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 patient 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 the 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 responsibilities 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. 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.

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.

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)

2)       Include the following sections when completing the assignment:

a.        Health History Assessment (30 points/30%)

b.       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.

c.        Perception of Health - This section must be written in paragraph format with a minimum of 3 sentences.

d.       Past Medical History - Include childhood illnesses, accidents or injuries, serious or chronic illnesses, hospitalizations & operations, obstetric history, immunizations, last examination dates, allergies, current medications, and substance use.  This section must be written in paragraph format with a minimum of 3 sentences.

e.        Family Medical History - Grandparents, Parents, Siblings, Children.  This section must be written in paragraph format with a minimum of 3 sentences.

f.         Review of Systems - CRITICAL: 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.

g.        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.

h.       Cultural Considerations - Definition, cultural traditions, cultural viewpoints on healing/healers, traditional and complementary medicine.  Cultural influence on health views and practices.  This section must be written in paragraph format with a minimum of 3 sentences.

i.           Psychosocial Considerations - Support systems: family, religious, occupational, community.  This section must be written in paragraph format with a minimum of 3 sentences.

j.         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.

3)       Physical Exam: Objective Data (20 points/20%)

a.        Perform a comprehensive physical examination using all four assessment techniques (inspection, palpation, percussion, and auscultation). 

b.       Document findings for all body systems, including general appearance/vital signs

                                                               i.        integumentary

                                                              ii.        HEENT

                                                            iii.        cardiovascular

                                                            iv.        respiratory

c.        All findings must be written in paragraph format with a minimum of 3 sentences per system.

4)        Needs Assessment (20 points/20%) Complete the needs assessment table below based on your health history assessment and physical examination findings.  You must identify a minimum of 2 health education needs and complete all columns for each identified need.

5)        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.

1)        Reflect on your interaction with the interviewee holistically.

a)         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.

2)        How did your interaction compare to what you have learned?

3)        What barriers to communication did you experience?

a)         How did you overcome them?

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%)

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 mechanics are free of errors.

2)        Verbalizes thoughts and reasoning clearly.

3)        Uses appropriate resources and ideas to support the topic with APA where applicable.

For writing assistance, visit the Writing 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.

Grading Rubric

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