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 studentto meet the following courseoutcomes:

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 processwhile obtaining a physical assessment. (POs 4 & 8)

CO 3: Recognize the influence that developmental stageshave on physical, psychosocial, cultural, and spiritual functioning. (PO 1)

CO 4: Utilizeeffective communication when performing a health assessment. (PO 3)

CO 5: Demonstrate beginning skill in performing a complete physicalexamination, using the techniques of inspection, palpation, percussion, and auscultation. (PO 2)

CO 6: Identifyteaching/learning needs from the healthhistory of an individual. (POs 2 &5)

CO 7: Explore the professional responsibility involved in conducting a comprehensive healthassessment and providing appropriate documentation. (POs 6 & 7)

Due date: Your faculty member will inform you when this assignment is due. The Late Assignment Policy applies to this assignment.

Totalpoints possible: 100 points

Preparing the assignment

Follow these guidelines when completing this assignment. Speak with your faculty memberif you have questions.

1. Complete a healthassessment/history on an individual of your choicewho 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 influencehow 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 obtainedwill be kept confidential and do not use identifying information within the assignment.

2. Include the followingsections when completing the assignment.

a. Health History Assessment (70 points/70%)

1) Demographics

2) Perception of Health

3)     Past MedicalHistory

4)     Family MedicalHistory

5)     Review of Systems

6) Developmental Considerations- use Erikson’s Stagesof Psychosocial Development- whichstage is your participant at and give examples of if they have met or not met the milestones for that stage.

7) Cultural Considerations- definition, cultural traditions, culturalviewpoints on healing/healers, traditional and complementary medicine, these are examples but please add more

8)      Psychosocial Considerations- support systems-family, religious, occupational, community theseare examples but please add more

9) Collaborative Resources to Improve Health-give examples of resourcesavailable to improvethe health of the participant such as community, nutritional recommendations, healthcare, spiritual, etc.

b. Reflection (20 points/20%)

Reflection is used to intentionally examine our thought processes, actions, and behaviors in order to evaluate outcomes. Providea 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 featuresrelevant to therapeutic communication and to the interview process.

2) How did your interaction compareto 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 duringthis assignment?

6)     Was there information you wished you had available but did not?

7) How will you alter your approach next time?

3.      Style and Organization (10 Points/10%)

Your writingshould 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 topic with APA where applicable.

For writing assistance, visit the WritingCenter.

Please note thatyour instructor may provide you with additional assessments in any form todetermine that you fully understand the concepts learned in the review module.

Grading Rubric

Criteria are met when the student’s application of knowledge withinthe paper demonstrates achievement of the outcomesfor 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

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
to Improve Health

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

Required criteria

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?

Includes 7 requirements for section.

6 requirements for section.

Includes 5 requirements for section.

Includes 1-4 requirements for section.

No requirements for this section presented.

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

Required criteria

1.        
Grammar and mechanics are free of errors.

2.        
Verbalizes thoughts and reasoning clearly.

3.        
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