Health History and Physical Assessment



Remember, assessment of the integumentary system is an integral part of the physical exam and should be2Health_History_and_Physical_Assessmentincluded throughout each system.e. Keep notes on each part of the health history and physical examination as you complete them so that you canrefer 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 data2) Reason for care3) Present illness (PQRST of current illness)4) Perception of health5) Past medical history (including medications, allergies, and vaccinations and immunizations)6) Family medical history7) Review of systems8) Developmental considerations- use Erikson’s Stages of Psychosocial Development- which stage is yourparticipant 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 andcomplementary medicine, these are examples but please add more10) Psychosocial considerations- support systems-family, religious, occupational, community these are examplesbut please add more11) Presence or absence of collaborative resources (community, family, groups, and healthcare system)b. Physical Examination: Objective Data (30 points/30% [1 paragraph])a) HEENT (head, eyes, ears, nose, and throat)b) Neck (including thyroid and lymph chains)c) Respiratory systemd) Cardiovascular systema) Neurological systemb) Gastrointestinal systemc) Musculoskeletal systemd) Peripheral vascular systemc. Needs Assessment (20 points/20% [2 paragraphs])1) Based on the health history and physical examination findings, determine at least two health educationneeds 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-reviewedjournal articles.3) Discuss how the interrelationships of physiological, developmental, cultural, and psychosocial considerationswill 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 toevaluate outcomes. Provide a written reflection that describes your experience with conducting thiscomplete 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?3 NR304_Health_History_and_Physical_Assessment _Guidelines_V7.docx Revised: 6/2021 34) 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.5) Adheres to APA recommendations for title page, running head, headings, in-text citations, and reference

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