RUA: Health History Guidelines

NR302 Health Assessment I

RUA: Health History Guidelines

Purpose

Before any nursing plan of care or intervention can be implemented or evaluated, the nurse assesses the in ivi ual through the collection of both subjective and objective data. 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 subjective assessment data, synthesizing the data, and on identifying health/wellness priorities based on the findings. The purpose of the assignment is two-fold:

  • To recognize the interrelationships of subjective data (physiological, psychosocial, cultural/spiritual, and developmental) affecting health and wellness.
  • To reflect on the interactive process between self and client when conducting a health assessment.

Course Outcomes: This assignment enables the student to meet the following course outcomes:

CO 1: Explain expected client behaviors while differentiating between normal findings variations, and abnormalities. (PO 1)

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 nu sing process while obtaining a physical assessment. (POs 4 & 8)

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 heal h ass ssm nt. (PO 3)

CO 5: Demonstrate beginning skill in performing a complete phy ical examination, using the techniques of inspection, palpation, percussion, and auscultation. (PO 2)

CO 6: Identify teaching/learning needs from the he lth hi tory of an individual. (POs 2 & 5)

CO 7: Explore the professional responsibility involved in conducting a comprehensive health assessment and providing appropriate documentation. (POs 6 & 7)

Due date: Your faculty member will inform you when this assignment is due. The Late Assignment Policy applies to this assignment.

Total points possible: 100 points

Preparing the assignment

Follow these guidelines when complet  g this assignment. Speak with your faculty member if you have questions.

  1. Complete a health assessment/h story on an individual of your choice who is 18 years of age or older and NOT a family member or close friend.
    1. The purpose of this restriction is to avoid any tendency to anticipate answers or to influence how the questions are answered. Your goal in choosing an interviewee is to simulate the interaction between you and an individual for whom you would provi e care.
  • Inform he individual that information obtained will be kept confidential and do not use identifying information within he assignm nt.
    • There  re hree parts to this assignment.
  • Include the following sections when completing the assignment
    • He lth History Assessment (50 points/50%)
      • D mogr phics
      • P rception of Health

NR302_Health_History_Guidelines_V7                                                                                                                Revised:Mar/22                                                                                                                                      1

NR302 Health Assessment I

RUA: Health History Guidelines

  • Past Medical History
  • Family Medical History
    • Review of Systems
    • 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.
    • Cultural Considerations- definition, cultural traditions, cultural viewpoints on healing/healers, traditional and complementary medicine, these are examples but please add more
  • Psychosocial Considerations- support systems-family, religious, occupational, community these are examples but please add more
  • Resources to Improve Health- give examples of resources available to improve the health of the participant such as community, nutritional recommendations, healthcare, spiritual, etc.
  • Reflection (40 points/40%)

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 Health History.

  1. Reflect on your interaction with the interviewee holistically.
    1. Describes the interaction in its entirety: include the envi onment, your approach to the individual, time of day, and other features relevant to therapeutic communication and to the interview process.
  • How did your interaction compare to what you have l a n d?
    • What barriers to communication did you experienc ?
      • How did you overcome them?
      • What will you do to overcome them in the fu ure?
    • What went well with this assignment?
5)Were there unanticipated challenges during this   ignment?
6)Was there information you wished you h d  v il ble but did not?
  • How will you alter your approach next time?
  • Style and Organization (10 Points/10%)

Your writing should reflect your synthesis of ideas based on prior knowledge, newly acquired information, and appropriate writing skills. Scoring of your work in written communication is based on proper use of grammar, spelling, APA, and how clearly you express your thoughts and reasoning in your writing.

  1. Grammar and mecha ics are free of errors.
    1. Verbalizes thoughts a d reaso i g clearly
  • Uses appropriate resources a d ideas to support topic with APA where applicable.

For writing assistance, visit the Wr t ng Center.

Please note that your instructor may provide you with additional assessments in any form to determine that you fully understand the concepts learned in the review module.

NR302_Health_History_Guidelines_V7                                                                                                                Revised:Mar/22                                                                                                                                      2

NR302 Health Assessment I

RUA: Health History Guidelines

Grading Rubric

Criteria are met when the student’s application of knowledge within the paper demonstrates achievement of the outcomes for this assignment.

           
  Assignment Section and Highest Level ofHigh Level ofSatisfactoryUnsatisfactory Section not
  Required Criteria PerformancePerformanceLevel ofLevel of present in
  (Points possible/% of total points available)   PerformancePerformance paper
           
  Health History Assessment 70 points66 points52 points35 points 0 points
  (70 points/70%)  
          
           
  Required criteria Includes 9Includes 7-8Includes 5-6Includes 1-5 No requirements
 1.Demographics requirements forrequirements forrequirementsrequirements for for this section
 2.Perception of Health section.section.for section.section. presented.
  • Past Medical History
  • Family Medical History
  • Review of Systems
  • Developmental Considerations
  • Cultural Considerations
  • Psychosocial Considerations
  • Collaborative Resources
Reflection 20 points18 points16 points10 points 0 points 
(20 points/20%)  
        
Required criteria Includes 76 requirementsIncludes 5Includes 1-4 No requirements 
1.  Reflect on your interaction with the requirements forfor section.requirements forrequirements for for this section
interviewee holistically. section. section.section. presented.
  1. Describes the interaction in its entirety: include the enviro me t, your approach to the ind v dual, t me of day, and other features relevant to therapeutic communication and to the
 interview process.
2.How did your in  rac ion compare to what you
 have learned?
3.Wh t b rriers o communication did you
 experience?
 )  How did you overcome them?

NR302 Health_History_Guidelines_V7                                                                                                                 Revised:MAR/2                                                                                                                                      3

NR302 Health Assessment I

RUA: Health History Guidelines

 Assignment Section andHighest Level of High Level ofSatisfactoryUnsatisfactorySec on not
 Required CriteriaPerformance PerformanceLevel ofLevel ofpresent in
 (Points possible/% of total points available)   PerformancePerformancepaper
        
 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?      
 Style and Organization10 points 8 points4 points0 points
 (10 points/10%) 
       
      
 Required criteriaIncludes no fewer than 3 requi ementsIncludes no fewerIncludes 1No requirements
1. Grammar and mechanics are free of errors.for section. than 2requirements forfor this section
2.Verbalizes thoughts and reasoning clearly   requirements forsection.presented.
3.Uses appropriate resources and ideas to   section.  
 support topic with APA where applicable.      
       
  Tot l Points Poible = 100 points  
        

NR302 Health_History_Guidelines_V7                                                                                                                 Revised:MAR/2                                                                                                                                      4

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