NR302 Health Assessment I RUA: Health History Guidelines

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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 individual 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 nursing process while obtaining a physical assessment. (POs 4 and 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 health assessment. (PO 3)

CO 5: 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 and 5)

CO 7: Explore the professional responsibility involved in conducting a comprehensive health assessment and providing appropriate documentation. (POs 6 and 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 completing this assignment. Speak with your faculty member if you have questions.

1. Complete a health assessment/history 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 provide care.
   2. Inform the individual that information obtained will be kept confidential and do not use identifying information within the assignment.
   3. The Health History Worksheet can be used to help you organize the Family Medical History information you will obtain from the Adult Participant (document link is on the Assignment page).
   4. The use of this tool is optional. There are three parts to this assignment.
2. Include the following sections when completing the assignment.
   1. Health History Assessment (70 points/70%)
      • Demographics
      • Perception of Health

NR302_RUA_Health_History_Guidelines_V5_Final                                                                                                                                                                                                                    1

NR302 Health Assessment I

RUA: Health History Guidelines

• Past Medical History
• Family Medical History
• Review of Systems
• Developmental Considerations
• Cultural Considerations
• Psychosocial Considerations
• Collaborative Resources

1. Reflection (20 points/20%)

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.

• Reflect on your interaction with the interviewee holistically.
  1. Describe the interaction in its entirety: include the environment, 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 learned?
• What barriers to communication did you experience?
  1. How did you overcome them?
  2. What will you do to overcome them in the future? 4) What went well with this assignment?
• Were there unanticipated challenges during this assignment?
• Was there information you wished you had available but did not? 7) How will you alter your approach next time?

1. 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.

• Grammar and mechanics are free of errors.
• Verbalizes thoughts and reasoning clearly.
• Uses appropriate resources and ideas to support topic with APA where applicable.

For writing assistance (APA, formatting, or grammar), visit the APA Citation and Writing page in the online library.

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.

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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 Required Criteria (Points possible/% of total points available)	Highest Level of Performance	High Level of Performance	Satisfactory Level of Performance	Unsatisfactory Level of Performance	Section not present in paper
	Health History Assessment  (70 points/70%)	70 points	66 points	52 points	35 points	0 points
1.2.3.4.5.6.7.8. 9.	Required criteria Demographics Perception of Health Past Medical History Family Medical History Review of Systems Developmental Considerations Cultural Considerations Psychosocial Considerations Collaborative Resources	Includes 9 requirements for section.	Includes 7-8 requirements for section.	Includes 5-6 requirements for section.	Includes 1-4 requirements for section.	No requirements for this section presented.
	Reflection (20 points/20%)	20 points	18 points	16 points	10 points	0 points
1. 2. 3.	Required criteria Reflect on your interaction with the interviewee holistically. a) Describe the interaction in its entirety: include the environment, 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 learned? What barriers to communication did you experience? a) How did you overcome them?	Includes 7 requirements for section.	Includes 6 requirements for section.	Includes 5 requirements for section.	Includes 1-4 requirements for section.	No requirements for this section presented.

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NR302 Health Assessment I

RUA: Health History Guidelines

Assignment Section and Required Criteria (Points possible/% of total points available)	Highest Level of Performance	High Level of Performance	Satisfactory Level of Performance	Unsatisfactory Level of Performance	Section not present in paper
	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 Organization (10 points/10%)	10 points	8 points	4 points	0 points
1.2. 3.	Required criteria Grammar and mechanics are free of errors. Verbalizes thoughts and reasoning clearly. Uses appropriate resources and ideas to support topic with APA where applicable.	Includes no fewer than 3 requirements for section.	Includes no fewer than 2 requirements for section.	Includes 1 requirement for section.	No requirements for this section presented.
	Total Points Possible = 100 points

NR302_RUA_Health_History_Guidelines_V5_Final                        

NR302 Health Assessment I RUA: Health History Guidelines

NR302 Health Assessment I RUA: Health History Guidelines

NR302 Health Assessment I RUA: Health History Guidelines