Health History: Subjective Data 1) Demographic data 2) Reaso
Health History: Subjective Data 1) Demographic data 2) Reason for… Health History: Subjective Data 1) Demographic data2) Reason for care3) Present illness (PQRST of current illness)4) Perception of health5) Past medical history (including medications, allergies, and vaccinations and immunizations)6) Family medical history7) Review of systems8) Developmental considerations- use Erikson’s Stages of Psychosocial Development- which stage is your participant at and give examples of if they have met or not met the milestones for that stage.9) Cultural considerations- definition, cultural traditions, cultural viewpoints on healing/healers, traditional and complementary medicine, these are examples but please add more10) Psychosocial considerations- support systems-family, religious, occupational, community these are examples but please add more11) Presence or absence of collaborative resources (community, family, groups, and healthcare system) Physical Examination: Objective Data From NR302a) HEENT (head, eyes, ears, nose, and throat) b) Neck (including thyroid and lymph chains) c) Respiratory systemd) Cardiovascular system From NR304a) Neurological systemb) Gastrointestinal systemc) Musculoskeletal systemd) Peripheral vascular system c. Needs Assessment 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 effectiveness of the proposed health education. 4) Describe how the individual’s strengths (personal, family, and friends) and collaborative resources (clinical, community, and health and wellness resources) effect proposed teaching. d. Reflection Reflection is used to intentionally examine our thought processes, actions, and behaviors in order to evaluate outcomes. Provide a written reflection that describes your experience with conducting this complete health history and physical assessment. 1) Reflect on your interaction with the interviewee holistically.a) Describe the interaction in its entirety: include the environment, your approach to the individual, time of day, and other features relevant to therapeutic communication and to the interview process. 2) How did your interaction compare to what you have learned? 3) What barriers to communication did you experience? a) How did you overcome them?b) What will you do to overcome them in the future? 4) What went well with this assignment?5) Were there unanticipated challenges during this assignment?6) Was there information you wished you had available but did not?7) How will you alter your approach next time? Health Science Science Nursing NURSING NR304
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