Week 7 NR304Health History and Physical Assessment
NR 304 RUA Grading Rubric and Grading Criteria V2.
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 Revised 11/05/18 EL/css 4
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.
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.
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
NR 304 RUA Grading Rubric and Grading Criteria V2.docx 10_16 SMa Revised 11/05/18 EL/css 4
o Neurological system
o Gastrointestinal system
o Musculoskeletalsystem
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)
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.
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.
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 Revised 11/05/18 EL/css 4
Using Microsoft Word, create a double-spaced document. The paper should be formatted according to APA sixth-edition guidelines for the title page,
Week 7 NR304Health History and Physical Assessment
NR 304 RUA Grading Rubric and Grading Criteria V2.
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 Revised 11/05/18 EL/css 4
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
NR 304 RUA Grading Rubric and Grading Criteria V2.docx 10_16 SMa Revised 11/05/18 EL/css 4
o Neurological system
o Gastrointestinal system
o Musculoskeletalsystem
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 Revised 11/05/18 EL/css 4
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 Revised 11/05/18 EL/css 4
Chamberlain College ofNursing 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 wellnessstatus.
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 peerreviewed 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 ofNursing NR304 Health Assessment II
NR 304 RUA Grading Rubric and Grading Criteria V2.docx 10_16 SMa Revised 11/05/18 EL/css 5
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
Chamberlain College ofNursing NR304 Health Assessment II
NR 304 RUA Grading Rubric and Grading Criteria V2.docx 10_16 SMa Revised 11/05/18 EL/css 4
GRADING RUBRIC
Assignment
Criteria
______________________
Health History and Physical Assessment
Hannah Gabon
Chamberlain College of Nursing
NR304 Health Assessment II
Professor Christa Stigler
August 2019
Health History Assessment and Physical Assessment 2
Health History Assessment and Physical Assessment
I conducted a health assessment on a 70 year’s old male patient from California who was
suffering from hypertension. The patient is currently taking diuretics medication which cause
increase urination. The medication also causes his sodium and fluids levels to drop thus lowering
patient’s blood pressure so it’s imperative to balance and monitor vital sign. The patient stated
that he was moderately satisfied with the care received in the facility. The patient is a smoker and
stated his concern of experiencing vision issues and heart failure, which prompted immediate
care for this patient.
Before being admitted to the hospital, patient stated that he was experiencing chest pain
which was not ending nor was it increasing in exertion. He did not experience nausea, vomiting,
dizziness or unconsciousness. He took some pain killers with no relief but managed to sleep in
the morning. After beginning his daily activities, the pain increased and was then rushed to the
hospital. He underwent some test that clarified that he was suffering from hypertension. When I
reviewed patient past medical records, it showed that he has condition at early age and minor
surgery. I reviewed the patient’s cardiovascular, eyes, nose, throat, respiratory system, and his
immune system. Patient immunization was also put into consideration when I reviewed his past
medical record as this will be helpful planning for his care.
Thirty years ago, the patient developed a diffuse rash after he was injected with penicillin
which he was allergic to, but it was not known. Some of his past health operations includes:
chest pains in 1990 and minor surgery on his left arm. He has a medical case of pneumonia at an
early age, which did not take long to heal. The patient was raised by his stepmother since his
mother passed away 72 years ago from heart failure. His father passed on 68 years ago after
committing suicide in his house. His wife died 10 years ago after struggling with tuberculosis for
Health History Assessment and Physical Assessment 3
a long period of time. He has six children; two are deceased after both suffered from
hypertension. He has 20 grandchildren and 10 great-grandchildren. His family have history of
hypertension but no known history of tuberculosis.
The patient’s physical assessment findings were that he had an elevated blood pressure of
125/80 which shows that it was high, but it is controllable. I also found that he had a unique heart
sound which was as a result of an enlarged heart. The patient had a swollen neck vein which was
probably caused by heart failure. He also had some abnormalities in the blood vessels behind the
eyes. He has no clinical cardiovascular disease or signs of hypertension-related target- organ
damage. The patient had narrowed kidney arteries and endocrine disorders. The patient had no
respiratory problems, but his lungs sounded as if it was congested. His peripheral pulses were
present and strong, and his thorax was under the normal shape.
Through health teaching topics, students can acquire knowledge, skills and positive
attitude about health. From these teaching, students can learn about physical, mental emotional
and mental health. This enables students to enhance and maintain their health in preventing
diseases and minimize risky habits (Don, 2000). Through this teaching, student acquire positive
changes and behaviors that reduce the risk of the student being around alcohol, tobacco, and
other drugs. Through this teaching, the community becomes aware of how to prevent chronic
diseases as well as how to maintain healthy nutrition and prevent obesity (Vadurro, 2018).
Through the finding in the scholarly articles, there has been great awareness about chronic
diseases and how they can be prevented and managed by integrating such as nutrition and how to
deal with stress. The findings also advance the understanding of how the mind and body
strategies impact health and well-being. The findings mainly focus on the treatment of diseases,
Health History Assessment and Physical Assessment 4
this has helped in finding treatment for diseases and the productiveness of pharmacologic
strategies in treating and controlling the illnesses (Green LW. Et al. 1980)
The interrelationship of psychological developmental, cultural and psychosocial
consideration impacts a person’s experiences and definition of health and illnesses. This
relationship guides the day to day lifestyle of people. It determines if people in given community
access to health care and their responses to disease pain and disabilities. Through the integration
of individual strength and collaborative resources, the proposed health teaching will be well
appreciated in the community since through these strengths they will improve the populationlevel health outcome by supporting the proposed health teaching which may lead to a sustainable
environmental transition in different parts of the community which are associated with health.
The patient was not willing to share the information with me as he considered it as a
distraction. To comfort patient, I began by explaining to him the importance of the interview. I
explained to him the information was required for learning purpose which helped in convincing
him that the interview was not aimed at interfering with his privacy since the information will
not be shared by any third party. I explained to him the benefits of speaking about his health
conditions and with the information shared, it will be easier to come up with a better medical
plan that will help a medical professional care for his needs. I explained to him that if he shared
his health information, I will be able to explain to him the living habits that he was expected to
adapt based on his condition. When conducting my next physical examination, I will ensure that
I implement the four techniques which involves inspections, palpation, percussion, and
auscultation.
Health History Assessment and Physical Assessment 5
References:
Don Nutbeam. (2000, September) Health literacy as a public health goal: a challenge for
contemporary health education and communication strategies into the 21st
century, Health Promotion International, 15(3), Pp. 259–267. Retrieved from
https://doi.org/10.1093/heapro/15.3.259
Vadurro Marcy. (2018, February 8). The Importance of Health Education. Retrieved from
https://www.snhu.edu/about-us/newsroom/2018/02/importance-of-health-education
Green LW. Et al. (1980). Health education planning: a diagnostic approach. Retrieved from
https://www.popline.org/node/499039
____________________________
Health History and Physical Examination
[Place title in center, bold, 12 pt Times New Roman font]
John Doe
Nursing 304: Health Assessment
Instructor Name
Date
[Place running head: HEALTH HISTORY AND PHYSICAL EXAMINATION in all caps, left justified]
Introduction
This paper will discuss the process of obtaining a health history and conducting a physical examination on John Doe (no identifying information will be provided to protect privacy). Notes were taken during the assessment to document both subjective and objective findings, which will be synthesized to identify two health education priorities. A reflection on the experience and supporting evidence from scholarly literature will also be included.
Subjective Data: Health History
Demographic data: John is a 28-year-old male.
Reason for care: Routine health assessment for school assignment.
Present illness: John reports generally feeling well with no current health concerns.
Perception of health: John perceives his health as “good” overall.
Past medical history: John had his tonsils removed as a child. He takes no medications. No known allergies or immunizations.
Family medical history: John’s mother has hypertension. Paternal grandfather had colon cancer.
Review of systems: John denies any issues with cardiac, pulmonary, gastrointestinal, genitourinary, musculoskeletal, neurological, or integumentary systems.
Developmental considerations: As a young adult, John is focused on career and relationships.
Cultural considerations: John was raised in a middle-class household. He identifies as heterosexual.
Psychosocial considerations: John is single and works full-time as an accountant. He enjoys spending free time with friends.
Resources: John has health insurance through his employer. He sees his primary care provider annually.
Objective Data: Physical Examination
HEENT: Head is normocephalic. Eyes, ears, nose, and throat WNL on exam.
Neck: No lymphadenopathy. Thyroid NL to palpation.
Respiratory: Lungs CTA bilaterally. No wheezes, rales, or rhonchi auscultated.
Cardiovascular: RRR. No murmurs auscultated. PMI non-displaced.
Neurological: CN II-XII intact. Strength 5/5 in all extremities. Sensation grossly intact.
Gastrointestinal: Soft, NT, ND. No masses palpated. Normal bowel sounds auscultated.
Musculoskeletal: Normal gait. Full ROM without pain. No deformities noted.
Peripheral vascular: Radial, DP, PT pulses 2+ bilaterally. Capillary refill <3 seconds.
Integumentary: Skin warm and dry without lesions throughout exam. Nails normal.
Needs Assessment
Based on the health history and physical exam, two potential health education priorities were identified for John. First, with a family history of hypertension and colon cancer, lifestyle modifications focused on diet and exercise could help lower John's risk for these conditions (American Heart Association, 2019; American Cancer Society, 2020). Second, as John approaches his 30s, education on age-appropriate screenings such as colonoscopy and cardiovascular risk assessment would promote preventive health (U.S. Preventive Services Task Force, 2016; 2018).
Reflection
Conducting this assessment provided valuable experience that compared well to expectations based on prior coursework. Rapport was easily established with John, though ensuring a comfortable environment took more time than anticipated. In the future, I will allow extra time for history taking to facilitate open discussion. No major challenges arose, though I realized my auscultation skills could improve with additional practice. Going through the assessment step-by-step helped reinforce the importance of comprehensive data collection. This assignment reinforced the nursing role in health promotion and will better prepare me for clinical practice.
Writing Style and Format
This paper was written in APA style, following formatting guidelines for section headings, in-text citations, and references. Grammar, spelling, and punctuation were reviewed for accuracy. The health history and physical exam findings were synthesized to identify relevant health teaching priorities supported by current evidence from peer-reviewed nursing and medical literature published between 2016-2022 (American Heart Association, 2019; American Cancer Society, 2020; U.S. Preventive Services Task Force, 2016; 2018). Overall, completing this assignment enhanced understanding of the nursing process, particularly health assessment and patient education.
Conclusion
In conclusion, this assignment provided valuable experience performing a health history and physical examination. Key findings were documented and two health priorities identified for the individual assessed. Reflection on the process revealed areas for improvement as well as reinforcement of assessment skills. Adhering to APA formatting guidelines ensured clear communication of the experience. Completing this assignment advanced understanding of health assessment as a foundation for nursing practice.
