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Health, Medicine, Nursing
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Research Paper
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Topic:

Completing Health History and Physical Examination

Research Paper Instructions:

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 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

Course Outcomes This assignment enables the student to meet the following course outcomes.

CO 1: Explain expected client behaviors while differentiating between normal findings, variations and

abnormalities. (PO1)

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, 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 5: Demonstrate beginning skill in performing a complete physical examination using the techniques of inspection,

palpation, percussion, and auscultation. (PO 2

CO 6: Identify teaching/learning needs from the health history of an individual. (POs 2, 5)

CO 7: Explore the professional responsibilitiesinvolved in conducting a comprehensive health assessment and providing

appropriate documentation. (PO 6, 7)

Due date Your faculty member will inform you when this assignment is due. The Late Assignment Policy applies to this

assignment.

Total points possible 100 points

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. This individual must be different from the

individual used for the NR302 health history and physical examination assignment. Using the following subjective

and objective components, as well as your textbook for explicit details about each category, complete a health

history and physicalexamination 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.

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.

2.

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

NR304_Health_History_and_Physical_Assessment _Guidelines_V9.docx © 2022 Chamberlain University. All Rights Reserved 2

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.

3. 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- supportsystems-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) Cardiovascularsystem

2) From NR304

a) Neurological system

b) Gastrointestinalsystem

c) Musculoskeletalsystem

d) Peripheral vascular system

c. Needs Assessment (20 points/20% [2 paragraphs])

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 (10 points/10% [1 paragraph])

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?

NR304_Health_History_and_Physical_Assessment _Guidelines_V9.docx © 2022 Chamberlain University. All Rights Reserved 3

5) Were there unanticipated challenges during this assignment?

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

7) How will you alter your approach next time?

e. Writing Style and Format (10 points/10%)

1) Writing reflects synthesis of information from prior learning applied to completion of the assignment.

2) Grammar and mechanics are free of errors.

3) Able to verbalize thoughts and reasoning clearly.

4) Use appropriate resources and ideas to support topic with APA where applicable.

5) HIPAA protocolsfollowed.

For writing assistance, visit the Writing Center.

Please note that your instructor may provide you with additional assessmen

Grading Rubric Criteria are met when the student’s application of knowledge demonstrates achievement of the outcomes for this assignment.

Assignment Section and

Required Criteria

(Points possible/% of total points available)

Highest Level of

Performance

High Level of

Performance

Satisfactory

Level of

Performance

Unsatisfactory

Level of

Performance

Section not

present in

paper

Health History: Subjective Data

(30 points/30%) 30 points 28 points 23 points 15.5 points 0 points

Required criteria

1. This individual must be different from the individual used for the

NR302 health history and physical examination assignment.

2. Demographic data.

3. Reason for care (why they are in the facility)

4. Present illness (PQRST of current illness)

5. Perception of health

6. Past medical history (including medications, allergies, and

vaccinations and immunizations)

7. Family medical history

8. Review ofsystems

9. Developmental considerations

10. Cultural considerations

11. Psychosocial considerations

12. Presence or absence of collaborative resources (community,

family, groups, and healthcare system)

Includes 12

requirementsfor

section.

Includes 10-11

requirementsfor

section.

Includes 6-9

requirement

forsection.

Includes 1-5

requirement for

section.

No requirements

for this section

presented.

Physical Examination: Objective Data

(30 points/30%) 30 points 28 points 23 points 15.5 points 0 points

Required criteria

1. From NR302

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

o Neck (including thyroid and lymph chains)

o Respiratory system

o Cardiovascularsystem

2. From NR304

o Neurological system

o Gastrointestinalsystem

o Musculoskeletalsystem

o Peripheral vascularsystem

Includes 8

requirement for

section.

Includes 7

requirement for

section.

Includes 4-6

requirements

forsection.

Includes 1-3

requirementsfor

section.

No requirements

for this section

presented.

Needs Assessment

(20 points/20%) 20 points 18 points 15 points 7.5 points 0 points

Required criteria

1. Based on the health history and physical examination findings,

determine at least two health education needs for the individual.

Includes 4

requirementsfor

section.

Includes 3

requirementsfor

section.

Includes 2

requirements

forsection.

Includes 1

requirement for

section.

No requirements

for this section

presented.

NR304 Health Assessment II

RUA Health History and Physical Assessment Guidelines

NR304_Health_History_and_Physical_Assessment _Guidelines_V9.docx © 2022 Chamberlain University. All Rights Reserved 6

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.

Reflection

(10points/10%) 10 points 9 points 8 points 4 points 0 points

Required criteria

1. 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 went well?

4. What barriers to communication did you experience?

5. How did you overcome them?

6. What will you do to overcome them in the future?

7. Were there unanticipated challenges to the interview?

8. Was there information you wished you had obtained?

9. How will you alter your approach next time?

Includes 9

requirementsfor

section.

Includes 7-8

requirementsfor

section.

Includes 5-6

requirementsfor

section.

Includes 1-4

requirementsfor

section.

No requirements

for this section

presented.

Style and Organization

(10 points/10%) 10 points 9 points 8 points 4 points 0 points

Required criteria

1. Writing reflectssynthesis of information from priorlearning

applied to completion of the assignment.

2. Grammar and mechanics are free of errors.

3. Able to verbalize thoughts and reasoning clearly.

4. Use appropriate resources and ideasto support topic with APA

where applicable.

5. HIPAA protocolsfollowed.

Includes 5

requirementsfor

section.

Includes 4

requirementsfor

section.

Includes 3

requirementsfor

section.

Includes 1-2

requirementsfor

section.

No requirements

for this section

presente

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.

To reflect on the interactive process that takes place between the nurse and an individual while conducting a health assessment and a physical examination.

Review and download the NR304 RUA Health History and Physical Examination Guidelines Links to an external site. for the assignment to assure you have addressed all required elements prior to submitting.



Rubric

NR304 RUA: Health History and Physical Assessment Guidelines (Sept20)

NR304 RUA: Health History and Physical Assessment Guidelines (Sept20)

Criteria Ratings Pts

This criterion is linked to a Learning OutcomeHealth History: Subjective Data

Required criteria

1. This individual must be different from the individual used for the NR302 health history and physical examination assignment.

2. Demographic data.

3. Reason for care (why they are in the facility)

4. Present illness (PQRST of current illness)

5. Perception of health

6. Past medical history (including medications, allergies, and vaccinations and immunizations)

7. Family medical history

8. Review of systems

9. Developmental considerations

10. Cultural considerations

11. Psychosocial considerations

12. Presence or absence of collaborative resources (community, family, groups, and healthcare system

30 pts

Highest Level of Performance

Includes 12 requirements for section.

28 pts

High Level of Performance

Includes 10-11 requirements for section.

23 pts

Satisfactory Performance

Includes 6-9 requirements for section.

15.5 pts

Unsatisfactory Performance

Includes 1-5 requirements for section.

0 pts

Not Present

No requirements for this section presented.

30 pts

This criterion is linked to a Learning OutcomePhysical Examination: Objective Data

Required criteria

1. From NR302:

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

o Neck (including thyroid and lymph chains)

o Respiratory system

o Cardiovascular system

2. From NR304:

o Neurological system

o Gastrointestinal system

o Musculoskeletal system

o Peripheral vascular system

30 pts

Highest Level of Performance

Includes 8 requirements for section.

28 pts

High Level of Performance

Includes 7 requirements for section.

23 pts

Satisfactory Performance

Includes 4-6 requirements for section.

15.5 pts

Unsatisfactory Performance

Includes 1-3 requirements for section.

0 pts

Not Present

No requirements for this section presented.

30 pts

This criterion is linked to a Learning OutcomeNeeds Assessment

Required criteria

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.

20 pts

Highest Level of Performance

Includes 4 requirements for section.

18 pts

High Level of Performance

Includes 3 requirements for section.

15 pts

Satisfactory Performance

Includes 2 requirements for section.

7.5 pts

Unsatisfactory Performance

Includes 1 requirement for section.

0 pts

Not Present

No requirements for this section presented.

20 pts

This criterion is linked to a Learning OutcomeReflection

Required criteria

1. 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 went well?

4. What barriers to communication did you experience?

5. How did you overcome them?

6. What will you do to overcome them in the future?

7. Were there unanticipated challenges to the interview?

8. Was there information you wished you had obtained?

9. How will you alter your approach next time?

10 pts

Highest Level of Performance

Includes 9 requirements for section.

9 pts

High Level of Performance

Includes 7-8 requirements for section.

8 pts

Satisfactory Performance

Includes 5-6 requirements for section.

4 pts

Unsatisfactory Performance

Includes 1-4 requirements for section.

0 pts

Not Present

No requirements for this section presented.

10 pts

This criterion is linked to a Learning OutcomeStyle and Organization

Required criteria

1. Writing reflects synthesis of information from prior learning applied to completion of the assignment.

2. Grammar and mechanics are free of errors.

3. Able to verbalize thoughts and reasoning clearly.

4. Use appropriate resources and ideas to support topic with APA where applicable.

5. HIPAA protocols followed.

10 pts

Highest Level of Performance

Includes 5 requirements for section.

9 pts

High Level of Performance

Includes 4 requirements for section.

8 pts

Satisfactory Performance

Includes 3 requirements for section.

4 pts

Unsatisfactory Performance

Includes 1-2 requirements for section.

0 pts

Not Present

No requirements for this section presented.

10 pts

Total Points: 100

Research Paper Sample Content Preview:

Health History
Student’s Name
University Affiliation
Professor’s Name
Course Title
Due Date
Health History
The person is a forty-five-year-old male, an African American who is a cook by profession. He has three biological children: twenty, eighteen, and thirteen. He lives with them all in a three-bedroom maisonette. He recently divorced his wife and targets to remarry in a few months. His reason for care includes recent discomfort with his health, such as frequent headaches, frequent urination, numbness and tingling at the toes and fingers, tiredness and fatigue, and situational irritability. He went to a nearby local clinic and was only given painkillers with an explanation that he works too much and he could be acutely fatigued. He is worried as he perceives health as essential and paramount. He plans to visit a renowned hospital soon. He has no significant past medical history and recalls that as a kid, he underwent all the immunizations required. He has also received the covid-19 vaccination. On his family medical history, he recalls that his father was diagnosed with high blood pressure at fifty years and later passed on due to chronic kidney injury. His mother is still alive though they do not get along well. He describes her as a healthy and strong woman.
Under the problem-pertinent review of systems, neurological, musculoskeletal, and urinary systems are highlighted. Under the neurological system, there is numbness and tingling in the fingers and toes. Under the musculoskeletal system, there is muscle ache. Under the urinary system, there is frequent and urgent urination. In Erickson's stages of development, the person is at the middle adulthood stage (forty to sixty-five years) (Dunkel & Harbke, 2017). Though not all, he has met some milestones for this stage, including having a strong sense of responsibility and care. Cultural considerations include all the cultural aspects that are likely to influence his health. His cultural traditions allow him to binge eat fatty and sugary foods, binge drink alcohol, and smoke during events as a cultural way of celebrating. He believes in healers and traditional medicine, such as oleifera seeds, to lower blood pressure and make the skin appear younger. As a man, his culture does not allow him to seek help, so he deals with his problems and fears all alone. Psychosocial considerations include the support he receives from people close to him and the fact that he is a Christian who believes that those who are faithful to God will receive healing and peace. Collaborative resources for him include his children and his young lover, who is always worried about him. In his community, he says there is a support group for the elderly and sick people, but only women attend meet-ups in those groups. There are several hospitals within his reach that are all equipped with modern technology.
Physical Examination
Here, the four techniques, inspection, palpation, auscultation, and percussion, are applied to examine the patient physically and effectively. There are no significant problems under the head, eyes, ears, nose, and throat (HEENT), respiratory, and cardi...
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