Chamberlain College of Nursing NR304 Health Assessment II
2 NR 304 RUA Grading Rubric and Grading Criteria V1.docx 10_16 SMa Revised 05/31/17 SP/nlh
NR304. Please be sure to avoid the use of any identifiers in preparing the assignment. 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 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)
***REMEMBER: Ma
ke 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 experiences 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 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