NR304 Health Assessment 2 Paper
NR304 Health Assessment 2 Paper
RUA: Health history and physical examination on an individual.
Ebook: Jarvis, C., Eckhardt, A., & Thomas, P. (2020). Physical examination & health assessment (8th ed.). Saunders.
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The purpose of the assignment is two-fold:
- To recognize the interrelationships of subjective data (physiological, psychosocial, cultural/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.
Review and download the NR304 RUA Health History and Physical Examination Guidelines (Links to an external site.) for the assignment to assure you have addressed all required elements prior to submitting.
PLEASE FOLLOW THE GUIDELINES ATTACHED IN THE FILES.
Please ensure that your submissions adhere to 7th edition APA formatting and submit in a Microsoft Word document format.
APA format (7th ed.) and is free of errors
Grammar and mechanics are free of errors free of Plagiarism
References: Use your book, the outside source must be within the last 5 yrs, Scholarly Articles,s or Nurse journals within the last 5 yrs.
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NR304_Health_History_and_Physical_Assessment_Guidelines_V7.pdfNR304 Health Assessment II
RUA Health History and Physical Assessment Guidelines
NR304_Health_History_and_Physical_Assessment _Guidelines_V7.docx Revised: 6/2021 1
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. 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
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NR304_Health_History_and_Physical_Assessment _Guidelines_V7.docx Revised: 6/2021 2
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. NR304 Health Assessment 2 Paper
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?
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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. 5) Adheres to APA recommendations for title page, running head, headings, in-text citations, and reference
page 6) HIPAA protocols followed.
For writing assistance (APA, formatting, or grammar) visit the APA Citation and Writing Assistance page in the online library. 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.
NR304 Health Assessment II RUA Health History and Physical Assessment Guidelines
NR304_Health_History_and_Physical_Assessment _Guidelines_V7.docx Revised: 6.2021 4
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 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 9. Cultural considerations 10. Psychosocial considerations 11. Presence or absence of collaborative resources (community,
family, groups, and healthcare system)
Includes 11 requirements for section.
Includes 9-10 requirements for section.
Includes 5-8 requirement for section.
Includes 1-4 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
NR304_Health_History_and_Physical_Assessment _Guidelines_V7.docx Revised: 6.2021 5
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 (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 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. 5. Adheres to APA recommendations for title page, running head,
headings, in-text citations, and reference page. 6. HIPAA protocols followed.
Includes 6 requirements for section.
Includes 5 requirements for section.
Includes 4 requirements for section.
Includes 1-3 requirements for section.
No requirements for this section presented.
Total = 100 points
NR304 Health Assessment II RUA Health History and Physical Assessment Guidelines
NR304_Health_History_and_Physical_Assessment _Guidelines_V7.docx Revised: 6.2021 6
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APA_7th_Edition_Paper_Template_RNBSN6.docx
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Scholarly Paper Phase 1
Your Name (without credentials)
Chamberlain University College of Nursing
Course Number: Course Name
Name of Instructor
Assignment Due Date
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PhysicalExaminationandHealthAssessmentE-BookbyCarolynJarvisz-lib.org.pdf
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RUAHealthHistoryguidelinetofolow.docx
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Health History Information Interview
Chamberlain University College of Nursing
NR302 Health Assessment 1
October 1, 2021
Demographic Information
Jeremy is a 52 year-old white male who reported complaints of abdominal pains. The patient complains of having abdominal pains that has been persistent for 3 days. He reports that the pain was acute at the onset with a scale of 9/10 but reduced to 5/10. The abdominal pains are general and there is no specific part of the stomach that is affected. Now he is able to eat, except that he nauseates after meals and also experiences diarrhea. There is no specific timing when the pains are severe, but it is a generalized pain. The patient reports that there are no exacerbating or relieving factors. The patient does not seem to have any growth abnormality and seems okay in all aspects. He also appears to be in good shape for his age and a BMI of 20.7. NR304 Health Assessment 2 Paper
Past Medical History
There is no record of pharmacological history, and no known immunizations were recorded. The patient also does not have any history of surgeries or illnesses related to the stomach. The patient did not indicate his occupation or hobbies. He denies any tobacco usage, but admits to being an occasional drunk. He is married with three children who are two boys and a girl. He has no drug allergies and is currently on Metformin 1000mg, Amlodipine 5 mg, Lantus 10 units qhs, and Lisinopril 10mg, medications.
Family History
The patient does not have a history of any form of cancer. The father had diabetes mellitus type 2 and hypertension. The mother suffered hyperlipidemia and gastroesophageal disease. The patient also never married and is not seeing anybody at the moment. Despite being a Catholic family, they never had any issues with seeking medical care. The family never had any religious or cultural restrictions that would hinder their pursuit of health. None of the family members also had a history of mental illness.
Cultural Considerations
The patient does not have any cultural issues that may influence his decision to seek medical attention. He is a devout Christian but does not let his religion interfere with his medical decisions.
Developmental Considerations
The patient has no developmental issues. His height is okay, and he has does not seem to be experiencing challenges pertaining to aging. He exhibits good morbidity and does not require any form of aid in going about his ADL.
Psychosocial Considerations
The patient is in his right state of mind and does not seem disoriented. His speech is okay and does not have any psychosocial issues. He has not suffered any significant form of stress or depression over the last seven years. NR304 Health Assessment 2 Paper
Collaborative Resources
The patient seems to be aware of his dieting requirements. However, he admits that he may require more knowledge from a dietitian as he never seeks information from any. He also admits that he does not handle the cooking at home, hence, only eats whatever his wife cooks.
Review of Systems
The patient exhibited a slight rise in the body temperature (99.7°F); RR 16; BP 160/86; P 92; Weight 248lbs; and HT 5’10”. There is no record of visual loss, blurred vision, or double vision recorded. There are also no yellow sclerae. No hearing loss, no sneezing or nasal blockage, and no sore throat or runny nose. The skin had no lesions, no urticaria, and no rash or itching. Cardiovascular examinations returned no murmurs in the heart, no chest pain, and no chest discomfort. No palpitations or edema. The respiratory examinations also revealed a symmetrical chest wall, no shortness of breath, and no cough or sputum. The patient also had a soft abdomen, and hyperactive bowel sounds. The patient experienced nausea after meals, and diarrhea. Genitourinary exams revealed no burning sensations on urination. The patient also indicated that he did not experience dizziness, headache, syncope, ataxia, paralysis, tingling in the extremities or numbness. However, there was a considerable change in bowel movement. There were no enlarged nodes or history of splenectomy, back, muscle, and stiffness or joint pains, anemia, bruising or bleeding, and no history of anxiety or depression. The endocrinologic report returned no reports of sweating, cold or heat intolerance. Also, there was no polydipsia or polyuria recorded. The patient appeared dehydrated. The skin was intact and the patient had lost some weight. His last medical examination was four months ago, and a full body exam was conducted on him. All his results came out fine.
Reflection
The interview occurred at a local health facility, and the patient chose the place because it was his day at the clinic. Admittedly, it was rather mind-boggling to approach him with the suggestion of conducting the interview. However, upon establishing the desired connection, I gained an insightful experience into the patient’s life experiences. Initially, I thought of conducting the interview in a relatively different place, but the patient suggested that I accompany him on his clinical visit. It was nice interacting with the caregivers, and I got a chance to learn a couple extra things from them too. We closed on a good note, and the patient was willing to grant me another interview in the future. NR304 Health Assessment 2 Paper
References
Jarvis, C., Eckhardt, A., & Thomas, P. (2020). Physical examination & health assessment (8th ed.). Saunders.