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