Utilize effective communication when performing a health assessment. (PO 3)
THE HEALTH HISTORY AND PHYSICAL EXAMINATION
PURPOSE
As you learned, 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.
• 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
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 6: Identify teaching/learning needs from the health history of an individual. (POs 2 and 5)
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, 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.
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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