RUA HEALTH HISTORY and PHYSICAL ASSESSMENT
RUA Health History and Physical Assessment
Your Name (without credentials)
Chamberlain University College of Nursing
NR304: Health Assessment II
Name of Instructor
August 15, 2021
RUA Health History and Physical Assessment
Health History: Subjective Data
This section should be one to two paragraphs in length. In the first paragraph, include your patient’s demographic data, the reason for care, present illness (PQRST of current illness), perception of health, past medical history (including medications, allergies, and vaccinations and immunizations), family medical history, and review of systems. Remember, the review of systems is the presence or absence of the specific disorders that you ask about for each body system.
In the second paragraph, include your patients developmental considerations, cultural considerations, psychosocial considerations, and presence or absence of collaborative resources (community, family, groups, and healthcare system).
Physical Examination: Objective Data
This section should be one paragraph. You will include the body systems from NR302; HEENT (head, eyes, ears, nose, and throat), neck (including thyroid and lymph chains), respiratory system, and cardiovascular system. You will also include the bod
y systems from NR304; neurological system, gastrointestinal system, musculoskeletal system, and peripheral vascular system.
Needs Assessment
This section should be two paragraphs. You will need to determine at least two health education needs for your patient. Support the identified health teaching needs selected with evidence from two current, peer-reviewed journal articles. Your supporting peer-reviewed journal articles should be within the past five years. Make sure to review the rubric for specific details for the needs assessment. You will need to use in-text citations for your journal articles.
In the second paragraph, include your patients developmental considerations, cultural considerations, psychosocial considerations, and presence or absence of collaborative resources (community, family, groups, and healthcare system).
Physical Examination: Objective Data
This section should be one paragraph. You will include the body systems from NR302; HEENT (head, eyes, ears, nose, and throat), neck (including thyroid and lymph chains), respiratory system, and cardiovascular system. You will also include the body systems from NR304; neurological system, gastrointestinal system, musculoskeletal system, and peripheral vascular system.
Needs Assessment
This section should be two paragraphs. You will need to determine at least two health education needs for your patient. Support the identified health teaching needs selected with evidence from two current, peer-reviewed journal articles. Your supporting peer-reviewed journal articles should be within the past five years. Make sure to review the rubric for specific details for the needs assessment. You will need to use in-text citations for your journal articles.
Reflection
This section should be one paragraph. Make sure to address each of the seven sections from the rubric for your reflection. Make sure to proofread your work and utilize spell check. Grammarly is available to you via the course shell. Review the RUA Health History and Physical Assessment Guidelines and rubric in-depth. Good luck with your RUA assignment!
References
Type your reference here using hanging indent and double line spacing (under Paragraph on the Home toolbar ribbon). See your APA Manual and the resources in the APA section of Resources for reference formatting.
SAMPLE
RUA: Health History
Name XXXXXXX
Institution XXXXXX
Health Assessment IIAugust 2021
Demographics
J.C is a 22-year-old Hispanic male and was born on February 10th, 1998, in Florida,Miami. His primary language is English and his secondary language is Spanish. He graduated HighSchool in 2016 and is currently an undergraduate student majoring in Biology. He currently livesin a house with his mom in a rural area. J.C work as a dental assistant and his job does notrequire any dangers to the body systems.
Reason for seeking Care
J.C came into the office for an annual check-up, depression screening, and physicalassessment. Getting annual check-ups is beneficial because each visit establishes a baseline of anindividual’s personal health. J.C decided to seek check-ups regularly as a preventative measurefor illnesses that may become present and manage chronic or ongoing conditions.
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