Obtain a Health History and Conduct a Physical Examination



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 choo

sing (not a patient);

(2.) Compile a Health Education Needs Assessment; 

(3.) Self‐Reflection; and 

(4.) Writing style and format.  Instructions for each part follow. 

Health History Assessment and Physical Assessment (25 points) 

Using the following subjective and objective components, and your textbook for explicit details a

bout eachcategory, complete a health history and physical examination on an individual. You ma

y choose to completeportions of this assignment as you obtain the health history and perform the 

physical examination associatedwith the body systems covered in NR304. . Please be sure to avo

id the use of any identifiers in preparing theassignment. 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 are they in the facility) •Present illness (PQRST of current illness)

Perception of health

Past medical history (including medications, allergies, and vaccinations/immunizations)

Family medical history •Review of systems •Developmental considerations

Cultural considerations •Psychosocial consideration


•Presence or absence of collaborative resources (Community, family, groups, and health care 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 experience 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

ng systems.

Keep notes on each part of the physical exam you complete them to reference as you write the pa


Refer to the course textbook for detailed components of each system exam. Remember: assessment

out of the

the integumentary system is an integral part of the physical exam and should be included throughout 

each system:

From NR302

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

Neck (including thyroid and lymph chains) o Respiratory system

Cardiovascular system

From NR304

Neurological system

Gastrointestinal system

Musculoskeletal system

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