How to document physical assessment findings

REQUIRED UNIFORM ASSIGNMENT GUIDELINES

THE HEALTH HISTORY AND PHYSICAL EXAMINATION

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.

• 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

CO1: CO1. 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) CO5: 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 responsibilities involved in conducting a comprehensive health assessment and providing appropriate documentation. (PO 6, 7)

DUE DATE Please see the Course Calendar.

TOTAL POINTS POSSIBLE 100 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.

NR 304 RUA Grading Rubric and Grading Criteria V2.docx 10_16 SMa 4 Revised 11/05/18 EL/css

Health History Assessment and Physical Assessment (50 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 

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

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

• Family medical history

• Review of systems

• Developmental considerations

• Cultural considerations

• Psychosocial considerations

• Presence or absence of collaborative resources (community, family, groups, and healthcare system)

***REMEMBER: Make notes of the health history findings, ensuring that you have addressed all of the

components listed here. Students are also encouraged to take notes about their experiences while

conducting the health history for reference when creating the assignment, particularly the reflection section.

2. Objective Data—Physical Exam Components to Be Included

 During the lab experiences, you will conduct a series of physical exams that includes the following systems.

 Keep notes on each part of the physical exam as you complete them to reference as you write the paper.

 Refer to the course textbook for detailed components of each system exam. Remember, assessment of the integumentary system is an integral part of the physical exam and should be included throughout each system.

 From NR302

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

o Neck (including thyroid and lymph chains)

o Respiratory system

o Cardiovascular system

 From NR304

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o Neurological system

o Gastrointestinal system

o Musculoskeletal system

o peripheral vascular system

***REMEMBER: Make notes of the physical examination findings, ensuring that you have addressed all of the

components listed on the Return Demonstration Checklist. Students are also encouraged to take notes

about their experiences while conducting the physical examination for reference when creating the

assignment, particularly the reflection section.

Needs Assessment (20 points)

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. Select two peer-reviewed journal articles that provide evidence-based support for the health teaching needs you have identified.

Reflection (20 points)

Nurses use reflection to, mindfully and intentionally, examine our thought processes, actions, and behaviors in order to better evaluate our patients’ outcomes. You have interviewed an individual, conducted a head-to-toe physical assessment, and identified at least two health teaching needs. You have also located within the literature evidence-based support for the teaching that will be used to address the individual’s health education needs. As you formulate your findings in writing within this assignment, it is time to turn your attention inward. The final element of this assignment is to write a reflection that describes your experience.

1. Be sure your reflection addresses each of the following questions.

a. How did this assignment compare to what you’ve learned and expected?

b. What enablers or barriers to communication did you encounter when performing a health history and physical exam? How could you overcome those barriers?

c. Were there any unanticipated challenges encountered during this assignment? What went well with this assignment?

d. Was there information you wished you had available but did not?

e. How will you alter your approach to a obtaining a health history and conducting a physical examination the next time?

Writing Style and Format (10 points)

Your writing should reflect your synthesis of ideas based on prior knowledge, newly acquired

information, and appropriate writing skills. Scoring of your written communication is based on

proper use of grammar, spelling, and APA sixth-edition formatting, as well as how clearly your

thoughts and reasoning are expressed in writing.

Documentation of Findings or How to Write the Paper

NR 304 RUA Grading Rubric and Grading Criteria V2.docx 10_16 SMa 4 Revised 11/05/18 EL/css

Using Microsoft Word, create a double-spaced document. The paper should be formatted according to APA sixth-edition guidelines for the title page, running head, and reference page. The use of headings is required for this paper. All portions of this assignment should be included within the paper, including the reflection.

1. Begin by writing one to two paragraphs describing the individual’s stated condition of health medications and allergies. Also, include any of the following information that may be pertinent: demographic data, perception of health, past medical history, vaccinations and immunizations, family medical history, review of systems, developmental considerations, cultural considerations, psychosocial considerations, and the presence or absence of resources from the community, family, groups, or the healthcare system.

2. Write one paragraph describing the physical assessment findings, ensuring proper terminology is used to describe any abnormal or unusual findings.

3. Write one paragraph discussing (1) the rationale for the selection of the health teaching topics and (2) how the findings in the scholarly articles (identified in the needs assessment portion of the assignment and properly cited) were used to develop the health teaching topics to promote the individual’s health and wellness status.

4. Write one paragraph discussing (1) how the interrelationships of physiological, developmental,

cultural, and psychosocial considerations will influence, assist, or become barriers to the effectiveness of the proposed health education and (2) a description of the impact of the individual’s strengths (personal, family, and friends) and collaborative resources (clinical, community, and health and wellness resources) on the proposed teaching.

5. Write one paragraph describing your reflection of this assignment from a holistic point of view.

Consider the following areas: Include the environment, your approach to the individual, time of day, and other features relevant to therapeutic communication and to the interview process. You may find your textbook helpful in providing a description of therapeutic communication and of the interview process. Be certain to address the questions listed above in the reflection instructions.

NR 304 RUA Grading Rubric and Grading Criteria V2.docx 10_16 SMa 4 Revised 11/05/18 EL/css

Chamberlain College of Nursing NR304 Health Assessment II

DIRECTIONS AND GRADING CRITERIA

Category Points % Description

Health History and Physical Assessment

50 50 Conducts a comprehensive health history and physical exam

1. Subjective data: demographic data; reason for care; present illness; perception of health; past medical history; family medical history; review of systems; developmental considerations; cultural considerations; psychosocial considerations; and collaborative resources.

2. Objective data: HEENT; neurological system, respiratory system, cardiovascular system, neck; gastrointestinal system; musculoskeletal system; and peripheral vascular system.

Provides a written narrative that includes the following

1. One to two paragraphs describing stated condition of health, medications, and allergies. Also includes the following information: demographic data, perception of health, past medical history, vaccinations and immunizations, family medical history, review of systems, any developmental considerations, cultural considerations or psychosocial considerations, presence or absence of resources from the community, family, groups, or from the healthcare system

2. One paragraph describing: the findings of the physical examination

3. One paragraph discussing (1) the rationale for the selection of the health education topics and (2) how the findings in the scholarly articles were used in support of the health teaching topic to promote or improve the individual’s health and wellness status.

4. One paragraph discussing (1) how the interrelationships of

physiological, developmental, cultural, and psychosocial considerations influence (assist or become barriers to the effectiveness) the proposed health education and (2) provide a description of the impact of the individual’s strengths (personal, family, and friends) and collaborative resources (clinical, family, community, and health and wellness resources) on the proposed nursing teaching.

Needs Assessment

20 20 1. Identifies two health education needs for the individual based on the health history and physical examination findings and two peer- reviewed journal articles providing evidence-based support for the identified health teaching needs

2. APA sixth-edition formatting used for in-text and reference page citations

Chamberlain College of Nursing NR304 Health Assessment II

NR 304 RUA Grading Rubric and Grading Criteria V2.docx 10_16 SMa 5 Revised 11/05/18 EL/css

Reflection 20 20 Reflects on the interaction with the interviewee holistically. Considers the interaction in its entirety: includes the environment, the approach to the individual, time of day, and other features relevant to therapeutic communication and the interview process. The reflection should address each of the following questions.

 How did your interaction compare to what you’ve learned and expected?

 What enablers or barriers to communication did you experience? How did you overcome the barriers?

 Were there any unanticipated challenges to conducting the interview or performing the physical examination? What went well?

 Was there information you wished you had but did not?

 How will you alter your approach the next time?

Writing Style and Format

10 10 Writing should reflect your synthesis of ideas based on prior knowledge, newly acquired information, and appropriate writing skills. Scoring of your work in written communication is based on proper use of grammar, spelling, and how clearly you express your thoughts and reasoning in writing. Proper use of APA sixth-edition style and format throughout this paper is required.

Total 100 100

NR304 Health Assessment II Chamberlain College of Nursing

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GRADING RUBRIC

Assignment Criteria

Outstanding or Highest Level of Performance

A (92–100%)

Very Good or High Level of Performance

B (84–91%)

Competent or Satisfactory Level of Performance

C (76–83%)

Poor, Failing or Unsatisfactory Level of Performance

F (0–75%)

Health History and Physical Examination (50 points)

Thoroughly presents a health history narrative that includes a detailed description of all the following components

 Demographic data

 Reason for care

 Present illness

 Perception of health

 Past medical history

 Family medical history

 Review of systems  Developmental

considerations

 Cultural considerations

 Psychosocial considerations

 Collaborative resources

Thoroughly presents a physical exam narrative that includes a detailed description of all the following components HEENT  Neurological system  Neck

 Respiratory system

One of the key elements of the health history narrative is not presented or lacks sufficient detail.

 Demographic data

 Reason for care

 Present illness

 Perception of health

 Past medical history

 Family medical history

 Review of systems  Developmental

considerations

 Cultural considerations

 Psychosocial considerations

 Collaborative resources

One of the key elements of the physical exam is not presented or lacks sufficient detail. HEENT • Neurological system • Neck • Respiratory system • Cardiovascular system • Gastrointestinal system

Two of the key elements of the health history narrative are not presented or lack sufficient detail.

 Demographic data

 Reason for care

 Present illness

 Perception of health

 Past medical history

 Family medical history

 Review of systems  Developmental

considerations

 Cultural considerations

 Psychosocial considerations

 Collaborative resources

Two of the key elements of the physical exam are not presented or lacks sufficient detail. • HEENT • Neurological system • Neck • Respiratory system • Cardiovascular system • Gastrointestinal system • Musculoskeletal system

Three or more of the key elements of the health history narrative are not presented or lack sufficient detail.

 Demographic data

 Reason for care

 Present illness

 Perception of health

 Past medical history

 Family medical history

 Review of systems  Developmental

considerations

 Cultural considerations

 Psychosocial considerations

 Collaborative resources

Three or more of the key elements of the physical exam are not presented or lack sufficient detail.

 HEENT

 Neurological system

 Neck

 Respiratory system

 Cardiovascular system

 Gastrointestinal system

NR304 Health Assessment II Chamberlain College of Nursing

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 Cardiovascular system

 Gastrointestinal system

 Musculoskeletal system

 Peripheral vascular system

 Integumentary system integrated in exam of all systems where appropriate

Information is presented in a clear, organized, and professional manner.

46-50 points

• Musculoskeletal system • Peripheral vascular system • Integumentary system

integrated in exam of all systems where appropriate

Information is presented in a clear, organized, and professional manner.

42-45 points

• Peripheral vascular system • Integumentary system

integrated in exam of all systems where appropriate

Information is not presented in a clear, organized, and professional manner.

38-41 points

 Musculoskeletal system

 Peripheral vascular system

 Integumentary system integrated in exam of all systems where appropriate

Information is not presented in a clear, organized, and professional manner.

0–37 points

Needs Assessment (20 Points)

Accurately identifies two health education needs for this individual and provides at least three factors that may, positively or negatively, influence the person’s ability to incorporate the health teaching to improve his or her well-being.

References two peer-reviewed journal articles that provide evidence-based support for the health teaching; APA format (most current edition) used to list the sources.

19-20 points

Accurately identifies a health education need for this individual and provides at least two factors that may, positively or negatively, influence the person’s ability to incorporate the health teaching to improve his or her well-being.

References two peer-reviewed journal articles that provide evidence-based support for the health teaching but does not use appropriate APA format (most current edition) to list the sources.

17-18 points

Accurately identifies a health education need for this individual and provides at least two factors that may, positively or negatively, influence the person’s ability to incorporate the health teaching to improve his or her well-being.

References one peer-reviewed journal articles that provides evidence-based support for the health teaching but does not use appropriate APA format (most current edition) to list the sources.

16 points

Accurately identifies a health education need for this individual and poorly or minimally applies one or more factors that may, positively or negatively, influence the person’s ability to incorporate the health teaching to improve his or her well-being.

No references are submitted or, if they are used, they have three or more types of errors in APA format (most current edition) to list the sources.

0–15 points

Reflection

(20 Points)

Thoughtfully appraises the individual holistically. Reflection

Thoughtfully appraises the individual holistically. One of the following questions is not

Broadly appraises the individual. Two of the following questions

Broadly appraises the individual. Three or more of the following

NR304 Health Assessment II Chamberlain College of Nursing

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includes a detailed response to all the following questions.

 How did your interaction compare to what you’ve learned?

 What went well?

 What barriers to communication did you experience?

 How did you overcome them?

 Were there unanticipated challenges to the interview?

 Was there information you wished you’d obtained?

 How will you alter your approach the next time?

Key and relevant information is presented in sufficient detail and is clear and organized.

19-20 points

presented or lacks sufficient detail.

 How did your interaction compare to what you’ve learned?

 What went well?

 What barriers to communication did you experience?

 How did you overcome them?

 Were there unanticipated challenges to the interview?

 Was there information you wished you’d obtained?

 How will you alter your approach the next time?

Key and relevant information is presented in sufficient detail and is clear and organized.

17-18 points

are not presented or lack sufficient detail.

 How did your interaction compare to what you’ve learned?

 What went well?

 What barriers to communication did you experience?

 How did you overcome them?

 Were there unanticipated challenges to the interview?

 Was there information you wished you’d obtained?

 How will you alter your approach the next time?

Key and relevant information is presented in insufficient detail but is clear and organized. 8 Points

questions are not presented or lack sufficient detail.

 How did your interaction compare to what you’ve learned?

 What went well?

 What barriers to communication did you experience?

 How did you overcome them?

 Were there unanticipated challenges to the interview?

 Was there information you wished you’d obtained?

 How will you alter your approach the next time?

Key and relevant information is presented in insufficient detail and is not clear or organized. 0–7 points

Writing Style and Format (10 points)

Student presents information using clear and logical language. Grammar, spelling, and punctuation are free of errors. APA sixth edition was used to guide the style and format of this paper. 10 points

Student presents information using clear and logical language. Grammar, spelling, and punctuation have two or fewer types of errors, or there is no more than one error in APA sixth-edition formatting. 9 points

Student presents information using clear and logical language. Grammar, spelling, and punctuation have three types of errors, or there are no more than two errors in APA sixth-edition formatting.

8 points

Information is unclear and difficult to follow. Grammar, spelling, and punctuation have three or more types of errors, or there are more than three errors in APA sixth-edition formatting.