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Chamberlain College of Nursing NR 302 Health Assessment

1 NR302 RUA The Health History.docx Revised 12/2016 SYM

REQUIRED UNIFORM ASSIGNMENT: THE HEALTH HISTORY

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 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. (PO 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 health assessment. (PO 3)

CO 6. Identify teaching/learning needs from the health history of an individual. (PO 2, 3)

DUE DATE: Please See Course Calendar.

TOTAL POINTS POSSIBLE: 50 points.

PREPARING THE ASSIGNMENT:

A Health History Worksheet may be used to help you organize the Family Medical History information needed to complete this assignment. The use of this tool is optional. There are three parts to this assignment.

Health History Assessment (35 points)

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:

 Demographic data

 Perception of health

 Past Medical History (including medications, allergies, and vaccinations/immunizations)

 Family Medical History

Chamberlain College of Nursing NR 302 Health Assessment

2 NR302 RUA The Health History.docx Revised 12/2016 SYM

 Review of Systems; Head-to-Chest

 Developmental considerations

 Cultural considerations

 Psychosocial considerations

 If you were to perform a physical assessment, which body system (Head-to- Chest) would be a top priority for evaluation and why?

 List two teaching/learning need priorities for this individual (Consider Age, Psychosocial, Cultural, Lifespan concerns)

 Collaborative resources (Think Community, Family, Groups, Health Care System)

Reflection (10 points)

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. First, reflect on your interaction with the interviewee holistically. 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). Finally, be sure your reflection

addresses each of these questions:

 How did your interaction compare to what you have learned?

 What went well?

 What barriers to communication did you experience?

o How did you overcome them? What will you do to overcome them in the future?

 Were there unanticipated challenges to the interview?

 Was there information you wished you had obtained?

 How will you alter your approach next time?

Written Communication (5 points)

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.

Feel free to consult with your faculty member as you work on this project.

NR302 RUA The Health History.docx Revised 12/2016 SYM

Chamberlain College of Nursing NR302 Health Assessment I

DIRECTIONS AND GRADING CRITERIA

Category Points % Description

Health History 35 70 Provide a comprehensive health history narrative that includes: demographic data; perception of health; past medical history; family medical history; review of systems (Head-to-Chest); developmental considerations; cultural considerations; psychosocial considerations; and collaborative resources.

Reflection 10 20 Reflect on the interaction with the interviewee holistically. 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 the interview process (if needed, refer to your text for a description of therapeutic communication and the interview process). Be sure your reflection addresses each of these questions: How did your interaction compare to what you have learned? What went well? What barriers to communication did you experience? How did you overcome them? Were there unanticipated challenges to the interview? Was there information you wished you had obtained? How will you alter the approach next time?

Grammar, Spelling, Clarity of Thought

5 10 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 writing.

Total 50 100

Chamberlain College of Nursing NR302 Health Assessment I

NR302 RUA The Health History.docx Revised 12/2016 SYM

GRADING RUBRIC

Assignment Criteria

Outstanding or Highest Level of Performance

Very Good or High Level of Performance

Competent or Satisfactory Level of Performance

Poor, Failing or Unsatisfactory Level of Performance

A (92–100%) B (84–91%) C (76–83%) F (0–75%)

Health History (35 points)

Thoroughly presents a health history narrative that includes a detailed description of ALL the following components:

 Demographic Data

 Perception of Health

 Past Medical History,

 Family Medical History

 Review of Systems;

Head-to-Chest

 Developmental Considerations

 Cultural Considerations

 Psychosocial Considerations

 Collaborative Resources.

Information is presented in a clear, organized, and professional manner.

33-35 points

ONE of the key elements of the health history narrative is not presented or lacks sufficient detail:

 Demographic Data

 Perception of Health

 Past Medical History,

 Family Medical History

 Review of Systems;

Head-to-Chest

 Developmental Considerations

 Cultural Considerations Psychosocial Considerations

 Collaborative Resources.

Information is presented in a clear, organized, and professional manner.

30-32 points

TWO of the key elements of the health history narrative is not presented or lacks sufficient detail:

 Demographic Data

 Perception of Health

 Past Medical History,

 Family Medical History

 Review of Systems;

Head-to-Chest

 Developmental Considerations

 Cultural Considerations

 Psychosocial Considerations

 Collaborative Resources.

Information is NOT presented in a clear, organized, and professional manner.

27-29 points

THREE or more of the key elements of the health history narrative is not presented or lacks sufficient detail:

 Demographic Data

 Perception of Health

 Past Medical History,

 Family Medical History

 Review of Systems;

Head-to-Chest

 Developmental Considerations

 Cultural Considerations

 Psychosocial Considerations

 Collaborative Resources.

Information is NOT presented in a clear, organized, and professional manner.

0-26 points

Reflection (10 points)

Thoughtfully appraises the interviewee holistically. Reflection includes a detailed response to ALL the following questions:

 Thoughtfully appraises the interviewee holistically. ONE of the following questions is not presented or lacks sufficient detail:

 Broadly appraises the interviewee. TWO of the following questions are not presented or lack sufficient detail:

 Broadly appraises the interviewee. THREE or more of the following questions are not presented or lack sufficient detail:

Chamberlain College of Nursing NR302 Health Assessment I

NR302 RUA The Health History.docx Revised 12/2016 SYM

 How did your interaction compare to what you’ve learned?

 What went well?

 What barriers to communication did you experience?

 How did you overcome them?

 Were there unanticipated challenges to the interview?

 Was there information you wished you’d obtained?

 How will you alter the approach next time?

 How did your interaction compare to what you’ve learned?

 What went well?

 What barriers to communication did you experience?

 How did you overcome them?

 Were there unanticipated challenges to the interview?

 Was there information you wished you’d obtained?

 How will you alter the approach next time?

 How did your interaction compare to what you’ve learned?

 What went well?

 What barriers to communication did you experience?

 How did you overcome them?

 Were there unanticipated challenges to the interview?

 Was there information you wished you’d obtained?

 How will you alter the approach next time?

 How did your interaction compare to what you’ve learned?

 What went well?

 What barriers to communication did you experience?

 How did you overcome them?

 Were there unanticipated challenges to the interview?

 Was there information you wished you’d obtained?

 How will you alter the approach next time?

Key/relevant information is presented in sufficient detail and is clear and organized.

Key/relevant information is presented in sufficient detail and is clear and organized.

Key/relevant information is presented in insufficient detail but is clear and organized.

Key/relevant information is presented in insufficient detail and is not clear or organized.

10 points 9 points 8 points 0-7 points

Grammar, spelling, clarity of thought (5 points)

Presents information using clear and logical language. Grammar, spelling, and punctuation are free of errors.

5 points

Presents information using clear and logical language. Grammar, spelling, and punctuation have two or less types of errors.

4.5 points

Presents information using clear and logical language. Grammar, spelling, and punctuation have three types of errors.

4 points

Information is unclear and difficult to follow. Grammar, spelling, and punctuation have three or more types of errors.

0–3 points

Total Points Possible = 50 points