NR 302 Health Assessment – PART 1: THE HEALTH HISTORY

13 Jun NR 302 Health Assessment – PART 1: THE HEALTH HISTORY

Question

NR 302 Health Assessment: Part I

REQUIRED UNIFORM ASSIGNMENT GUIDELINES
PART 1: THE HEALTH HISTORY
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 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. (PO 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 6. Identify teaching/learning needs from the health history of an individual. (PO 2, 3)

DUE DATE: Please See Course Calendar.
TOTAL POINTS POSSIBLE: 50 points.
PREPARING THE ASSIGNMENT:
A Health 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. There are three parts to this assignment.

Health History Assessment (25 points)
Using the following components of a health history assessment and your textbook for explicit details
about each category, complete a health assessment/history on an individual of your choice. The
person interviewed must be 18 years of age or older and should NOT be a family member or close
friend. 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. It is important that you inform the
person of your assignment and assure him/her that the information obtained will be kept
confidential. Please be sure to avoid the use of any identifiers in preparing the assignment.
Health History components to be included:
Demographic data
Perception of health
Past Medical History (including medications, allergies, and vaccinations/immunizations)

NR 302 RUA 022216 LS

1

NR 302 Health Assessment: Part I

Family Medical History
Review of Systems
Developmental considerations
Cultural considerations
Psychosocial considerations
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)
Collaborative resources (Think Community, Family, Groups, Health Care System)

Reflection (20 points)
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. First, reflect on your interaction with the interviewee holistically. Consider 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 (if needed, refer
to your text for a description of therapeutic communication and of the interview process). Finally, be
sure your reflection addresses each of these questions:
How did your interaction compare to what you have learned?
What went well?
What barriers to communication did you experience?
o How did you overcome them? What will you do to overcome them in the future?
Were there unanticipated challenges to the interview?
Was there information you wished you had obtained?
How will you alter your approach next time?

Written Communication (5points)
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.
Feel free to consult with your faculty member as you work on this project.

NR 302 RUA 022216 LS

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NR302 Health Assessment I

DIRECTIONS AND GRADING CRITERIA
Category

Points

%

Health History

25

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

20

40

Reflect on the interaction with the interviewee holistically.
Consider the interaction in its entirety: include the environment,
your approach to the individual, time of day, and other features
relevant to therapeutic communication and the interview process
(if needed, refer to your text for a description of therapeutic
communication and the interview process). Be sure your
reflection addresses each of these questions: How did your
interaction compare to what you have learned? What went well?
What barriers to communication did you experience? How did
you overcome them? Were there unanticipated challenges to the
interview? Was there information you wished you had obtained?
How will you alter the approach next time?

Grammar,
Spelling,
Clarity of
Thought

5

10

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 writing.

Total

50

Description

100

NR 302 RUA Grading Rubric and Grading Criteria

Chamberlain College of Nursing

NR302 Health Assessment I

GRADING RUBRIC
Assignment
Criteria

Health
History
(25 points)

Outstanding or Highest Level
of Performance

Very Good or High Level of
Performance

Competent or Satisfactory
Level of Performance

Poor, Failing or Unsatisfactory
Level of Performance

A (92–100%)

B (84–91%)

C (76–83%)

F (0–75%)

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.

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
Considerations
Psychosocial
Considerations
Collaborative
Resources.

Information is presented in a
clear, organized, and
professional manner.
23-25 points
Reflection
(20 points)

Thoughtfully appraises the
interviewee holistically.
Reflection includes a detailed
response to ALL the following
questions:

NR 302 RUA Grading Rubric and Grading Criteria

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.

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 presented in a
clear, organized, and professional
manner.

Information is NOT presented in a
clear, organized, and professional
manner.

Information is NOT presented in a
clear, organized, and professional
manner.

21-22 points

19-20 points

0-18 points

Thoughtfully appraises the
interviewee holistically.
ONE of the following
questions is not presented
or lacks sufficient detail:

Broadly appraises the
interviewee. TWO of the
following questions are not
presented or lack sufficient
detail:

Broadly appraises the
interviewee. THREE or
more of the following
questions are not presented
or lack sufficient detail:

Chamberlain College of Nursing

How did your
interaction compare to
what you’ve learned?
What went well?
What barriers to
communication did
you experience?
How did you
overcome them?
Were there
unanticipated
challenges to the
interview?
Was there information
you wished you’d
obtained?
How will you alter the
approach next time?

Key/relevant information is
presented in sufficient detail
and is clear and organized.

19-20 points
Grammar,
spelling,
clarity of
thought
(5 points)

Presents information using clear
and logical language. Grammar,
spelling, and punctuation are free
of errors.

NR302 Health Assessment I

How did your
interaction compare to
what you’ve learned?
What went well?
What barriers to
communication did
you experience?
How did you
overcome them?
Were there
unanticipated
challenges to the
interview?
Was there information
you wished you’d
obtained?
How will you alter the
approach next time?

Key/relevant information is
presented in sufficient detail
and is clear and organized.

How did your
interaction compare to
what you’ve learned?
What went well?
What barriers to
communication did
you experience?
How did you
overcome them?
Were there
unanticipated
challenges to the
interview?
Was there information
you wished you’d
obtained?
How will you alter the
approach next time?

Key/relevant information is
presented in insufficient detail
but is clear and organized.

17-18 points
Presents information using clear
and logical language. Grammar,
spelling, and punctuation have
two or less types of errors.

16 points
Presents information using clear
and logical language. Grammar,
spelling, and punctuation have
three types of errors.

4.5 points

4 points

5 points
Total Points Possible =

NR 302 RUA Grading Rubric and Grading Criteria

50 points

How did your
interaction compare to
what you’ve learned?
What went well?
What barriers to
communication did
you experience?
How did you
overcome them?
Were there
unanticipated
challenges to the
interview?
Was there information
you wished you’d
obtained?
How will you alter the
approach next time?

Key/relevant information is
presented in insufficient detail
and is not clear or organized.

0-15 points
Information is unclear and difficult
to follow. Grammar, spelling, and
punctuation have three or more
types of errors.
0–3 points