Chamberlain University Patient Physical Examination Paper

Chamberlain University Patient Physical Examination Paper

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Purpose NR304 Health Assessment II RUA 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. 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, 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, 5) CO 7: Explore the professional responsibilities involved in conducting a comprehensive health assessment and providing appropriate documentation. (PO 6, 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. 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 NR304_Health_History_and_Physical_Assessment _Guidelines_V8.docx 1 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? 2 NR304_Health_History_and_Physical_Assessment _Guidelines_V8.docx 2 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. 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. 3 NR304_Health_History_and_Physical_Assessment _Guidelines_V8.docx 3 NR304 Health Assessment II 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 1. Demographic data 2. Reason for care (why they are in the facility) 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 9. Cultural considerations 10. Psychosocial considerations 11. Presence or absence of collaborative resources (community, family, groups, and healthcare system) 1. 2. 1. Physical Examination: Objective Data (30 points/30%) Required criteria 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 o Neurological system o Gastrointestinal system o Musculoskeletal system o Peripheral vascular system Needs Assessment (20 points/20%) Required criteria Based on the health history and physical examination findings, determine at least two health education needs for the individual. NR304_Health_History_and_Physical_Assessment _Guidelines_V8.docx 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 11 requirements for section. Includes 9-10 requirements for section. Includes 5-8 requirement for section. Includes 1-4 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 Includes 4 requirements for section. Includes 3 requirements for section. Includes 2 requirements for section. Includes 1 requirement for section. No requirements for this section presented. 4 NR304 Health Assessment II RUA Health History and Physical Assessment Guidelines 2. 3. 4. 1. 2. 3. 4. 5. 6. 7. 8. 9. 1. 2. 3. 4. 5. 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 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. 10 points 9 points 8 points 4 points Includes 9 requirements for section. Includes 7-8 requirements for section. 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 5-6 Includes 1-4 requirements for requirements for section. section. 0 points No requirements for this section presented. Total = 100 points NR304_Health_History_and_Physical_Assessment _Guidelines_V8.docx 5 NR304 Health Assessment II RUA Health History and Physical Assessment Guidelines NR304_Health_History_and_Physical_Assessment _Guidelines_V8.docx 6 Tyra -Health History: Subjective Data 1) Demographic data: 29 year old white Hispanic male from Dominican Republic. Came to the US when he was 3 years old and currently resides in Pembroke Pines FL. He is not married however he is in a committed relationship and he currently works as an AC tech. 2) Reason for care: Patient Just needs a basic check up for their health baseline 3) Present illness (PQRST of current illness): Patient doesn’t have any current illness however he does get sinus pressure headaches and rates them a 5. P: Sinus medicine (pseudoephedrine)usually helps Q: dull R: Doesn’t radiate S: 5 T: Constant usually starts at night 4) Perception of health: Believes good health is having a balanced diet and daily exercise 5) Past medical history (including medications, allergies, and vaccinations and immunizations): Patient doesn’t not have any allergies. Was prescribed Ritalin for ADHD as a child, however had not taken medication since the beginning of highschool. Patient has all of his required vaccines with most recent being COVID vaccination booster 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 (Part one) . Physical Examination: Objective Data (30 points/30% [1 paragraph]) a) HEENT: Normal (head, eyes, ears, nose, and throat) ( PERLA Intact & Six fields of gaze is normal) b) Neck (including thyroid and lymph chains) Normal ( No lumps or mumps present) c) Respiratory system ( no respiratory distress, normal lung sounds) d) Cardiovascular system 2) ( S1 and S2 sounds are normal, all pulses are +2 normal) -B (Part two) a) Neurological system ( all cranial nerves are intact) b) Gastrointestinal system ( bowel sounds are normal, no distention or tenderness, the abdomen is symmetrical, and flat, bowel movements are normal) c) Musculoskeletal system Upper joints/muscles ( shoulder & wrist) and lower joints/muscles (knee and ankle) are normal and move normally d) Peripheral vascular system- Normal ( No edema, no discoloration, skin is warm to touch and moist, pedal pulse is +2, cap refill less than 3 secs on toes) -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, peerreviewed 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? 3 NR304_Health_H 3 istory_and_Physical_Assessment _Guidelines_V8.docx 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?
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