RUA Health History and Physical Assessment

 

 

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.
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


Explain expected patient behaviors while differentiating between normal findings, variations, and abnormalities. (PO 1)
2.  Utilize prior knowledge of theories and principles of nursing and related disciplines to integrate clinical judgment in professional decision-making and implementation of the nursing process while obtaining a physical assessment. (POs 4 and 8)
3.  Recognize the influence that developmental stages have on physical, psychosocial, cultural, and spiritual functioning. (PO 1)
4.  Utilize effective communication when performing a health assessment. (PO 3)
5.  Demonstrate beginning skill in performing a complete physical examination, using the techniques of inspection, palpation, percussion, and auscultation. (PO 2)
6.  Identify teaching/learning needs from the health history of an individual. (POs 2 and 5)
7.  Explore the professional responsibilities involved in conducting a comprehensive health assessment and providing appropriate documentation. (POs 6 and 7)

 

Sample Answer

 

 

 

 

 

 

That sounds like a comprehensive and insightful assignment focusing on the foundational skills of nursing assessment! Since your prompt outlines the learning objectives of your assignment, I will structure my response to directly address and explain each objective, providing the conceptual content necessary to fulfill them.

 

📝 Health Assessment: Key Nursing Objectives

 

 

1. Differentiating Assessment Findings and Expected Patient Behaviors

 

The ability to categorize data is fundamental to clinical judgment.

Integrating Clinical Judgment with the Nursing Process

 

Clinical judgment is the process by which a nurse uses critical thinking and knowledge to make decisions. During the physical assessment, this integrates with the Nursing Process (Assessment, Diagnosis, Planning, Implementation, Evaluation).

Assessment Phase (Integration): While gathering objective data (e.g., listening to lung sounds), the nurse utilizes prior knowledge of Anatomy & Physiology (A&P) to interpret the sounds heard (e.g., identifying crackles). Pharmacology principles are used to ask relevant questions (e.g., "Are you taking any diuretics that might affect your fluid balance?").

Judgment during Assessment: If an unexpected finding occurs (e.g., a sudden drop in blood pressure), the nurse's clinical judgment dictates an immediate shift from completing the routine physical exam to a focused, priority assessment (e.g., checking heart rate, level of consciousness, and ordering fluids/notifying the provider based on established protocols). This is an essential application of prioritization theory.

Aced Essays

Free Resources