REQUIRED UNIFORM ASSIGNMENT GUIDELINESPART1:THE HEALTH HISTORY
PURPOSEBeforeanynursingplanofcareorinterventioncanbeimplementedorevaluated, thenurseassessestheindividualthrough thecollection ofbothsubjectiveandobjectivedata. Thedatacollectedare usedto determineareasofneedorproblemsto beaddressedbythe nursingcare plan. Thisassignmentwill focusoncollectingsubjectiveassessmentdata, synthesizingthedata, andon identifyinghealth/wellness priorities based on the findings. Thepurposeoftheassignmentis two-fold:• To recognize the interrelationships of subjective data (physiological, psychosocial, cultural/spiritual,anddevelopmental) affectinghealthandwellness• Toreflecton the interactiveprocessbetweenself and client when conducting ahealth assessmentCOURSE OUTCOMESThis assignment enables the student to meet the following course outcomes: CO 2. Utilizepriorknowledgeoftheoriesandprinciplesof nursingandrelated disciplinestointegrate clinical judgmentin professional decision-makingandimplementationof nursingprocesswhile obtainingaphysical assessment.(PO4,8)CO 3.Recognizetheinfluencethatdevelopmental stageshaveonphysical, psychosocial, cultural, andspiritual functioning(PO 1)CO 4. Utilizeeffectivecommunicationwhen performingahealth assessment.(PO3)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: 100 points.PREPARING THE ASSIGNMENT:AHealth 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. Therearethree partsto this assignment.
HealthHistoryAssessment(50 points)
Usingthefollowingcomponents of a health historyassessmentandyour textbookforexplicitdetailsabouteachcategory, completea health assessment/history onan individual ofyourchoice. Thepersoninterviewed mustbe18years ofageorolder andshouldNOTbea family memberor closefriend. Thepurposeof this restrictionis toavoidanytendencyto anticipateanswersor toinfluencehowthe questions areanswered.Your goal inchoosingan interviewee istosimulate theinteractionbetweenyouandanindividual forwhom youwould providecare.Itis important that youinformthepersonofyourassignment andassurehim/her that the information obtained will be keptconfidential. Please be sure to avoid the use ofany identifiers in preparing the assignment.Health History components to be included:• Demographicdata• Perceptionofhealth• PastMedical History(includingmedications, allergies,andvaccinations/immunizations)• FamilyMedical History• Reviewof Systems • Developmental considerations• Culturalconsiderations• Psychosocialconsiderations• If you were to perform a physical assessment, which body system would be a top priority for evaluation and why?• List two teaching/learning need priorities for this individual (Consider Age, Psychosocial, Cultural, Lifespan concerns)• Collaborativeresources(ThinkCommunity,Family, Groups, Health CareSystem)
Reflection(40 points)
Reflectionis used tointentionallyexamineour thoughtprocesses, actions,andbehaviors inorderto evaluateoutcomes. Providea written reflectionthatdescribesyourexperience with conducting this Health History.First, reflectonyour interactionwith theintervieweeholistically. Considertheinteractionin its entirety: includetheenvironment, your approachtothe individual, timeof day, and other features relevant to therapeuticcommunicationandto the interview process (if needed, refertoyour textfor a description oftherapeutic communication and of the interview process).Finally, be sure your reflection addresses each of these questions: • Howdidyourinteraction comparetowhatyou havelearned?• Whatwent well?• Whatbarrierstocommunicationdid you experience?o Howdid you overcomethem?What will you do to overcome them in the future?• Were thereunanticipated challengesto theinterview?• Wasthereinformation youwished you hadobtained? • Howwillyoualteryour approachnext time?
Written Communication (10 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.
Feelfreetoconsultwithyourfacultymemberasyouworkonthisproject. DIRECTIONS AND GRADING CRITERIACategory Points % DescriptionHealth History 50 50 Provide a comprehensive health history narrative that includes: demographic data; perception of health; past medical history; family medical history; review of systems; developmental considerations; cultural considerations; psychosocial considerations; and collaborative resources.Reflection 40 40 Reflectonthe interactionwith theinterviewee holistically. Considertheinteractionin its entirety: include theenvironment, your approachtothe individual, timeof day, and other features relevant to therapeuticcommunicationand the interview process (if needed, referto your text for a description oftherapeutic communication and the interview process).Be sure your reflection addresses each of these questions: Howdidyourinteraction comparetowhatyou havelearned? Whatwent well?Whatbarrierstocommunicationdid you experience?Howdid you overcomethem? Were thereunanticipated challengesto theinterview?Wasthereinformation youwished you hadobtained? Howwillyoualterthe approachnext time?
Grammar, Spelling, Clarity of Thought 10 10 Writing shouldreflectyour synthesisof ideasbased onpriorknowledge,newlyacquired information,andappropriate writingskills. Scoringofyourworkinwritten communicationisbased onproperuseof grammar,spelling, andhowclearly youexpressyourthoughts andreasoningin writing.
Total 100100
GRADING RUBRICAssignment Criteria Outstanding or Highest Level of Performance A (92–100%) Very Good or High Level of Performance
B (84–91%) Competent or Satisfactory Level of Performance C (76–83%) Poor, Failing or Unsatisfactory Level of Performance
F (0–75%)HealthHistory(50 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• Developmental Considerations• Cultural Considerations• Psychosocial Considerations• Collaborative Resources.
Information is presented in aclear,organized,and professionalmanner.
46-50 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• Developmental Considerations• Cultural ConsiderationsPsychosocial Considerations• Collaborative Resources.
Information ispresented in aclear,organized,and professionalmanner.
42-45 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• Developmental Considerations• Cultural Considerations• Psychosocial Considerations• Collaborative Resources.
Information is NOTpresentedin aclear,organized,and professionalmanner.
38-41 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• Developmental Considerations• Cultural Considerations• Psychosocial Considerations• Collaborative Resources.
Information is NOTpresented in aclear,organized,and professionalmanner.
0-37 pointsReflection(40 points) Thoughtfully appraises the interviewee holistically. Reflection includes a detailed response to ALL the following questions: • Howdidyourinteraction comparetowhatyou’velearned?• Whatwent well?• Whatbarrierstocommunicationdid you experience?• Howdid you overcomethem?• Were thereunanticipated challengesto theinterview?• Wasthereinformation youwished you’dobtained? • Howwillyoualterthe approachnext time?
Key/relevant information is presented in sufficient detail and is clear and organized.
37-40 points • Thoughtfully appraises the interviewee holistically. ONE of the followingquestions is not presented or lacks sufficient detail: • Howdidyourinteraction comparetowhatyou’velearned?• Whatwent well?• Whatbarrierstocommunicationdid you experience?• Howdid you overcomethem?• Were thereunanticipated challengesto theinterview?• Wasthereinformation youwished you’dobtained? • Howwillyoualterthe approachnext time?
Key/relevant information is presented in sufficient detail and is clear and organized.
34-36 points • Broadly appraises the interviewee. TWO of the following questions are not presented or lack sufficient detail: • Howdidyourinteraction comparetowhatyou’velearned?• Whatwent well?• Whatbarrierstocommunicationdid you experience?• Howdid you overcomethem?• Were thereunanticipated challengesto theinterview?• Wasthereinformation youwished you’dobtained? • Howwillyoualterthe approachnext time?
Key/relevant information is presented in insufficient detail but is clear and organized.
31-33 points • Broadly appraises the interviewee. THREE or more of the following questionsare not presented or lack sufficient detail: • Howdidyourinteraction comparetowhatyou’velearned?• Whatwent well?• Whatbarrierstocommunicationdid you experience?• Howdid you overcomethem?• Were thereunanticipated challengesto theinterview?• Wasthereinformation youwished you’dobtained? • Howwillyoualterthe approachnext time?
Key/relevant information is presented in insufficient detail and is not clear or organized.
0-30 pointsGrammar,spelling,clarity ofthought(10 points) Presents information using clear and logical language. Grammar, spelling, and punctuation are free of errors.
10 points Presents information using clear and logical language. Grammar, spelling, and punctuation have two or less types of errors.
9 points Presents information using clear and logical language. Grammar, spelling, and punctuation have three types of errors.
8 points Information is unclear and difficult to follow. Grammar, spelling, and punctuation have three or more types of errors.
0–7 pointsTotal Points Possible = 100 points