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.

Health Education Need	Evidence Support	Interrelationships	Individual Strengths	Collaborative Resources
Based on assessment findings	Current peer-reviewed journal articles with specific findings	Physiological, developmental, cultural, and psychosocial factors that influence or create barriers	Personal, family, and friend strengths that support learning	Clinical, community, wellness resources available
Based on assessment findings	Current peer-reviewed journal articles with specific findings	Physiological, developmental, cultural, and psychosocial factors that influence or create barriers	[Personal, family, and friend strengths that support learning	Clinical, community, wellness resources available

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.

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 (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 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 for this section are presented.
Physical Exam: Objective Data (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 three sentences per system  All four assessment techniques must be demonstrated Required Assessment Techniques: • Inspection • Palpation • Percussion • Auscultation Required Body Systems: 1.          • General appearance/vital signs 2.            From NR302 o   HEENT (head, eyes, ears, nose, and throat) o   Neck (including thyroid and lymph chains) o   Respiratory system o   Cardiovascular 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 Minimum 2 health education needs identified • Health Education Need (based on assessment findings) • Evidence Support (2 current peer-reviewed articles) • Interrelationships (physiological, developmental, cultural, psychosocial influences/barriers) • Individual Strengths (personal, family, friends) • Collaborative Resources (clinical, community, health/wellness resources) Student must demonstrate  Critical thinking skills • Evidence-based practice • Cultural competence • Resource identification abilities	Comprehensive needs assessment table with all required components completed. Identifies at least 2 health education needs with strong evidence-based support. Demonstrates thorough analysis of interrelationships and collaborative resources. Shows critical thinking in linking assessment data to health education planning.	Good needs assessment table with most required components completed. Most health education needs identified with adequate evidence support. Good analysis of most interrelationships and resources. Shows good critical thinking skills.	Basic needs assessment table with some required components completed. Some health education needs identified with basic evidence support. Adequate analysis of some interrelationships and resources. Basic critical thinking demonstrated.	Limited needs assessment table OR missing key components OR inadequate identification of health education needs OR poor evidence support OR minimal analysis of interrelationships/resources.	No needs assessment table provided OR table format not used OR major components missing OR fails to demonstrate educational planning reasoning.
Reflection (20 points/20%)	20 points	17 points	15 points	8 points	0 points
Required criteria NO bullet point format use (automatic ZERO) Paragraph format with a minimum of three sentences per subsection Required Components: 1.         Holistic interaction reflection (including environment, approach, time of day, therapeutic communication) 2.         Comparison of learned concepts 3.         Communication barriers experienced 4.         How barriers were overcome 5.         Future strategies 6.         What went well 7.         Unanticipated challenges 8.         Missing information you wished were available 9.         How will your approach be altered next time? a.       What will you do to overcome them in the future	Includes all nine 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 six 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 five required reflection components with adequate analysis.  All subsections in paragraph format with a minimum of 3 sentences each.  Basic reflection demonstrated.	Includes 1-4 required reflection components OR lacks a minimum of a sentence.  Limited self-reflection is evident.	No requirements met, OR assignment submitted in bullet point format, OR inadequate reflection provided.

 

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
Style and Organization (10 points/10%)	10 points		8 points	4 points	0 points
Required criteria • Professional grammar and mechanics (use Grammarly) • Clear verbalization of thoughts • Proper APA format • Minimum one scholarly resource for Erikson section • In-text citations with matching reference page • NO bullet points, lists, or fragmented sentences	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.		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.	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.	Numerous errors throughout the OR assignment submitted in bullet point format; the OR fails to meet basic writing standards.
Total Points Possible = 100 points