2019-01-21T11:20:37+00:00 Assignments

Topic: NR304 Assignment Paper: Health History and Physical Examination

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Topic: NR304 Assignment Paper: Health History and Physical Examination

Instructions:

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 on identifying health/wellness priorities for the person. The purpose of the assignment is two‐fold:   • 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.   COURSE OUTCOMES   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. (PO 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)   CO 6     Identify teaching/learning needs from the health history of an individual. (PO 2, 5)  

Content:

Health History 2 Student: Professor: Course title: Date: Health History 2 Health History and Physical Examination Subjective data: health history Demographic data: 45 year old, married Hispanic-American female. She is slightly overweight. Her name is Martha Bruni. Reason for care: Martha Bruni is in the facility because of chest pain. She stated that she has been having chest pains for 7 straight days now. Present illness: this is Martha Bruni’s first admission at the facility. She stated that she was in her normal good health state until 7 days before her admission, when she noticed a sudden onset of aching and dull chest pains. Since that first pain 7 days prior, she has experienced 2 more episodes of pain, each lasting about 12 minutes. This evening, Martha Bruni experienced an episode of pain that lasted 26 minutes, which lead her to visit the facility. Perception of health: individual considers herself relatively healthy but notes that her hypertension is controllable, and her chest pains are getting worse. Past medical history: Martha

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