Chamberlain College of Nursing
NR 304 Health Assessment II
REQUIRED UNIFORM ASSIGNMENT: THE HEALTH HISTORY AND PHYSICAL EXAMINATION
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 on identifying health/wellness priorities for the person.
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;
and
• 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
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. (PO 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 6 Identify teaching/learning needs from the health history of an individual. (PO 2, 5)
DUE DATE
Please see the Course Calendar.
TOTAL POINTS POSSIBLE
50 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.
Health History Assessment and Physical Assessment (25 points)
Using the following subjective and objective components, and 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. . 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.
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NR 304 Health Assessment II
1. Subjective data ‐‐ Health History components to be included:
• Demographic data
• Reason for care (why are they in the facility)
• Present illness (PQRST of current illness)
• Perception of health
• Past medical history (including medications, allergies, and vaccinations/immunizations)
• Family medical history
• Review of systems
• Developmental considerations
• Cultural considerations
• Psychosocial consideration
• Presence or absence of collaborative resources (Community, family, groups, and health care 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 experience 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 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)
o Respiratory system
o Cardiovascular system
From NR304
o Neurological system
o Gastrointestinal system
o Musculoskeletal system
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 experience while conducting the physical examination for reference when creating the assignment,
particularly the reflection section.
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NR 304 Health Assessment II
Needs Assessment (10 points)
1. Based on the health history and physical examination findings, determine at least TWO (2) health education
needs for the individual. Remember, you may identify an educational topic that is focused on wellness.
2. Select TWO (2) peer‐reviewed journal articles that provide evidence–based support for the health teaching
needs you have identified.
Reflection (10 points)
Nurses use reflection to, mindfully and intentionally, examine our thought processes, actions, and behaviors in
order to better‐evaluate our patients’ outcomes. You have interviewed an individual, conducted a head to toe
physical assessment and identified at least two health teaching needs. You have also located within the
literature evidence‐based support for the teaching that will be used to address the individual’shealth education
needs. As you formulate your findings in writing within this assignment, it is time to turn your attention inward.
The final element of this assignment is to write a reflection that describes your experience.
1. Be sure your reflection addresses each of the following questions:
a. How did this assignment compare to what you’ve learned/expected?
b. What enablers or barriers to communication did you encounter when performing a health history
and physical exam? How could you overcome those barriers?
c. Were there any unanticipated challenges encountered during this assignment? ? What went well
with this assignment?
d. Was there information you wished you had available, but did not?
e. How will you alter your approach to a obtaining a health history and conducting a physical
examination the next time?
Writing Style and Format (5 points)
Your writing should reflect your synthesis of ideas based on prior knowledge, newly acquired information, and
appropriate writing skills. Scoring of your written communication is based on proper use of grammar, spelling,
and your use of APA 6th ed. formatting, as well as how clearly your thoughts and reasoning are expressed in
writing.
Documentation of Findings – or How to Write the Paper
Using Microsoft Word, create a double spaced document. The paper should be formatted according to
APA 6TH edition guidelines for the title page, running head, and reference page. The use of headings is
required for this paper. All portions of this assignment should be included within the paper including the
Reflection.
1. Begin by writing ONE to TWO (1‐2) paragraphs describing: the individual’s stated condition of health
medications, and allergies. Also, include any of the following information that may be pertinent demographic
data, perception of health, past medical history, vaccinations/immunizations, family medical history, review of
systems, developmental considerations, cultural considerations, psychosocial considerations, and the presence
or absence of resources from the community, family, groups, or the health care system.
2. Write ONE (1) paragraph describing: the physical assessment findings ensuring proper terminology is used to
describe any abnormal or unusual findings.
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NR 304 Health Assessment II
3. Write ONE (1) paragraph discussing: (1.) the rationale for the selection of the health teaching topics; (2.) how
the findings in the scholarly articles (identified in the Needs Assessment portion of the assignment and properly
cited) were used to develop the health teaching topics to promote the individual’s health/wellness status.
4. Write ONE (1) paragraph discussing: (1.) how the interrelationships of physiological, developmental, cultural,
and psychosocial considerations will influence, assist, or become barriers to the effectiveness of the proposed
health education; and (2.) a description of the impact of the individual’s strengths (personal, family, and friends)
and collaborative resources (clinical, community, and health/wellness resources on the proposed teaching.
5. Write ONE (1) paragraph describing your reflection of this assignment from a holistic point of view. Consider
following areas: include the environment, your approach to the individual, time of day, and other features
relevant to therapeutic communication and to the interview process. You may find your textbook helpful in
providing a description of therapeutic communication and of the interview process. Be certain to address the
questions listed above in the Reflection instructions.
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NR304 Health Assessment II
DIRECTIONS AND GRADING CRITERIA
Category
Health
History and
Physical
Assessment
Points
%
25
50
Description
Conducts a comprehensive health history and physical exam:
1. Subjective data: demographic data; reason for care; present
illness; perception of health; past medical history; family medical
history; review of systems; developmental considerations;
cultural considerations; psychosocial considerations; and
collaborative resources.
2. Objective data: HEENT; Neurological system, Respiratory system,
Cardiovascular system, neck; Gastrointestinal system;
Musculoskeletal system; and Peripheral Vascular system.
Provides a written narrative that includes:
1. ONE ‐ Two (1 ‐ 2) paragraphs describing: stated condition of
health, medications, and allergies. Also includes the following
information t: demographic data, perception of health, past
medical history, vaccinations/immunizations, family medical
history, review of systems, any developmental considerations,
cultural considerations or psychosocial considerations, presence
or absence of resources from the community, family, groups, or
from the health care system.
2. ONE (1) paragraph describing: the findings of the physical
examination.
3. ONE (1) paragraph discussing: (1.) the rationale for the selection
of the health education topics; (2.) how the findings in the
scholarly articles were used in support of the health teaching
topic to promote or improve the individual’s health/wellness
status.
4. ONE (1) paragraph discussing: (1.) how the interrelationships of
physiological, developmental, cultural, and psychosocial
considerations influence (assist or become barriers to the
effectiveness) to the proposed health education; and (2.) provides
a description of the impact of the individual's strengths (personal,
family, and friends) and collaborative resources (clinical, family,
community, and health/wellness resources) on the proposed
nursing teaching.
Needs
Assessment
10
20
1. Identifies two health education needs for the individual based on
the health history and physical examination findings TWO peer‐
reviewed journal articles providing evidence‐based support for the
identified health teaching needs.
2. APA 6th ed. formatting used for in‐text and reference page citations.
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NR304 Health Assessment II
Reflection
10
20
Reflects on the interaction with the interviewee holistically. Considers
the interaction in its entirety: includes the environment, the approach to
the individual, time of day, and other features relevant to therapeutic
communication and the interview process. The reflection should address
each of the following questions
How did your interaction compare to what you’ve
learned/expected?
What enablers or barriers to communication did you
experience? How did you overcome the barriers?
Were there any unanticipated challenges to conducting the
interview or performing the physical examination? What went
well?
Was there information you wished you had, butdid not?
How will you alter your approach the next time?
Writing style
and format
5
10
Writing should reflect your synthesis of ideas based on prior
knowledge, newly acquired information, and appropriate writing skills.
Scoring of your work in written communication is based on proper use
of grammar, spelling, and how clearly you express your thoughts and
reasoning in writing. Proper use of APA 6th ed. style and format
throughout this paper is required.
50
100
Total
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NR304 Health Assessment II
GRADING RUBRIC
Assignment
Criteria
Health
History and
Physical
Examination
(25 points)
Outstanding or Highest Level of
Performance
Very Good or High Level of
Performance
Competent or Satisfactory Level
of Performance
Poor, Failing or Unsatisfactory
Level of Performance
A (92–100%)
B (84–91%)
C (76–83%)
F (0–75%)
ONE of the key elements of the
health history narrative is not
presented or lacks sufficient
detail:
• Demographic Data
• Reason for Care
• Present Illness
• Perception of Health
• Past Medical History
• Family Medical History
• Review of Systems
• Developmental Considerations
• Cultural Considerations
• Psychosocial Considerations
• Collaborative Resources.
TWO of the key elements of the
health history narrative are not
presented or lacks sufficient
detail:
• Demographic Data
• Reason for Care
• Present Illness
• Perception of Health
• Past Medical History
• Family Medical History
• Review of Systems
• Developmental Considerations
• Cultural Considerations
• Psychosocial Considerations
• Collaborative Resources.
THREE or more of the key
elements of the health history
narrative are not presented or
lacks sufficient detail:
• Demographic Data
• Reason for Care
• Present Illness
• Perception of Health
• Past Medical History
• Family Medical History
• Review of Systems
• Developmental Considerations
• Cultural Considerations
• Psychosocial Considerations
• Collaborative Resources.
ONE of the key elements
of the physical exam is not
presented or lacks sufficient
detail:
HEENT
• Neurological system
• Neck
• Respiratory system
• Cardiovascular system
• Gastrointestinal system
TWO of the key elements of
the physical exam is not
presented or lacks sufficient
detail:
• HEENT
• Neurological system
• Neck
• Respiratory system
• Cardiovascular system
• Gastrointestinal system
THREE or more of the key
elements of the physical exam is
not presented or lacks sufficient
detail:
• HEENT
• Neurological system
• Neck
• Respiratory system
• Cardiovascular system
• Gastrointestinal system
Thoroughly presents a health
history narrative that includes
a detailed description of ALL
the following components:
• Demographic Data
• Reason for Care
• Present Illness
• Perception of Health
• Past Medical History
• Family Medical History
• Review of Systems
• Developmental
Considerations
• Cultural Considerations
• Psychosocial Considerations
• Collaborative Resources.
Thoroughly presents a
physical exam narrative that
includes a detailed description
of ALL the following
components:
HEENT
• Neurological system
• Neck
• Respiratory system
• Cardiovascular system
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• Gastrointestinal system
• Musculoskeletal system
• Peripheral Vascular system •
Integumentary system
integrated in exam of all
systems where appropriate
• Musculoskeletal system
• Peripheral Vascular system •
Integumentary system integrated
in exam of all systems where
appropriate
• Musculoskeletal system
• Peripheral Vascular system
•Integumentary system
integrated in exam of all systems
where appropriate
• Musculoskeletal system
• Peripheral Vascular system •
Integumentary system integrated
in exam of all systems where
appropr1ate
Information is presented in a
clear, organized, and
professional manner.
Information is presented in a
clear, organized, and professional
manner.
Information is NOT presented in
a clear, organized, and
professional manner.
Information is NOT presented in
a clear, organized, and
professional manner.
21-22 points
19-20 points
0‐18 points
Accurately identifies TWO health
education needs for this
individual and provides at least
three factors that may, positively
or negatively, influence the
person’s ability to incorporate
the health teaching to improve
their well‐being.
Accurately identifies a health
education need for this
individual and provides at least
two factors that may, positively
or negatively, influence the
person’s ability to incorporate
the health teaching to improve
their well‐being.
Accurately identifies a health
education need for this
individual and provides at least
two factors that may, positively
or negatively, influence the
person’s ability to incorporate
the health teaching to improve
their well‐being.
Accurately identifies a health
education need for this
individual and poorly/minimally
applies one or more factors that
may, positively or negatively,
influence the person’s ability to
incorporate the health teaching
to improve their well‐being.
References TWO peer‐reviewed
journal articles that provide
evidence‐based support for the
health teaching; APA format
(most current edition) used to
list the sources.
10 points
References TWO peer reviewed
journal articles that provide
evidence‐based support for the
health teaching but does not use
appropriate APA format (most
current edition) to list the
sources.
9 points
References ONE peer‐reviewed
journal articles that provides
evidence‐based support for the
health teaching but does not use
appropriate APA format (most
current edition) to list the
sources.
8 points
No references are submitted,
or if used, have three or more
types of errors in APA format
(most current edition) to list the
sources.
0‐7 points
Thoughtfully appraises the
individual holistically. Reflection
includes a detailed response to
ALL the following questions:
Thoughtfully appraises the
individual holistically. ONE of the
following questions is not
presented or lacks sufficient
detail:
Broadly appraises the individual.
TWO of the following questions
are not presented or lack
sufficient detail:
Broadly appraises the individual.
THREE or more of the following
questions are not presented or
lack sufficient detail:
23-25 points
Needs
Assessment
(10 Points)
Reflection
(10 Points)
NR304 Health Assessment II
NR304 RUA The Health History and Physical Examination for JUL16.docx
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• How did your interaction
compare to what you’ve
learned?
• What went well?
• What barriers to
communication did you
experience?
• How did you overcome them?
• Were there unanticipated
challenges to the interview?
• Was there information you
wished you’d obtained?• How
will you alter your approach the
next time?
Key/relevant information is
presented in sufficient detail and
is clear and organized.
10 points
Writing
Style and
Format
(5 points)
NR304 Health Assessment II
How did your interaction
compare to what you’ve
learned?
What went well?
What barriers to
communication did you
experience?
How did you overcome
them?
Were there unanticipated
challenges to the interview?
Was there information you
wished you’d obtained?
How will you alter your
approach the next time?
•
How did your interaction
compare to what you’ve
learned?
What went well?
What barriers to
communication did you
experience?
How did you overcome
them?
Were there unanticipated
challenges to the interview?
Was there information you
wished you’d obtained?
How will you alter your
approach the next time?
•
How did your interaction
compare to what you’ve
learned?
What went well?
What barriers to
communication did you
experience?
How did you overcome
them?
Were there unanticipated
challenges to the interview?
Was there information
obtained?
How will you alter your
Approach the next time?
Key/relevant information is
presented in sufficient detail and
is clear and organized.
9 points
Key/relevant information is
presented in insufficient detail
but is clear and organized.
8 Points
Student presents information
using clear and logical language.
Grammar, spelling, and
punctuation are free of errors.
APA 6th edition used to guide
style and format of this paper.
Student presents information
using clear and logical language.
Grammar, spelling, and
punctuation have two or fewer
types of errors. OR no more than
1 error in APA 6th ed. formatting.
Student presents information
using clear and logical language.
Grammar, spelling, and
punctuation have three types of
errors. OR no more than 2 errors
in APA 6th ed. formatting.
Information is unclear and
difficult to follow. Grammar,
spelling, and punctuation have
three or more types of errors. OR
more than 3 errors in APA 6th ed.
formatting.
5 points
4.5 points
4 points
0–3 points
Total Points Possible = 50 points
NR304 RUA The Health History and Physical Examination for JUL16.docx
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Key/relevant information is
presented in insufficient
detail and is not clear or
organized.
0‐7 points
Health history and physical assessment
Subjective data
Patient is a 54 yrs.’ Old African American male with no significant past medical history,
who went to see his primary care doctor, and stated for the past five days he had been urinating
a lot, very thirsty and very tired. He was encouraged to seek immediate medical care in the
emergency department. Lab work up in the emergency revealed a blood glucose level of 342 and
HgbAIC of 9. Chest x-ray completed revealed patchy left lower lobe infiltrate and small
bilateral pleural effusions-community acquired pneumonia, and also diagnosed as a new Type
one diabetic. He was started on oral antibiotics, blood glucose monitoring with insulin coverage
and was told to follow up with his doctor.
Past medical history: Hypertension, currently prescribed Metoprolol 50mg every 12 hours.
Depression, not controlled with Paxil, as he reports to still feels depressed
Surgical history: Bilateral knee replacement
Family history: Mother died from a stroke, father died from old age
Social History: The patient and family migrated from Haiti twelve years ago. He currently
works as a handyman in his neighborhood. He has been married for 15 years and lives with wife,
have 3 grown children and two grandchildren who currently lives with him. He reported that he
used tobacco in the past, but quit 20 years ago. He denies past or present illicit drug use. He
denies alcohol use. He does not have health insurance.
Allergies: None
Vaccines: Influenzas not up to date. Pneumonia not up to date
Objective data
Temperature: 98.3
Respirations: 16 breaths per minutes
Blood pressure: 128/75
Oxygen Saturation: 97% on 2-3L/NC
Height: 74 inches
Weight: 210 pounds
HEENT
Head: denies headache or dizziness
Ears: denies any changes in hearing or ringing
Eyes: reports some blurred vision
Nose: denies any stuffiness or drainage
Throat: denies difficulties swallowing or any lump in throat
NEUROLOGICAL
Pt is awake, alert and oriented to time date place and situation. Patient denies any loss of
consciousness or confusion
RESPIRATORY
Patient reports some shortness of breath and intermitting coughing, lungs sounds are
clear to right upper and lower lobes and diminished to left upper and lower lobes. No use of
accessory muscles noted
CARDIOVASCULAR
Heart sound is regular with apical beats of 76 beats per minute. No pulsations visible and
there is no presence heaves or lifts.
NECK
The muscles of the neck are equal in size and the trachea is midline. The
patient was able to show smooth and coordinated head without pain or discomfort. The lymph
nodes are not palpable, and thyroid glands upon inspection are not visible.
GASTROINTESTINAL
Patient reports a bowel movement of form soft stool every day, bowel sounds upon
auscultation are normal and present in all quadrant. No tenderness reported while palpated or no
mass felt.
PERIPHERAL VASCULAR
No discoloration or muscle wasting noted, capillary refill is less than three seconds. No
numbness or tingling reported by patient. All limbs and joints are intact.
INTEGUMENTARY
Skin color is appropriate for race and uniform in color, turgor is normal, no lesions are
open areas noted, temperature is normal. No foul odor noted.
After interviewing the patient it was clear that the patient lacks education about these
diseases that he is faced with, as he stated that he only take the prescribed Metoprolol only when
he feels like his blood pressure is high and the Paxil make his sleepy so he hardy takes it. The
patient is currently the head of his household, therefore he spends a lot of time working to
provide for the family, leaving little time to care or worry about himself and his health. He
professed he is in good health, as he has not even had a cold in the past few years. He drinks a
cup of herbal tea every night before he goes to bed. He stated that his appetite is very good and
enjoys whatever his wife prepares. Patient also stated that his parent lived a very long life and
never took any medications.
According to a peer reviewed article by Ginn, A. (2014). Self-management is the key to
obtain optimal result of blood glucose, but in order for this to be successful one has to take into
consideration a number of things which can be barriers to success. Obesity is the Caribbean
American population in a major problem, as eating foods that are fried and high in sugar fats are
consider the norm, and being overweight is alleged to be healthy. Another barrier is low socioeconomic and systemic oppression that placed the African American population at a
disadvantage in obtaining resources and funds to obtain health insurance. Illiteracy is another
major problem that this population face, so teaching and available resources will make a big
difference where it comes to self-management for these patients.
The proposed health education for this patient is to get his wife and children involved in
his care. They will be taught how to prepare and eat food items that are low in glycemic levels
and also how to substitute some of the foods that they enjoy with something else. I will, also
encourage him to incorporate some exercise activities in his daily routine for at least 30 minutes.
He will also be taught how to use the blood glucose monitor accurately and to recognize and
identify symptoms of hyperglycemia. The teaching and education will be done in layman’s term
as the patient and family is health illiterate. The patient’s personal strength will be the determine
factor, as he will have to welcome the change in order maintain a healthy lifestyle.
The patient will be provided with information about obtaining health insurance or visiting
the county clinic for treatment and disease management. He will also reach out to the church
community for outside support and information regarding wellness programs, such as walk
groups discount memberships for exercise facilities.
Needs assessment
Two health education need for this patient based on his assessment findings are and selfmotivation, and nutrition. According to Stanley, K. (2014)
………………………………………….
REFLECTION...............................................
SYNTHESIS.
In summary, being diagnosed with diabetes should be taken very seriously, as this is a complex
disease that needs careful monitoring. Diet, exercise, medication compliance, and lifestyle
changes will promote a positive outcome. The surge of new diabetics can decrease drastically if
patients are educated and have access to available resources. Knowledge and resources will
empower these patients to be the author of their own lives.
REFRENCES
Stanley, K. (2014). Nutrition considerations for the growing population of older adults with
diabetes. Diabetes Spectrum, 27(1), 21-30. Retrieved from CINAHL with Full text database.
Ginn, A. (2014). Diabetes self-management improves outcomes. Today’s Geriatric Medicine, 7
(4), 24-25. Retrieved from http://www.todaysgeriatricmedecine.com/archive/0714924.shtml
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