Utilize effective communication when performing a health assessment. (PO 3)As you learned, before any nursing plan of care or intervention can be implemented or evaluated,

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Utilize effective communication when performing a health assessment. (PO 3)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.

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.
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


 

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