Health History Report Document Help

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:

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 (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. 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)

· 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 (40 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?

· 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 (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.