Write an health history for a patient. He is 25 years african american

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Assignment Section

(Points Possible/% of Total Points)

Subjective and/or Objective Data

Health History

(30 points/30%)

Subjective Data

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)

Physical Examination

(30 points/30%)

Objective Data

1. HEENT (head, eyes, ears, nose, and throat)

2. Neck (including thyroid and lymph chains)

3. Respiratory system

4. Cardiovascular system

5. Neurological system

6. Gastrointestinal system

7. Musculoskeletal system

Needs Assessment

(20 points/20%)

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 effectivene

NR306 Health Assessment
RUA Health History and Physical Assessment Guidelines

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. (POs 6 and 7)

Due date: Your faculty member will inform you when this assignment is due. The Late Assignment Policy applies to this

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 protoco


Health Assessment Assignment Presentation

NR 306 Health Assessment Assignment

1. Demographic Data

Rich (not his real name) is a 60-year old African American husband and father of four. He lives with his extended family in Bozeman Montana, where he has established a small farm where he breeds horses. He states that this is not only his current job but a hobby too. Rich is a retired Lumberjack who spent most of his younger life in the forests of British Columbia felling trees and supervising his colleagues. HE worked in the field for 30 years, after which he quit to take care of his ailing wife, who was suffering from cervical cancer. He would climb many hills felling trees while carrying a 40-pound chainsaw in 10-hour day shifts. Later on, he was promoted to a supervisor, tasked with monitoring and overseeing the work of his colleagues. After his wife’s recovery, they both decided to retire on a rural farm and established a business out of their passion. Rich. His wife was a housewife, taking care of the family and volunteering at a local children’s home on regular basis. He works out three times a week and is very particular about what he eats. He does not have any chronic condition but had hip replacement surgery two years ago. Rich does not smoke but likes to enjoy a cold beer with his friends on game nights

2. Review of Systems

The patient indicated that he has no known allergies. No physical abnormalities were observed on his skin, and he indicated no known issues. He denied experiencing any muscle weakness, fever or chill. The patient has presbyopia and has to wear glasses for correction of both short-sightedness and long-sightedness. He underwent Lasik surgery when he was 40, which corrected his myopia until he turned 55. He can read well and don’t experience any eye pains during the examination. Rich does not experience any shortness of breath or chest pain that would indicate a respiratory issue. Neither was an abnormality detected in his cardiovascular, musculoskeletal, and neurological or gastrointestinal systems. However, he indicates his struggles with an ingrown toenail which is preventing him from properly wearing a shoe. Rich is proud of his current health status and associates it with regular exercising at his age and having a proper diet.

3. Past/Family/Perception of Medical History

Rich comes from a family with a history of diabetes, but he is not affected. His wife is hypertensive but they manage the condition through diet and alternative medicine such as herbs and nutritional supplements. His mother was a chain smoker who succumbed to the complications of liver cirrhosis and diabetes. She passed away at the age of 53 after being in a coma for two weeks. Rich also has a sister, who is currently battling cystic fibrosis. She