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NR306 Health Assessment
RUA Health History and Physical Assessment Guidelines
Purpose
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.
CO 1: 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 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 5: 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 and 5)
CO 7: Explore the professional responsibilities involved in conducting a comprehensive health assessment and providing
appropriate documentation. (PO 6 and 7)
Due date Your faculty member will inform you when this assignment is due. The Late Assignment Policy applies to this
assignment.
Total points possible 100 points
Preparing the assignment
Follow these guidelines when completing this assignment. Speak with your faculty member if you have questions.
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. 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.
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
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NR306 Health Assessment
RUA Health History and Physical Assessment Guidelines
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.
2. 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.
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NR306 Health Assessment
RUA Health History and Physical Assessment Guidelines
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?Were there unanticipated challenges during this assignment?
5) Was there information you wished you had available but did not?
6) 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.
For writing assistance, visit the Writing Center.
Please note that your instructor may provide you with additional assessments in any form to determine that you
fully understand the concepts learned in the review material.
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NR306 Health Assessment
RUA Health History and Physical Assessment Guidelines
Grading Rubric Criteria are met when the student’s application of knowledge demonstrates achievement of the outcomes for this assignment.
Assignment Section and
Required Criteria
(Points possible/% of total points available)
Health History: Subjective Data
(30 points/30%)
Required criteria
This individual must be different from the individual used for the NR302
health history and physical examination assignment.
2. Demographic data.
3. Reason for care (why they are in the facility)
4. Present illness (PQRST of current illness)
5. Perception of health
6. Past medical history (including medications, allergies, and
vaccinations and immunizations)
7. Family medical history
8. Review of systems
9. Developmental considerations
10. Cultural considerations
11. Psychosocial considerations
12. Presence or absence of collaborative resources (community, family,
groups, and healthcare system)
1.
Physical Examination: Objective Data
(30 points/30%)
Required criteria
1.
2.
3.
4.
5.
6.
7.
8.
HEENT (head, eyes, ears, nose, and throat)
Neck (including thyroid and lymph chains)
Respiratory system
Cardiovascular system
Neurological system
Gastrointestinal system
Musculoskeletal system
Peripheral vascular system
Needs Assessment
(20 points/20%)
Highest Level of
Performance
High Level of
Performance
Satisfactory
Level of
Performance
Unsatisfactory
Level of
Performance
Section not
present in
paper
30 points
28 points
23 points
15.5 points
0 points
Includes 12
requirements for
section.
Includes 10-11
requirements for
section.
Includes 6-9
requirement
for section.
Includes 1-5
requirement for
section.
No requirements
for this section
presented.
30 points
28 points
23 points
15.5 points
0 points
Includes 8
requirement for
section.
Includes 7
requirement for
section.
Includes 4-6
requirements
for section.
Includes 1-3
requirements for
section.
No requirements
for this section
presented.
20 points
18 points
15 points
7.5 points
0 points
© 2023 Chamberlain University. All Rights
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NR306 Health Assessment
RUA Health History and Physical Assessment Guidelines
Required criteria
1.
2.
3.
4.
1.
2.
3.
4.
5.
6.
7.
8.
9.
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.
Support the identified health teaching needs selected with evidence
from two current, peer-reviewed journal articles.
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.
Describe how the individual’s strengths (personal, family, and friends)
and collaborative resources (clinical, community, and health and
wellness resources) effect proposed teaching.
Reflection
(10 points/10%)
Required criteria
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.
How did your interaction compare to what you have learned?
What went well?
What barriers to communication did you experience?
How did you overcome them?
What will you do to overcome them in the future?
Were there unanticipated challenges to the interview?
Was there information you wished you had obtained?
How will you alter your approach next time?
Style and Organization
(10 points/10%)
Required criteria
1.
2.
3.
4.
5.
Writing reflects synthesis of information from prior learning
applied to completion of the assignment.
Grammar and mechanics are free of errors.
Able to verbalize thoughts and reasoning clearly.
Use appropriate resources and ideas to support topic with APA where
applicable.
HIPAA protocols followed.
Includes 4
requirements for
section.
Includes 3
requirements for
section.
Includes 2
requirements
for section.
10 points
9 points
8 points
4 points
0 points
Includes 9
requirements for
section.
Includes 7-8
requirements for
section.
Includes 5-6
requirements
for section.
Includes 1-4
requirements for
section.
No requirements
for this section
presented.
10 points
9 points
8 points
4 points
0 points
Includes 5
requirements for
section.
Includes 4
requirements for
section.
Includes 3
requirements
for section.
Includes 1-2
requirements for
section.
No requirements
for this section
presented.
Includes 1
requirement for
section.
No requirements
for this section
presented.
Total = 100 points
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NR306_MAR23_Health_History_and_Physical_Assessment _Guidelines.docx
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1
Health History and Physical
Student Name
Chamberlain University
Course Number and Title
Instructor
Due Date
2
Complete a health history and physical examination of an individual. Using the following subjective and objective
components and your textbook for explicit details about each category, complete an individual’s health history
and physical examination and fill in the template below. Make sure to use correct terminology while
documenting the details of each section. The person interviewed must be 18 years of age or older. Please avoid
using any identifiers in preparing the assignment and follow HIPAA protocols.
Assignment Sections and
Required Criteria
Health History
Demographic data
Reason for care
Present illness (PQRST of current
illness)
Perception of health
Past medical history (including
medications, allergies,
vaccinations, and
immunizations)
Family medical history
Review of systems
Developmental considerations
(using Erikson’s Stages of
Psychosocial Development)
Cultural considerations
Psychosocial considerations
Presence or absence of
collaborative resources
Physical Examination:
Objective Data
HEENT (head, eyes, ears, nose,
Assessment Documentation
Reference Citations
(If needed)
3
and throat)
Neck (includes thyroid and
lymph chains)
Respiratory system
Cardiovascular
Neurological system
Gastrointestinal system
Musculoskeletal system
Peripheral vascular system
Needs Assessment
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.
Support the identified health
teaching needs selected with
evidence from two peerreviewed journal articles.
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.
Describe how the individual’s
strengths (personal, family, and
friends) and collaborative
resources (clinical, community,
and health and wellness
4
resources) affect proposed
teaching.
Reflection
5
References
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