Essay: Clinical judgment in professional decision-making

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.

• 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

• 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

CO1: CO1. Explain expected client behaviors while differentiating between normal findings, variations and abnormalities. (PO1)

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. (POs 4, 8)

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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)

CO5: Demonstrate beginning skill in performing a complete physical examination using the techniques of inspection, palpation, percussion, and auscultation. (PO 2

CO 6: Identify teaching/learning needs from the health history of an individual. (POs 2, 5)

CO 7: Explore the professional responsibilities involved in conducting a comprehensive health assessment and providing appropriate documentation. (PO 6, 7)

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 choosing (not a patient), (2) compile a health education needs assessment, (3) self-reflection, and (4) writing style and format.

Health History Assessment and Physical Assessment (50 points)

Using the following subjective and objective components, as well as your textbook for explicit details about each category, complete a health history and physical examination on an individual. You may choose to complete portions of this assignment as you obtain the health history and perform the physical examination associated with the body systems covered

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 Essay: Clinical judgment in professional decision-making

2. • Demographic data

3. • Reason for care (why they are in the facility)

4. • Present illness (PQRST of current illness)

5. • Perception of health

6. • Past medical history (including medications, allergies, and vaccinations and immunizations)

7. • Family medical history

8. • Review of systems

9. • Developmental considerations

10. • Cultural considerations

11. • Psychosocial considerations

12. • Presence or absence of collaborative resources (community, family, groups, and healthcare 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 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