RUA: Health History and Physical Examination

 Select two peer-reviewed journal articles that provide evidence-based support for the health teaching needs you have identified.

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)
    • 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)
    o Respiratory system
    o Cardiovascular system
     From NR304
    NR 304 RUA Grading Rubric and Grading Criteria V2.docx 10_16 SMa 4 Revised 11/05/18 EL/css
    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 experiences while conducting the physical examination for reference when creating the
assignment, particularly the reflection section.

Needs Assessment (20 points)

  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. Select two peer-reviewed journal articles that provide evidence-based support for the health
    teaching needs you have identified.

Reflection (20 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’s health 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 and 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 (10 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 APA sixth-edition formatting, as well as how clearly your
thoughts and reasoning are expressed in writing.

Documentation of Findings or How to Write the Paper
NR 304 RUA Grading Rubric and Grading Criteria V2.docx 10_16 SMa 4 Revised 11/05/18 EL/css
Using Microsoft Word, create a double-spaced document. The paper should be formatted according
to APA sixth-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 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 and 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 healthcare system.
  2. Write one paragraph describing the physical assessment findings, ensuring proper terminology
    is used to describe any abnormal or unusual findings.
  3. Write one paragraph discussing (1) the rationale for the selection of the health teaching topics
    and (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 and wellness status.
  4. Write one 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 and wellness resources) on the proposed teaching.
  5. Write one paragraph describing your reflection of this assignment from a holistic point of view.
    Consider the 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

Answer preview  Select two peer-reviewed journal articles that provide evidence-based support for the health teaching needs you have identified.

APA

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