Health History and Physical Assessment Guidelines

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.
Explain expected client behaviors while differentiating between normal findings, variations and abnormalities. (PO1)
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)
Recognize the influence that developmental stages have on physical, psychosocial, cultural, and spiritual functioning. (PO 1)
Utilize effective communication when performing a health assessment. (PO 3)
Demonstrate beginning skill in performing a complete physical examination using the techniques of inspection, palpation, percussion, and auscultation. (PO 2
Identify teaching/learning needs from the health history of an individual. (POs 2, 5)
Explore the professional responsibilities involved in conducting a comprehensive health assessment and providing appropriate documentation. (PO 6, 7)

Our customer support team is here to answer your questions. Ask us anything!