Head to toe assessment (Health history assessment)

 

To recognize the interrelationships of subjective data (physiological, psychosocial, cultural/spiritual values, and developmental) and objective data (physical examination findings) in planning and implementing nursing care; and To reflect on the interactive process that takes place between the nurse and an individual while conducting a health assessment and a physical examination. 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) . 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 o Neurological system o Gastrointestinal system o Musculoskeletal system o Peripheral vascular system 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? 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. THE PATIENT USED HERE HAS NO HEALTH ISSUES. SHE IS 35 YEARS OF AGE, SINGLE AND HAVE THREE CHILDREN. LIVE WITH KIDS AND BOYFRIEND. DOES NOT SMOKE OR TAKE ANY DRUGS.

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