Health History Assignment Essay
Health History
Think about a recent patient that you have provided nursing care. How can the health history relate to clinical prevention for that specific patient? How can you as the nurse advocate for your patient to receive effective, efficient, cost-effective and equitable care?Health History Assignment Essay
ORDER HERE A PLAGIARISM-FREE PAPER HERE
(make up a patient and a scenario)
200 word minimum. APA format. 2 references
You must proofread your paper. But do not strictly rely on your computer’s spell-checker and grammar-checker; failure to do so indicates a lack of effort on your part and you can expect your grade to suffer accordingly. Papers with numerous misspelled words and grammatical mistakes will be penalized. Read over your paper – in silence and then aloud – before handing it in and make corrections as necessary. Often it is advantageous to have a friend proofread your paper for obvious errors. Handwritten corrections are preferable to uncorrected mistakes.
Use a standard 10 to 12 point (10 to 12 characters per inch) typeface. Smaller or compressed type and papers with small margins or single-spacing are hard to read. It is better to let your essay run over the recommended number of pages than to try to compress it into fewer pages.Health History Assignment Essay
Likewise, large type, large margins, large indentations, triple-spacing, increased leading (space between lines), increased kerning (space between letters), and any other such attempts at “padding” to increase the length of a paper are unacceptable, wasteful of trees, and will not fool your professor.
The paper must be neatly formatted, double-spaced with a one-inch margin on the top, bottom, and sides of each page. When submitting hard copy, be sure to use white paper and print out using dark ink. If it is hard to read your essay, it will also be hard to follow your argument.
Course Project Milestone 1: Health History Form
Directions: Refer to the Milestone 1: Health History guidelines and grading rubric found in Doc Sharing to complete the information below. This assignment is worth 175 points, with 5 points awarded for clarity of writing, which means the use of proper grammar, spelling and medical language.
Type your answers on this form. Click “Save as” and save the file with the assignment name and your last name, e.g., “NR305_Milestone1_Form_Smith” When you are finished, submit the form to the Milestone #1 Dropbox by the deadline indicated in your guidelines. Post questions in the Q&A Forum or contact your instructor if you have questions about this assignment.
Feels tired all the time, running after her very active toddler and also 20 weeks pregnant. She has been diagnosed with anemia and fibroids. | Health patterns: | I try to maintain a healthy diet with whole grains, lean proteins, and 2 cups of fresh fruits and 2-3 cups vegetables. Basically I love to eat so I do not miss meals. I love Jamaican dishes, but I only eat them on special occasions. Since I have been pregnant, my energy level is about half so my exercise regimen has been nonexistent. I am usually very active and exercise at least 3-4 times per week for an hour. The only activity I get is about 30 minutes of chasing my toddler around the park about 3 times per week. I sleep well at night at least 7-8 hours per night and sometimes take an hour nap with my toddler during the day. Even though I was covered under my father’s medical and dental insurance as a child, my parents practice was only go to the doctor when sick. So wellness check-ups was not a part of my practice, but as I got older that changed.Health History Assignment Essay In my adult years I do my yearly check-ups and since I have been pregnant I have had my prenatal care at the obstetrician’s office. | Health goals: | To have a healthy newborn and safe delivery. In addition to lose unwanted weight gained from pregnancy and to restart exercise regimen. | HEALTH BELIEFS AND PRACTICES (15 pts) | | Beliefs and practices: | Maintaining
NR 304 RUA Grading Rubric and Grading Criteria V2.docx 10_16 SMa 4 Revised 11/05/18 EL/css
REQUIRED UNIFORM ASSIGNMENT GUIDELINES
THE HEALTH HISTORY AND PHYSICAL EXAMINATION
PURPOSE
As you learned in NR302, before any nursing plan of care or intervention can be implemented or evaluated, the nurse conducts an assessment, collecting subjective and objective data from an individual. 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 both subjective and objective data, synthesizing the data, and identifying health and wellness priorities for the person. The purpose of the assignment is twofold.Health History Assignment Essay
• To recognize the interrelationships of subjective data (physiological, psychosocial, cultural and spiritual values, and developmental) and objective data (physical examination findings) in planning and implementing nursing care
• To reflect on the interactive process that takes place between the nurse and an individual while conducting a health assessment and a physical examination
COURSE OUTCOMES
CO1: CO1. Explain expected client behaviors while differentiating between normal findings, variations and abnormalities. (PO1)
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) CO5: 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 responsibilities involved in conducting a comprehensive health assessment and providing appropriate documentation. (PO 6, 7)Health History Assignment Essay
DUE DATE Please see the Course Calendar.
TOTAL POINTS POSSIBLE 100 points
PREPARING THE ASSIGNMENT
There are four graded parts to this assignment: (1) Obtain a health history and conduct a physical examination on an individual of your choosing (not a patient), (2) compile a health education needs assessment, (3) self-reflection, and (4) writing style and format.
Instructions for each part follow.
NR 304 RUA Grading Rubric and Grading Criteria V2.docx 10_16 SMa 4 Revised 11/05/18 EL/css
Health History Assessment and Physical Assessment (50 points)
Using the following subjective and objective components, as well as your textbook for explicit details about each category, complete a health history and physical examination on an individual. You may choose to complete portions of this assignment as you obtain the health history and perform the physical examination associated with the body systems covered
NR304. Please be sure to avoid the use of any identifiers in preparing the assignment. Students may seek input from the course instructor on securing an individual for this assignment. Keep notes on each part of the health history and physical examination as you complete them so that you can refer to the notes as you write the paper. 1. Health History Assignment Essay
• Demographic data
• Reason for care (why they are in the facility)
• Present illness (PQRST of current illness)
• Perception of health
• Past medical history (including medications, allergies, and vaccinations and immunizations)
• Family medical history
• Review of systems
• Developmental considerations
• Cultural considerations
• Psychosocial considerations
• Presence or absence of collaborative resources (community, family, groups, and healthcare system)
***REMEMBER: Make notes of the health history findings, ensuring that you have addressed all of the
components listed here. Students are also encouraged to take notes about their experiences while
conducting the health history for reference when creating the assignment, particularly the reflection section.
2. Objective Data—Physical Exam Components to Be Included
During the lab experiences, you will conduct a series of physical exams that includes the following systems.
Keep notes on each part of the physical exam as you complete them to reference as you write the paper.
Refer to the course textbook for detailed components of each system exam. Remember, assessment of the integumentary system is an integral part of the physical exam and should be included throughout each system.Health History Assignment Essay
From NR302
o HEENT (head, eyes, ears, nose, and throat)
o Neck (including thyroid and lymph chains)
o Respiratory system
o Cardiovascular system
From NR304
NR 304 RUA Grading Rubric and Grading Criteria V2.docx 10_16 SMa 4 Revised 11/05/18 EL/css
o Neurological system
o Gastrointestinal system
o Musculoskeletal system
o peripheral vascular system
***REMEMBER: Make notes of the physical examination findings, ensuring that you have addressed all of the
components listed on the Return Demonstration Checklist. Students are also encouraged to take notes
about their experiences while conducting the physical examination for reference when creating the
assignment, particularly the reflection section.
Needs Assessment (20 points)
1. Based on the health history and physical examination findings, determine at least two health education needs for the individual. Remember, you may identify an educational topic that is focused on wellness.
2. Select two peer-reviewed journal articles that provide evidence-based support for the health teaching needs you have identified.
Reflection (20 points)Health History Assignment Essay
Nurses use reflection to, mindfully and intentionally, examine our thought processes, actions, and behaviors in order to better evaluate our patients’ outcomes. You have interviewed an individual, conducted a head-to-toe physical assessment, and identified at least two health teaching needs. You have also located within the literature evidence-based support for the teaching that will be used to address the individual’s health education needs. As you formulate your findings in writing within this assignment, it is time to turn your attention inward. The final element of this assignment is to write a reflection that describes your experience.
1. Be sure your reflection addresses each of the following questions.
a. How did this assignment compare to what you’ve learned and expected?
b. What enablers or barriers to communication did you encounter when performing a health history and physical exam? How could you overcome those barriers?
c. Were there any unanticipated challenges encountered during this assignment? What went well with this assignment?
d. Was there information you wished you had available but did not?
e. How will you alter your approach to a obtaining a health history and conducting a physical examination the next time?
Writing Style and Format (10 points)
Your writing should reflect your synthesis of ideas based on prior knowledge, newly acquired
information, and appropriate writing skills. Scoring of your written communication is based on Health History Assignment Essay
proper use of grammar, spelling, and APA sixth-edition formatting, as well as how clearly your
thoughts and reasoning are expressed in writing.
Documentation of Findings or How to Write the Paper
NR 304 RUA Grading Rubric and Grading Criteria V2.docx 10_16 SMa 4 Revised 11/05/18 EL/css
Using Microsoft Word, create a double-spaced document. The paper should be formatted according to APA sixth-edition guidelines for the title page, running head, and reference page. The use of headings is required for this paper. All portions of this assignment should be included within the paper, including the reflection.
1. Begin by writing one to two paragraphs describing the individual’s stated condition of health medications and allergies. Also, include any of the following information that may be pertinent: demographic data, perception of health, past medical history, vaccinations and immunizations, family medical history, review of systems, developmental considerations, cultural considerations, psychosocial considerations, and the presence or absence of resources from the community, family, groups, or the healthcare system.
2. Write one paragraph describing the physical assessment findings, ensuring proper terminology is used to describe any abnormal or unusual findings.Health History Assignment Essay
3. Write one paragraph discussing (1) the rationale for the selection of the health teaching topics and (2) how the findings in the scholarly articles (identified in the needs assessment portion of the assignment and properly cited) were used to develop the health teaching topics to promote the individual’s health and wellness status.
4. Write one paragraph discussing (1) how the interrelationships of physiological, developmental,
cultural, and psychosocial considerations will influence, assist, or become barriers to the effectiveness of the proposed health education and (2) a description of the impact of the individual’s strengths (personal, family, and friends) and collaborative resources (clinical, community, and health and wellness resources) on the proposed teaching.
5. Write one paragraph describing your reflection of this assignment from a holistic point of view.
Consider the following areas: Include the environment, your approach to the individual, time of day, and other features relevant to therapeutic communication and to the interview process. You may find your textbook helpful in providing a description of therapeutic communication and of the interview process. Be certain to address the questions listed above in the reflection instructions.
NR 304 RUA Grading Rubric and Grading Criteria V2.docx 10_16 SMa 4 Revised 11/05/18 EL/css
Chamberlain College of Nursing NR304 Health Assessment II
DIRECTIONS AND GRADING CRITERIA
Category Points % Description
Health History and Physical Assessment
50 50 Conducts a comprehensive health history and physical exam
1. Subjective data: demographic data; reason for care; present illness; perception of health; past medical history; family medical history; review of systems; developmental considerations; cultural considerations; psychosocial considerations; and collaborative resources.
2. Objective data: HEENT; neurological system, respiratory system, cardiovascular system, neck; gastrointestinal system; musculoskeletal system; and peripheral vascular system.
Provides a written narrative that includes the following
1. One to two paragraphs describing stated condition of health, medications, and allergies. Also includes the following information: demographic data, perception of health, past medical history, vaccinations and immunizations, family medical history, review of systems, any developmental considerations, cultural considerations or psychosocial considerations, presence or absence of resources from the community, family, groups, or from the healthcare system
2. One paragraph describing: the findings of the physical examination
3. One paragraph discussing (1) the rationale for the selection of the health education topics and (2) how the findings in the scholarly articles were used in support of the health teaching topic to promote or improve the individual’s health and wellness status.
4. One paragraph discussing (1) how the interrelationships of
physiological, developmental, cultural, and psychosocial considerations influence (assist or become barriers to the effectiveness) the proposed health education and (2) provide a description of the impact of the individual’s strengths (personal, family, and friends) and collaborative resources (clinical, family, community, and health and wellness resources) on the proposed nursing teaching.Health History Assignment Essay
Needs Assessment
20 20 1. Identifies two health education needs for the individual based on the health history and physical examination findings and two peer- reviewed journal articles providing evidence-based support for the identified health teaching needs
2. APA sixth-edition formatting used for in-text and reference page citations
Chamberlain College of Nursing NR304 Health Assessment II
NR 304 RUA Grading Rubric and Grading Criteria V2.docx 10_16 SMa 5 Revised 11/05/18 EL/css
Reflection 20 20 Reflects on the interaction with the interviewee holistically. Considers the interaction in its entirety: includes the environment, the approach to the individual, time of day, and other features relevant to therapeutic communication and the interview process. The reflection should address each of the following questions.
How did your interaction compare to what you’ve learned and expected?
What enablers or barriers to communication did you experience? How did you overcome the barriers?
Were there any unanticipated challenges to conducting the interview or performing the physical examination? What went well?Health History Assignment Essay
Was there information you wished you had but did not?
How will you alter your approach the next time?
Writing Style and Format
10 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. Proper use of APA sixth-edition style and format throughout this paper is required.Health History Assignment Essay
Total 100 100
NR304 Health Assessment II Chamberlain College of Nursing
NR 304 RUA Grading Rubric and Grading Criteria V2.docx 10_16 SMa Revised 11/05/18 EL/css 4
GRADING RUBRIC
Assignment Criteria
Outstanding or Highest Level of Performance
A (92–100%)
Very Good or High Level of Performance
B (84–91%)
Competent or Satisfactory Level of Performance
C (76–83%)
Poor, Failing or Unsatisfactory Level of Performance
F (0–75%)
Health History and Physical Examination (50 points)
Thoroughly presents a health history narrative that includes a detailed description of all the following components
Demographic data
Reason for care
Present illness
Perception of health
Past medical history
Family medical history
Review of systems Developmental
considerations
Cultural considerations
Psychosocial considerations
Collaborative resources
Thoroughly presents a physical exam narrative that includes a detailed description of all the following components HEENT Neurological system Neck
Respiratory system
One of the key elements of the health history narrative is not presented or lacks sufficient detail.
Demographic data
Reason for care
Present illness
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 physical exam is not presented or lacks sufficient detail. HEENT • Neurological system • Neck • Respiratory system • Cardiovascular system • Health History Assignment Essay Gastrointestinal system
Two of the key elements of the health history narrative are not presented or lack sufficient detail.
Demographic data
Reason for care
Present illness
Perception of health
Past medical history
Family medical history
Review of systems Developmental
considerations
Cultural considerations
Psychosocial considerations
Collaborative resources
Two of the key elements of the physical exam are not presented or lacks sufficient detail. • HEENT • Neurological system • Neck • Respiratory system • Cardiovascular system • Gastrointestinal system • Musculoskeletal system
Three or more of the key elements of the health history narrative are not presented or lack sufficient detail.
Demographic data
Reason for care
Present illness
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 physical exam are not presented or lack sufficient detail.Health History Assignment Essay
HEENT
Neurological system
Neck
Respiratory system
Cardiovascular system
Gastrointestinal system
NR304 Health Assessment II Chamberlain College of Nursing
NR 304 RUA Grading Rubric and Grading Criteria V2.docx 10_16 SMa Revised 11/05/18 EL/css 5
Cardiovascular system
Gastrointestinal system
Musculoskeletal system
Peripheral vascular system
Integumentary system integrated in exam of all systems where appropriate
Information is presented in a clear, organized, and professional manner.
46-50 points
• Musculoskeletal system • Peripheral vascular system • Integumentary system
integrated in exam of all systems where appropriate
Information is presented in a clear, organized, and professional manner.
42-45 points
• Peripheral vascular system • Integumentary system
integrated in exam of all systems where appropriate
Information is not presented in a clear, organized, and professional manner.Health History Assignment Essay
38-41 points
Musculoskeletal system
Peripheral vascular system
Integumentary system integrated in exam of all systems where appropriate
Information is not presented in a clear, organized, and professional manner.
0–37 points
Needs Assessment (20 Points)
Accurately identifies two health education needs for this individual and provides at least three factors that may, positively or negatively, influence the person’s ability to incorporate the health teaching to improve his or her well-being.
References two peer-reviewed journal articles that provide evidence-based support for the health teaching; APA format (most current edition) used to list the sources.
19-20 points
Accurately identifies a health education need for this individual and provides at least two factors that may, positively or negatively, influence the person’s ability to incorporate the health teaching to improve his or her well-being.
References two peer-reviewed journal articles that provide evidence-based support for the health teaching but does not use appropriate APA format (most current edition) to list the sources.Health History Assignment Essay
17-18 points
Accurately identifies a health education need for this individual and provides at least two factors that may, positively or negatively, influence the person’s ability to incorporate the health teaching to improve his or her well-being.
References one peer-reviewed journal articles that provides evidence-based support for the health teaching but does not use appropriate APA format (most current edition) to list the sources.
16 points
Accurately identifies a health education need for this individual and poorly or minimally applies one or more factors that may, positively or negatively, influence the person’s ability to incorporate the health teaching to improve his or her well-being.Health History Assignment Essay
No references are submitted or, if they are used, they have three or more types of errors in APA format (most current edition) to list the sources.
0–15 points
Reflection
(20 Points)
Thoughtfully appraises the individual holistically. Reflection
Thoughtfully appraises the individual holistically. One of the following questions is not
Broadly appraises the individual. Two of the following questions
Broadly appraises the individual. Three or more of the following
NR304 Health Assessment II Chamberlain College of Nursing
NR 304 RUA Grading Rubric and Grading Criteria V2.docx 10_16 SMa Revised 11/05/18 EL/css 6
includes a detailed response to all the following questions.
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 your approach the next time?
Key and relevant information is presented in sufficient detail and is clear and organized.
19-20 points
presented or lacks sufficient detail.
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 your approach the next time?
Key and relevant information is presented in sufficient detail and is clear and organized.
17-18 points
are not presented or lack sufficient detail.
How did your interaction compare to what you’ve learned?
What went well?Health History Assignment Essay
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 your approach the next time?
Key and relevant information is presented in insufficient detail but is clear and organized. 8 Points
questions are not presented or lack sufficient detail.
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 your approach the next time?
Key and relevant information is presented in insufficient detail and is not clear or organized. 0–7 points
Writing Style and Format (10 points)
Student presents information using clear and logical language. Grammar, spelling, and punctuation are free of errors. APA sixth edition was used to guide the style and format of this paper. 10 points
Student presents information using clear and logical language. Grammar, spelling, and punctuation have two or fewer types of errors, or there is no more than one error in APA sixth-edition formatting. Health History Assignment Essay
