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NR302HealthHistoryGuidelinesV4.pdf
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NR302 Health Assessment I
RUA: Health History Guidelines
NR302 Health History Guidelines V3.docx Revised: 04/2019
11
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:
CO1. Explain expected client behaviors while differentiating between normal findings, variations, and abnormalities. (PO1)
CO2. 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. (PO 4, 8)
CO3. Recognize the influence that developmental stages have on physical, psychosocial, cultural, and spiritual functioning. (PO 1)
CO4. Utilize effective communication when performing a health assessment. (PO 3) CO6. Identify teaching/learning needs from the health history of an individual. (PO 2, 3) CO7. Explore the professional responsibilities involved in conducting a comprehensive health assessment and
providing appropriate documentation. (PO 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 A Health History Worksheet that can be used to help you organize the Family Medical History information you will obtain from the Adult Participant is located in the Resources section of the Expand page for Unit 2. The use of this tool is optional. There are three parts to this assignment.
1. Health History Assessment (50 points/50%)
Using the following components of a health history assessment and your textbook for explicit details about each category, complete a health assessment/history on an individual of your choice. The person interviewed must be 18 years of age or older and should NOT be a family member or close friend. 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. It is important that you inform the person of your assignment and assure him/her that the information obtained will be kept confidential. Please be sure to avoid the use of any identifiers in preparing the assignment. Health History components to be included:
a) Demographics b) Perception of Health c) Past Medical History d) Family Medical History
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NR302 Health Assessment I
RUA: Health History Guidelines
NR302 Health History Guidelines V3.docx Revised: 04/2019
21
e) Review of Systems f) Developmental Considerations g) Cultural Considerations h) Psychosocial Considerations i) Collaborative Resources
2. 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.
a) Reflect on your interaction with the interviewee holistically.
I. Consider 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 (if needed, refer to your text for a description of therapeutic communication and of the interview process).
b) How did your interaction compare to what you have learned?
c) What went well?
d) What barriers to communication did you experience?
I. How did you overcome them?
II. What will you do to overcome them in the future?
e) Were there unanticipated challenges to the interview?
f) Was there information you wished you had obtained?
g) How will you alter your approach next time?
3. 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 and how clearly you express your thoughts and reasoning in your writing.
• Grammar and mechanics are free of errors. • Able to verbalize thoughts and reasoning clearly • Use appropriate resources and ideas to support topic
For writing assistance (APA, formatting, or grammar) visit the Citation and Writing Assistance: Writing Papers at CU page in the online library.
NR302 Health Assessment I
RUA: Health History Guidelines
NR302 Health History Guidelines V3.docx Revised: 04/2019
31
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
Introduction of Disease (50 points/50%)
50 points 46 points 41 points 25 points 0 points
Required criteria 1. Demographics 2. Perception of Health 3. Past Medical History 4. Family Medical History 5. Review of Systems 6. Developmental Considerations 7. Cultural Considerations 8. Psychosocial Considerations 9. Collaborative Resources
Includes no fewer than 9 requirements for section.
Includes no fewer than 8 requirements for section.
Includes no less than 7 requirement for section.
Present, yet includes no required criteria.
No requirements for this section presented.
Reflection (40 points/40%)
40 points 36 points 33 points 20 points 0 points
Required criteria 1. Reflect on your interaction with the
interviewee holistically. a) Consider 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 (if needed, refer to your text for a description of therapeutic communication and of the interview process).
b) How did your interaction compare to what you have learned?
Includes no fewer than 7 requirements for section.
Includes no fewer than 6 requirements for section.
Includes no fewer than 5 requirements for section.
Includes 4 or fewer requirements for section.
No requirements for this section presented.
NR302 Health Assessment I
RUA: Health History Guidelines
NR302 Health History Guidelines V3.docx Revised: 04/2019
41
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
c) What went well? d) What barriers to communication did you
experience? I. How did you overcome them?
II. What will you do to overcome them in
the future?
e) Were there unanticipated challenges to the
interview?
f) Was there information you wished you had
obtained?
g) How will you alter your approach next
time?
Style and Organization (10 points/10%)
10 points 8 points 4 points 0 points
Required criteria
1. Grammar and mechanics are free of errors.
2. Able to verbalize thoughts and reasoning clearly 3. Use appropriate resources and ideas to support
topic
Includes no fewer than 3 requirements for section.
Includes no fewer than 2 requirements for section.
Includes 1 requirements for section.
No requirements for this section presented.
Total Points Possible = 100 points
