Before implementing or evaluating any nursing plan of care or intervention, the nurse assesses the individual by collecting both subjective and objective data. The data collected are used to identify areas of need or problems
Purpose
Before implementing or evaluating any nursing plan of care or intervention, the nurse assesses the individual by collecting both subjective and objective data. The data collected are used to identify areas of need or problems that require addressing through the nursing care plan. This assignment will focus on collecting subjective assessment data, synthesizing the data, and 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. (PO1)
· 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 the nursing 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 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, 5)
· CO 7: 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
Follow these guidelines when completing this assignment. Please speak with your faculty member if you have any questions.
IMPORTANT FORMATTING REQUIREMENTS:
- Assignments submitted in bullet point format will receive a zero.
- All sections must be written in paragraph format with a minimum of 3 sentences per section.
- Omission of Review of Systems information will result in an automatic unsatisfactory grade for that section.
- 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.
a. 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.
b. Inform the individual that information obtained will be kept confidential, and do not use identifying information within the assignment.
c. Use your textbook as a reference tool for understanding how to conduct a health history. (Ch 4)
- Include the following sections when completing the assignment.
Health History Assessment (30 points/30%)
a. Demographics - Do not include name, but use First and Last initial; age; birthplace; gender and preferred pronoun; relationship status; race; ethnic origin; and occupation. Record the person's primary language. Include who is giving the history. This section must be written in paragraph format with a minimum of 3 sentences. Record the person's primary language. Include who is giving the history- the client, another person, and their relationship to the client, or an interpreter.
b. Perception of Health This section must be written in paragraph format with a minimum of
3 sentences.
c. Past Medical History
§ Past Health Past health events are important because they may have residual effects on the current health state. Previous experience with illness may also give clues about how the person responds to disease and the significance they attribute to it.
§ Childhood Illnesses, Accidents or Injuries (Auto accidents; sports-related injuries; fractures; penetrating wounds; head injuries, including concussions, primarily if associated with unconsciousness; and burns.), Severe or Chronic Illnesses, Hospitalizations & Operations- what for and when,
§ Obstetric History (Number of pregnancies (gravidity), number of deliveries in which the fetus reached full term (term), number of deliveries before 37 weeks' gestation (preterm), number of incomplete pregnancies (miscarriages or abortions), and number of children living (living). Recorded as: Grav 3, Term 2, Preterm 1, Ab 0, Living 3).
§ Immunizations,
§ Last Examination Date, including dental,
§ Allergies (medicine, food, seasonal, other allergies such as latex or adhesive)
§ Current medications, including prescription and over-the-counter, substance use (alcohol, tobacco, street drugs).
§ This section must be written in paragraph format with a minimum of 3 sentences.
d. Family Medical History Grandparents, Parents, Siblings, Children This section must be written in paragraph
format with a minimum of 3 sentences.
e. Review of Systems This section must be written in paragraph format with a minimum of 3 sentences.
Physical Examination: Objective Data (20 points/20%)
Omission of Review of Systems information will result in an automatic unsatisfactory grade for this section.
This section must be written in paragraph format with a minimum of 3 sentences or a faculty-approved template.
a. From NR302
§ HEENT (head, eyes, ears, nose, and throat)
§ Neck (including thyroid and lymph chains)
§ Respiratory system
§ Cardiovascular system
b. From NR304
§ Neurological system
§ Gastrointestinal system
§ Musculoskeletal system
§ Peripheral vascular system
Needs Assessment (20 points/20%)
Omission of Review of Systems information will result in an automatic unsatisfactory grade for this section.
This section must be written in paragraph format with a minimum of 3 sentences or a faculty-approved template.
a. Developmental Considerations
Use Erikson's Stages of Psychosocial Development- which stage is your participant at, and give examples of whether they have met or not met the milestones for that stage. This needs to be cited in-text and then referenced on your reference page. Use APA guidelines! This section must be written in paragraph format with a minimum of 3 sentences.
b. Cultural Considerations
Definition, cultural traditions, cultural viewpoints on healing/healers, traditional and complementary medicine, these are examples, but please add more. Cultural influence on health views and practices? Food and nutrition? This section must be written in paragraph format with a minimum of 3 sentences.
c. Psychosocial Considerations
Support systems: family, religious, occupational, community. This section must be written in paragraph format with a minimum of 3 sentences.
d. Collaborative Resources to Improve Health
Give examples of resources available to improve the health of the participant, such as community, nutritional recommendations, healthcare, spiritual, etc. This section must be written in paragraph format with a minimum of 3 sentences.
Reflection (20 points/20%)
Reflection is used to intentionally examine our thought processes, actions, and behaviors to evaluate outcomes. Provide a written reflection that describes your experience with conducting this Health History. This entire section must be written in paragraph format with a minimum of 3 sentences per subsection.
a. Reflect on your interaction with the interviewee holistically. This subsection must be written in paragraph format with a minimum of 3 sentences. Describes 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. This subsection must be written in paragraph format with a minimum of 3 sentences.
b. How did your interaction compare to what you have learned? This subsection must be written in paragraph format with a minimum of 3 sentences.
c. What barriers to communication did you experience? How did you overcome them? What will you do to overcome them in the future? This subsection must be written in paragraph format with a minimum of 3 sentences.
d. What went well with this assignment? This subsection must be written in paragraph format with a minimum of 3 sentences.
e. Were there unanticipated challenges during this assignment? This subsection must be written in paragraph format with a minimum of 3 sentences.
f. Was there information you wished you had available, but it was not available? This subsection must be written in paragraph format with a minimum of 3 sentences.
g. How will you alter your approach next time?
h. This subsection must be written in paragraph format with a minimum of 3 sentences.
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 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.
REMINDER: Assignments submitted in bullet point format will receive a score of zero. All content must be presented in paragraph format.
a. Grammar and mechanics are free of errors. (USE GRAMMARLY)
b. Verbalizes thoughts and reasoning clearly.
c. Use appropriate resources and ideas to support the topic with APA where applicable. A minimum of 1 resource is needed for the Erikson section. May include others as needed. In-text Citations and Reference page with a reference to match each in-text citation
For writing assistance, visit the Writing Center. Use the Chamberlain-provided BSN APA Template
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.
Grading Rubric
Criteria are met when the student's application of knowledge within the paper demonstrates achievement of the outcomes for this assignment.
RUA Health History and Physical Assessment Guidelines
Grading Rubric Criteria are met when the student’s application of knowledge 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
the paper |
|
Health History: Subjective Data (30 points/30%) |
30 points |
26 points |
23 points |
11 points |
0 points |
|
Required criteria NO bullet point format (automatic ZERO) Paragraph format with a minimum of 3 sentences per
section Missing Review of Systems = automatic UNSATISFACTORY Required Sections: •
1. Demographics •
2. Perception of Health •
3. Past Medical History •
4. Family Medical History •
5. Review of Systems |
Includes
all five required sections with comprehensive content. All sections are written in paragraph
format with a minimum of three sentences each. Demonstrates thorough understanding of
health assessment principles. |
Includes 4-5
required sections with good content depth.
All sections in paragraph format with a minimum of 3 sentences each. Shows solid understanding of health
assessment concepts. |
Includes 5-3
required sections with adequate content—all sections in paragraph format with
a minimum of 3 sentences each. Basic
understanding demonstrated. |
Includes <
4 required sections, OR sections lack a minimum of the required sentences, OR
are missing Review of Systems information.
Shows limited understanding. |
No
requirements met, OR assignment submitted in bullet point format, OR fewer
than the minimum required sections present. |
|
Physical Examination: Objective Data (20 points/20%) |
20 points |
17 points |
15 points |
8 points |
0 points |
|
Required criteria 1.
From NR302 o
HEENT (head, eyes,
ears, nose, and throat) o
Neck (including thyroid and lymph chains) o
Respiratory system o
Cardiovascular system 2.
From NR304 o
Neurological system o
Gastrointestinal system o
Musculoskeletal system o
Peripheral vascular system |
A comprehensive physical examination was performed
using all four assessment techniques. All
body systems were assessed, and accurate findings were documented. Demonstrates proficiency in inspection,
palpation, percussion, and auscultation.
Professional documentation of normal and abnormal findings. |
Good physical examination performed using 3-4
assessment techniques. Most body
systems assessed with generally accurate findings. Shows good understanding of assessment
techniques with mostly professional documentation. |
Basic physical examination
is performed using 2-3 assessment techniques.
Some body systems were assessed with adequate findings documented.
Basic understanding of assessment techniques demonstrated. |
Limited physical examination performed, OR fewer
than two assessment techniques used, OR inadequate documentation of findings,
OR sections lack the required sentence minimum. |
No physical examination performed, OR assignment
submitted in bullet point format, OR fails to demonstrate assessment
techniques. |
|
Needs Assessment (20 points/20%) |
20 points |
17 points |
15 points |
8 points |
0 points |
|
Required criteria NO bullet point format
(automatic ZERO) Paragraph format with a
minimum 3 sentences per section Required Sections: 1.
Developmental Considerations 2.
Cultural Considerations 3.
Psychosocial Considerations 4.
Collaborative Resources to
Improve Health. |
All
required sections have comprehensive content.
All sections are written in paragraph format with a minimum of 3
sentences each. Demonstrates thorough
understanding of health assessment principles. |
All
sections in paragraph format with a minimum of 3 sentences each. Shows solid understanding of health
assessment concepts. |
Includes two
required sections with adequate content—all sections in paragraph format with
a minimum of three sentences each. Basic
understanding demonstrated. |
Includes one
required section OR sections lack a minimum of the required number of
sentences OR are missing Review of Systems information. Shows limited understanding. |
No
requirements met, OR assignment submitted in bullet point format, OR fewer
than the minimum required sections present. |
RUA Health History and Physical Assessment Guidelines
|
Reflection (20points/20%) |
20 points |
17 points |
15 points |
8 points |
0 points |
|
Required criteria • NO bullet point format
(automatic ZERO) • Paragraph format with a
minimum of 3 sentences per subsection Required Components: 1.
Holistic interaction
reflection (including environment, approach, time of day, therapeutic
communication) 2.
Comparison of concepts
learned 3.
Communication barriers
experienced •
How barriers were overcome •
Future strategies 4.
What went well •
Unanticipated challenges •
Missing information you wished were available How the approach will be
altered next time |
Includes all five required reflection components
with thorough analysis. All
subsections in paragraph format with a minimum of 3 sentences each. Demonstrate deep self-reflection and
critical thinking about the interview process. |
Includes four required reflection components with
good analysis. All subsections in
paragraph format with a minimum of 3 sentences each. Shows good self-awareness and reflection. |
Includes three required reflection components with
adequate analysis—all subsections in paragraph format with a minimum of three
sentences each. Basic reflection
demonstrated. |
Includes two required reflection components OR
lacks a minimum of the required number of sentences. Limited self-reflection is evident. |
No requirements met, OR assignment submitted in
bullet point format, OR inadequate reflection provided. |
|
Style and Organization (10 points/10%) Required criteria 1.
Writing reflects the synthesis of information from prior learning applied to
the completion of the assignment. 2.
Grammar and mechanics are free of errors. 3.
Able to verbalize thoughts and
reasoning clearly. 4.
Use appropriate resources and ideas
to support the topic with APA where applicable. 5.
NO bullet points or fragmented sentences HIPAA protocols
followed. |
10 points Grammar and mechanics are free of errors. Thoughts and reasoning are clearly
verbalized. Appropriate APA resources
used. All content in proper paragraph
format with minimum sentence requirements met. Professional writing quality throughout |
9 points Fewer
than two grammatical/mechanical errors.
Thoughts are generally clear.
APA format is mostly correct. All content in paragraph format with
minimum sentence requirements met.
Good writing quality overall. |
8 points Greater
than two grammatical/mechanical errors.
Thoughts are generally clear.
APA format is mostly correct.
All content in paragraph format with minimum sentence requirements met. Acceptable writing quality overall. Sentence requirements consistently. |
4 points Multiple
grammatical/mechanical errors are present.
Unclear reasoning in some areas.
APA errors present. Paragraph
format used, but may not meet minimum sentence requirements consistently. |
0 points No
requirements for this section are presented. |
|
|
. |
|
|
|
|
|
Total = 100 points |
|||||
Summary of Automatic Failure Conditions
The following will result in automatic point deductions or failure:
|
Condition |
Consequence |
|
Bullet point format is used anywhere |
Automatic ZERO for the entire assignment |
|
Missing Review of Systems section |
Automatic UNSATISFACTORY (35 points max) for Health History
Assessment section |
|
Sections with fewer than 3 sentences |
Points deducted according to rubric criteria |
|
Missing required reflection components |
Reduced points in the Reflection section |
|
APA format errors |
Points deducted in the Style and Organization section |
