelines provide a clear structure for completing the health history and physical examination. Students will be expected to gather subjective data, such as the individual’s demographic data, reason for care, perception of health, and past medical history. They will also conduct a physical examination, focusing on various systems such as the integumentary, HEENT, respiratory, cardiovascular, neurological, gastrointestinal, and peripheral vascular systems.
Following the completion of the health history and physical examination, students will be required to identify health education needs for the individual based on their findings. This will involve considering the interrelationships of physiological, developmental, cultural, and psychosocial factors, as well as the individual’s strengths and collaborative resources. Additionally, students will reflect on their experience with the assignment, including their interaction with the interviewee, challenges faced, and areas for improvement.
In evaluating student performance on this assignment, I will consider several criteria. First, I will assess the completeness and accuracy of the health history and physical examination, ensuring that students have followed the appropriate guidelines. I will also evaluate the students’ ability to identify health education needs and support them with evidence from current, peer-reviewed journal articles. Furthermore, I will look for a clear understanding of the interrelationships of physiological, developmental, cultural, and psychosocial factors, as well as the ability to reflect on the experience and make suggestions for improvement.
Providing feedback to students is an essential part of the learning process. Through examinations and assignments, I will provide detailed feedback on their strengths, areas for improvement, and the overall quality of their work. This feedback will aim to enhance their critical thinking skills, knowledge acquisition, and application of concepts. By evaluating student performance and providing constructive feedback, I can support their growth and development as future healthcare professionals.
To maintain the integrity and confidentiality of patient information, students must adhere to HIPAA protocols and avoid the use of client identifiers in their assignments. This ensures that patient privacy is protected and ethical considerations are maintained throughout the learning process.
Overall, this assignment aims to provide students with a hands-on opportunity to apply their theoretical knowledge, develop their assessment and communication skills, and gain a deeper understanding of the complexities involved in conducting a health history and physical examination. Through careful evaluation and feedback, students can continuously improve their abilities and become competent healthcare professionals.
