NUR 401-H&P

NUR 401-History and Physical Exam of A Patient

Jessica Listman-Ward
Frostburg State University

NUR 401-H&P

NUR 401-History and Physical Exam of a Patient

As nurses we follow a code of conduct and rely on guidelines and polices during our daily
practices. The guidelines that have been set in place are used as standards for the medical
profession, and in this case specifically for nursing. The Essentials for Baccalaureate Education
for Professional Nursing Practice is an example of one guideline that is followed by nursing
students. As nurses there are many ways in which we can become licensed. Nurses can obtain
a diploma, associate degree or bachelor degree. As with any profession continuing education is
important. Many nurses are advancing their degrees from the basic associate degree to a
bachelor degree. When obtaining a bachelor of nursing they will utilize the guidelines created
by the American Association of Colleges of Nursing. Each course that is taken utilizes a different
standard in order to meet the graduation requirements set in place by the group.
History and Physical of a Patient
During this course we had the opportunity to complete a full history and physical on a
patient of our choice. Each week we learned assessment techniques for the different body
systems. For example, during week 3 we learned how to perform eye, ears, nose, throat, head,
neck, and abdomen assessments. Each week we met with the patient that we had chosen for
the assignment and completed the portion of the assessment that we had learned about that
week. After six weeks we were finally able to compile the assessment findings into one paper.
This assignment sounded easy, but it was actually time consuming for both the patient
and the nurse. After reviewing the history and physical we were asked to come up with two
nursing diagnoses that relate to the patient. We had to talk to the patient about their goals and

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make sure that they were appropriate not only for themselves, but also for the nursing
diagnosis. We were then asked to determine how we could help the patient meet the goal for
the diagnosis. This is the part that I found to be the most challenging. I found it difficult to
determine what the top two nursing diagnoses should be. As we have learned in other classes I
began thinking what could kill/harm the patient first. I began thinking of the ABCs-airway,
breathing and circulation. There was not anything that was emergent in that area for my
patient. I then looked at Maslows Hierarchy of Needs. This is what I based my decisions on.
My patient appeared to have a self-actualization need. I determined that this was the best
choice for choosing a nursing diagnosis.
I found this assignment to be a great review of the skills we learn during nursing school.
As nurses we do not always have the time to do a complete head to toe assessment on all of
our patients. Often times we do a focused assessment based on why the patient is in the
hospital. We still check pulses, listen to the lungs and heart, but how we do not always have
the patient move into all the positions. This assignment illustrated the importance of good
technique and why we should take the time to do a thorough exam.
Reflection
Nursing 401, Health Assessment, utilized assignments like the history and physical to
meet the American Association of Colleges of Nursing essentials for a bachelor degree. The
essential requires the student to practice with patients, including individuals, families, groups,
communities, and populations across the lifespan and across the continuum of healthcare

NUR 401-H&P

environments (American Association of Colleges of Nursing, 2008, p. 3). The history and
physical assignment helped us practice the skills with a patient of our choice.
The assignment gave us flexibility since we were able to pick someone that we know to
be used as a patient. This took some of the pressure away and made it easier to complete since
we needed to meet several times. The assignment was actually time consuming since we broke
it down into smaller parts over the six weeks. That meant that once a week for six weeks we
needed to meet the patient and complete the weekly assignment.
As nurses we are the direct link between the patient and access to medical care.
Sometimes patients will talk to us about issues but not to the doctor. We need to be able to
thoroughly assess our patients and provide the needed resources to them. This assignment
reinforced that idea by allowing us to complete a history and physical of the patient. We can
recognize cultural and spiritual boundaries that many prevent the patient from seeking medical
attention (American Association of Colleges of Nursing, 2008, p. 32). Sometimes doctors do not
realize that there are cultural differences that need to be addressed. As nurses we can
complete a cultural assessment so that we can make sure that we are meeting the needs of the
patient.
The assessment also allows nurses to create a nursing diagnosis and work on helping the
patient meet their health goals. This is part of the essentials. Nurses can implement
interventions that can help alleviate issues (American Association of Colleges of Nursing, 2008,
p. 32). For example is a patient is having respiratory issues we can elevate the head of the bed,
apply oxygen and teach the patient to use the incentive spirometer. If we do not do a thorough

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assessment and take the time to look at body language and expressions, as well as listen to our
patients, then we might not pick up on these issues.
This assignment allowed us to review our assessment practices and remember to take
the time to listen to our patients. Sometimes patients will open up to the nurse before they will
talk to a doctor. If we take the time to assess our patient and create a good rapport with them,
then we can help them in a quicker manner.

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Reference
American Association of Colleges of Nursing. (2008). The Essentials of Baccalaureate Education
for Professional Nursing Practice. Washington, DC: American Association of Colleges of
Nursing.