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.

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.
   1. 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.
   2. Inform the individual that information obtained will be kept confidential and do not use identifying information within the assignment.
   3. The Health History Worksheet can be used to help you organize the Family Medical History information you will obtain from the Adult Participant (document link is on the Assignment page).
   4. The use of this tool is optional. There are three parts to this assignment.
2. Include the following sections when completing the assignment.
   1. Health History Assessment (70 points/70%)
      1. Demographics
      2. Perception of Health

 

1. Past Medical History
2. Family Medical History
3. Review of Systems
4. Developmental Considerations
5. Cultural Considerations
6. Psychosocial Considerations
7. Collaborative Resources
3. 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.
   1. Describe 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?
   1. How did you overcome them?
   2. 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?

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.