Health History

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. 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.

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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 include 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 included throughout each system.

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.

Utilize proper medical terminology.

3. Include the following sections, used as section headers within the paper.

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
9) Cultural considerations
10) Psychosocial considerations
11) Presence or absence of collaborative resources (community, family, groups, and healthcare system)

Physical Examination: Objective Data (30 points/30% [1 paragraph])

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

b) Neck (including thyroid and lymph chains)

c) Respiratory system

d) Cardiovascular system

2)a) Neurological system
b) Gastrointestinal system
c) Musculoskeletal system
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?

5) Were there unanticipated challenges during this assignment?

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

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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.

5) Adheres to APA recommendations for title page, running head, headings, in-text citations, and reference page.

6) HIPAA protocols followed.

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