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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 eachcategory, complete a health history and physical examination on an individual. You may choose to completeportions of this assignment as you obtain the health history and perform the physical examination associatedwith the body systems covered in NR304. . Please be sure to avoid the use of any identifiers in preparing theassignment. 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 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

2.      •Review of systems

•Developmental considerations

 •Cultural considerations

•Psychosocial consideration •Presence or absences 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

  HEENT (head, eyes, ears, nose, and throat)

  Neck (including thyroid and lymph chains) o Respiratory system

 Cardiovascular system

 Neurological system

 Gastrointestinal system

  Musculoskeletal system

  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. 

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)  APA FORMAT

1.Begin by writing ONE to TWO (12) paragraphs describing: the individual’s stated condition of healthmedications, and allergies. Also, include any of the following information that may be pertinent demographicdata, perception of health, past medical history, vaccinations/immunizations, family medical history, review of systems, developmental considerations, cultural considerations, psychosocial considerations, and the presenceor 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.

Chamberlain College of Nursing NR 304Health Assessment II

NR304 RUA: The Health History and Physical Examination for JUL16.docx Revised 06‐2016 4

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 properlycited) 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. Considerfollowing areas: include the environment, your approach to the individual, time of day, and other featuresrelevant to therapeutic communication and to the interview process. You may find your textbook helpful inproviding a description of therapeutic communication and of the interview process. Be certain to address thequestions listed above in the Reflection instructions.

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