Health History Assessment Essay
Health History Assessment Essay
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. Health History Assessment Essay 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
COURSE OUTCOMES
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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) Health History Assessment Essay
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 Revised 11/05/18 EL/css 4
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
• Demographic data
• Reason for care (why they are in the facility)
• Present illness (PQRST of current illness) Health History Assessment Essay
• Perception of health
• Past medical history (including medications, allergies, and vaccinations and
immunizations)
• Family medical history
• Review of systems
• Developmental considerations
• Cultural considerations
• Psychosocial considerations
• Presence or absence of collaborative resources (community, family, groups, and
healthcare system)
***REMEMBER: Make notes of the health history findings, ensuring that you have addressed all of the
components listed here. Students are also encouraged to take notes about their experiences while
conducting the health history for reference when creating the assignment, particularly the reflection section.
2. Objective Data—Physical Exam Components to Be Included
During the lab experiences, you will conduct a series of physical exams that includes the
following systems.
Keep notes on each part of the physical exam as you complete them to reference as you write
the paper.
Refer to the course textbook for detailed components of each system exam. Remember,
assessment of the integumentary system is an integral part of the physical exam and should be
included throughout each system.
From NR302
o HEENT (head, eyes, ears, nose, and throat)
o Neck (including thyroid and lymph chains)Health History Assessment Essay
o Respiratory system
o Cardiovascular system
From NR304
NR 304 RUA Grading Rubric and Grading Criteria V2.docx 10_16 SMa Revised 11/05/18 EL/css 4
o Neurological system
o Gastrointestinal system
o Musculoskeletalsystem
o peripheral vascular system
***REMEMBER: Make notes of the physical examination findings, ensuring that you have addressed all of the
components listed on the Return Demonstration Checklist. Students are also encouraged to take notes
about their experiences while conducting the physical examination for reference when creating the
assignment, particularly the reflection section Health History Assessment Essay
