Comprehensive Nursing History and Physical Assessment
The written comprehensive history and physical assessment is to be performed on a relatively healthy individual with at least one well-managed health alteration, such as high cholesterol, diabetes or heart disease. Keep in mind that the focus of this assessment is to learn how to perform appropriate techniques on a medically stable individual, and so it is best to choose someone you know, rather than a sick individual in a clinical setting.
For more detailed explanation of the components of this assignment, refer to Chapter 28 of the course textbook entitled Pulling It All Together. Be sure to follow the grading rubric from the syllabus as a checklist. The Review of Systems (ROS) and Physical Exam (PE) that should be included in this assignment are as follows: skin, hair, nails, head, neck, ears, eyes, nose, mouth, throat, sinuses, thorax, lungs, heart, neck vessels, peripheral vascular system, abdomen, mental status, musculoskeletal and nervous systems.
list only the expected normal findings – DO NOT perform exams on breasts and regional lymphatics, anus, rectum, prostate, or genitalia.