REQUIRED UNIFORM ASSIGNMENT GUIDELINES
THE HEALTH HISTORY
A very part of any plan of care for a client is the health history. Collecting a health history helps the nurse identify issues, needs, and health promotion activities for the client.
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: Week 3
TOTAL POINTS POSSIBLE: 100 points.
PREPARING THE ASSIGNMENT:
You will first use The Health History Worksheet to collect health history information on your patient to prepare for this assignment.
You will submit two major parts for this assignment.
1. Health History Assessment (50 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. 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. Instead use initials only.
Using the information, you gathered on the Health History Worksheet, during your client interview, complete and submit the RUA Health History Template (located in the Files of the Lecture folder) to report your findings from each section:
Reason for Seeking Care
o “Pain” of any kind cannot be used for this assignment. Please have your patient choose from the following complaints for you to complete this section: Nausea, Dizziness, Vision change, Rash, Swelling, Diarrhea, Hair loss, or Nose bleed
Present Health/History of Present Illness
Past Medical History (including medications, allergies, and vaccinations/immunizations)
Family Medical History
Review of Systems
2. Reflection (40 points/40%)
The 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. The Reflection must be submitted as an APA style paper using the Chamberlain Guidelines for Writing Professional Papers. First-person may be used.
1) Reflect on your interaction with the interviewee holistically.
a. 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).
2) How did your interaction compare to what you have learned?
3) What went well?
4) What barriers to communication did you experience?
a. How did you overcome them?
b. What will you do to overcome them in the future?
5) Were there unanticipated challenges to the interview? Stating that there were no challenges will not be accepted for points
6) Was there information you wished you had obtained? Stating that there was no information you wished you had obtained will not be accepted for points
7) How will you alter your approach next time?
3. 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. A cover page should be included in APA format as well as any other reflective writing. All pages should be typed. Handwritten assignments will not be accepted. Your document should be submitted as one single file. A reference page is not required. Data Collection Date:
Client Initials: Gender: Birth date and Month:
Race: Date of last physical exam:
Occupation: Source of Information:
REASON FOR SEEKING CARE
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PRESENT HEALTH/HISTORY OF PRESENT ILLNESS
Immunizations and dates: Tetanus Pneumonia
Influenza MMR Measles, Mumps, Rubella
Year Reason Hospital
Year Injury/Accident description Treatment
Name the Drug Dosage/Frequency Reason
Allergies to medications
Name the Drug Reaction You Had
REVIEW OF SYSTEMS
Skin, Hair, Nails
Eyes, Ears, Nose, Mouth, Throat, Neck
Provide an Overview for:
Alcohol or drug addiction
Cancer: breast, colorectal, ovarian, other type of cancer
Coronary heart disease
High blood pressure
Sickle cell anemia
FUNCTIONAL ASSESSMENT AND ADLS
Provide an Overview for:
Activity and Exercise:
Sleep and Rest:
Nutrition and Elimination:
Perception of Health:
Intimate partner violence:
Coping and stress management:
Illicit or Street Drugs: