NR302 Health Assessment I
RUA: Health History Guidelines
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 student to meet the following course outcomes:
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 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 responsibility involved in conducting a comprehensive health assessment 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.
Total points possible: 100 points
Preparing the assignment
Follow these guidelines when completing this assignment. Speak with your faculty member if you have questions.
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.
2. Include the following sections when completing the assignment.
a. Health History Assessment (70 points/70%)
1) Demographics
2) Perception of Health
3) Past Medical History
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NR302_RUA_Health_History_Guidelines_V10
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NR302 Health Assessment I
RUA: Health History Guidelines
4) Family Medical History
5) Review of Systems
6) Developmental Considerations- use Erikson’s Stages of Psychosocial Development- which stage
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, cultural viewpoints on healing/healers,
traditional and complementary medicine, these are examples but please add more
8) Psychosocial Considerations- support systems-family, religious, occupational, community these are
examples but please add more
9) 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.
b. 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?
3. 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 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.
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NR302_RUA_Health_History_Guidelines_V10
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NR302 Health Assessment I
RUA: Health History Guidelines
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
Highest Level of
High Level of
Satisfactory
Unsatisfactory
Required Criteria
Performance
Performance
Level of
Level of
Performance
Performance
(Points possible/% of total points available)
Health History Assessment
(70 points/70%)
1.
2.
3.
4.
5.
6.
7.
8.
9.
Required criteria
Demographics
Perception of Health
Past Medical History
Family Medical History
Review of Systems
Developmental Considerations
Cultural Considerations
Psychosocial Considerations
Collaborative Resources to Improve Health
Reflection
(20 points/20%)
70 points
35 points
0 points
Includes 1-4
requirements for
section.
No requirements
for this section
presented.
16 points
10 points
0 points
Includes 5
requirements for
section.
Includes 1-4
requirements for
section.
No requirements
for this section
presented.
66 points
Includes 9
requirements for
section.
Includes 7-8
requirements for
section.
20 points
18 points
Includes 7
Required criteria
1. Reflect on your interaction with the
requirements for
interviewee holistically.
section.
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?
52 points
6 requirements
for section.
Section not
present in
paper
Includes 5-6
requirements
for section.
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NR302_RUA_Health_History_Guidelines_V10
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NR302 Health Assessment I
RUA: Health History Guidelines
Assignment Section and
Required Criteria
(Points possible/% of total points available)
4.
5.
6.
7.
b) What will you do to overcome them in
the future?
What went well with this assignment?
Were there unanticipated challenges during
this assignment?
Was there information you wished you had
available but did not?
How will you alter your approach next time?
Style and Organization
(10 points/10%)
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.
Highest Level of
Performance
High Level of
Performance
Satisfactory
Level of
Performance
Unsatisfactory
Level of
Performance
Section not
present in
paper
10 points
8 points
4 points
0 points
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
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NR302_RUA_Health_History_Guidelines_V10
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