Nursing Individuals Health History and Physical Examination Worksheet

Purpose

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

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. 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.

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

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.

2. 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

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 

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.

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?

4) What went well with this assignment?Were there unanticipated challenges during this assignment?

5) Was there information you wished you had available but did not?

6) How will you alter your approach next time?