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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.

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 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- 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 (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?

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 protocols followed.

1
Title of Your Paper in Upper and Lower Case (Centered, Bold)
Your Name (without credentials)
Chamberlain University College of Nursing
Course Number: Course Name
Name of Instructor
Assignment Due Date
2
Title of Your Paper in Upper and Lower Case (Centered, Bold)
Type your introduction here and remove the instructions. Although the first paragraph
after the paper title is the introduction, no heading labeled “Introduction” is used. Refer to your
assignment instructions for the headings to be used for the body of the paper. There are
additional resources located in your courses and the Chamberlain Library.
Level 1 Paper Heading (Bold and centered)
Begin to type the body of your paper here. Use as many paragraphs as needed to cover
the content appropriately based on the assignment instructions.
Level Two Heading (If required) (Bold and starts at left margin)
Type additional content here if a section with a subheading is needed.
Next Level Two Heading
Continue to add content in this section.
Next Level 1 Heading
Levels of headings will depend on the length and organization of your paper. Use as
many headings as necessary and required to organize your paper. Short papers may only have
level 1 headings. Longer papers may require more organizational detail. See your APA Manual
for additional instructions on formatting multiple levels of headings.
Conclusion
Papers should end with a conclusion or summary. The assignment directions will specify
which is required. It should be concise and contain no new information. No matter how much
space remains on the page, the references always start on a separate page (insert a page break
after the conclusion so that the references will start on a new page).
3
References (centered, bold)
Type your reference here using hanging indent and double line spacing (under “Paragraph” on
the Home toolbar ribbon). See your APA Manual and the resources in the APA section
of Resources for reference formatting.
1
Title of Your Paper in Upper and Lower Case (Centered, Bold)
Your Name (without credentials)
Chamberlain University College of Nursing
Course Number: Course Name
Name of Instructor
Assignment Due Date
2
Title of Your Paper in Upper and Lower Case (Centered, Bold)
Type your introduction here and remove the instructions. Although the first paragraph
after the paper title is the introduction, no heading labeled “Introduction” is used. Refer to your
assignment instructions for the headings to be used for the body of the paper. There are
additional resources located in your courses and the Chamberlain Library.
Level 1 Paper Heading (Bold and centered)
Begin to type the body of your paper here. Use as many paragraphs as needed to cover
the content appropriately based on the assignment instructions.
Level Two Heading (If required) (Bold and starts at left margin)
Type additional content here if a section with a subheading is needed.
Next Level Two Heading
Continue to add content in this section.
Next Level 1 Heading
Levels of headings will depend on the length and organization of your paper. Use as
many headings as necessary and required to organize your paper. Short papers may only have
level 1 headings. Longer papers may require more organizational detail. See your APA Manual
for additional instructions on formatting multiple levels of headings.
Conclusion
Papers should end with a conclusion or summary. The assignment directions will specify
which is required. It should be concise and contain no new information. No matter how much
space remains on the page, the references always start on a separate page (insert a page break
after the conclusion so that the references will start on a new page).
3
References (centered, bold)
Type your reference here using hanging indent and double line spacing (under “Paragraph” on
the Home toolbar ribbon). See your APA Manual and the resources in the APA section
of Resources for reference formatting.

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