Health assignment

I have to create a fake patient and do an assessment on it

Needs to be APA format with resources

5-6 pages

requirement & example is down below

HEALTH HISTORY

DO NOT ALTER THIS FORM

Patient must be 35 years or older

Must follow HIPPA guidelines

Interview must be completed in person

BIOGRAPHIC DATA (2 points)

Name (Initials): Age: Gender: Marital Status:

Date of Birth: Birthplace:

Address (City/State only)

Race:

Religion/Culture: None is NOT an answer!

Occupation:

Insurance Coverage: Only need to know if they have health insurance – do not need policy name or number

Source of Information AND Reliability: ex: Patient and appears to be reliable

PRESENT HEALTH OR ILLNESS

Reason for Seeking Care: (“In quotes”) (2 points)

“I am helping (insert your name here) with their school project”

Present Health: (chronological account of
one
priority health issue) (3 points)

(This section will be how you address the ANALYSIS OF DATA on page 6)

Do this section last!

Chronological account – give a thorough history (like an OLDCART)

PAST HISTORY (10 points)

Childhood Diseases (age; measles, mumps, rubella, chickenpox, pertussis, strep throat, rheumatic fever, scarlet fever, poliomyelitis)

Ex: Measles early childhood (or their age, if they remember)

Denies all other diseases listed

Immunization Dates (influenza, pneumococcal, shingles; date of last tetanus; and date and results of last TB test)

If patient cannot recall the date, they can just provide an approximate date/age. For example: Patient states that they received their TB test within the last 5 years but cannot recall the exact date. Patient states that it was negative.

Accidents or Injuries (year; auto accidents, fractures, penetrating wounds, head trauma-especially if associated with unconsciousness, burns; complications)

Serious or Chronic Illnesses (asthma, depression, diabetes, hypertension, heart disease, HIV infection, hepatitis, sickle-cell anemia, cancer, seizure disorder;
year of diagnosis)

Hospitalizations (year; cause, name of hospital, doctor, how the condition was treated, how long the person recovered)

Surgeries (year; type of surgery, date, name of surgeon, name of hospital, how person recovered)

If Surgery required an overnight stay in the hospital, then copy this in the hospital section as well. If the surgery was done as an outpatient procedure, then state that here only.

Last Examination Date (physical, dental, vision, hearing, ECG, chest x-ray, mammogram, colonoscopy, serum cholesterol)

Allergies (allergan and reaction)

(This can be food, medication and/or seasonal allergies)

Current Medications (prescription and OTC;
name, dose, schedule)

FAMILY HISTORY (coronary artery disease, high blood pressure, stroke, diabetes, obesity, blood disorders, breast/ovarian cancer, colon cancer, sickle-cell anemia, arthritis, allergies, alcohol or drug addiction, mental illness, suicide, seizure disorder, kidney disease, TB) (6 points)

List all family members here, along with whatever diseases they have. Then state that they deny all other diseases listed (for those diseases not in the family history).

This information should be what you transfer onto your Genogram.

Mother; HTN

Father DM

Paternal GPa COD: stroke; history of CAD

Denies all other diseases listed.

Genogram (3 generations to include parents and grandparents) – May complete on a separate page

REVIEW OF SYSTEMS (30 points)

Instructions: Highlight the symptom if present, then complete analysis for each symptom using OLDCART: (O = Onset, L = Location, D = Duration, C = Characteristics, A = Aggravating Factors, R = Relieving Factors, T = Treatment). EACH SYSTEM MUST BE ADDRESSED.

General Overall Health Status: Weight gain or loss, fatigue weakness or malaise, fever, chills, sweats or night sweats.

Example:

Skin: History of skin disease (eczema, psoriasis, hives), pigment or color change, change in a mole, excessive dryness or moisture, pruritus, excessive bruising, rash, or lesion.

Patient has noticed a recent change in a mole, but denies all other diseases listed:

O: Started 3 weeks ago

L: on their right shoulder

D: It has been consistently growing larger, with occasional bleeding.

C: Experiences tenderness when applying any pressure to the site.

A: Nothing that appears to aggravate this condition

R: Nothing appears to relieve this condition.

T: Has not used any medications on this site.

Health Promotion:
Amount of sun exposure; method of self-care for skin.

Patient states that they get an average of 8-10 hours in the sun during the Summer, during life-guarding season. Patient states that they apply sunscreen at the beginning of the day but will occasionally not take time to re-apply sunscreen later in the day. Patient states that they shower once/day and applies lotion after bathing.

Hair: Recent loss, change in texture.
Nails: change in shape, color, or brittleness.

Health Promotion:

Method of self-care for hair and nails.

Head: Any unusual frequent or severe headache, any head injury, dizziness (syncope) or vertigo.

Eyes: Difficulty with vision (decreased acuity, blurring, blind spots), eye pain, diplopia (double vision), redness or swelling, watering or discharge, glaucoma or cataracts.

Health Promotion:

Wears glasses or contacts; last vision check or glaucoma test; and how coping with loss of vision if any.

Ears: Earaches, infections, discharge and its characteristics, tinnitus or vertigo.

Health Promotion:

Hearing loss, hearing aid use, how loss affects the daily life, any exposure to environmental noise, and method of cleaning ears.

Nose and Sinuses: Discharge and its characteristics, any unusually frequent or severe colds, sinus pain, nasal obstruction, nosebleeds, allergies or hay fever, or change in sense of smell.

Mouth and Throat: Mouth pain, frequent sore throat, bleeding gums, toothache, lesion in mouth or tongue, dysphagia, hoarseness or voice change, tonsillectomy, altered taste.

Health Promotion:

Pattern of daily dental care, use of dentures, bridge, and last dental checkup.

Neck: Pain, limitation of motion, lumps or swelling, enlarged or tender nodes, goiter.

Respiratory System: History of lung diseases (asthma, emphysema, bronchitis, pneumonia, tuberculosis), chest pain with breathing, wheezing or noisy breathing, shortness of breath, how much activity produces shortness of breath, cough, sputum (color, amount), hemoptysis, toxin or pollution exposure.

Health Promotion:

Last chest x-ray study, TB skin test.

Cardiovascular System: Precordial or retrosternal pain, palpitation, cyanosis, dyspnea on exertion (specify amount of exertion [e.g., walking one flight of stairs, walking from chair to bath, or just talking]), orthopnea, paroxysmal nocturnal dyspnea, nocturia, edema, history of heart murmur, hypertension, coronary artery disease, anemia.

Health Promotion:

Date of last ECG or other heart tests, cholesterol screening.

Hematologic System: Bleeding tendency of skin or mucous membranes, excessive bruising, lymph node swelling.

Endocrine System: history of thyroid disease, intolerance to heat and cold, change in skin pigmentation or texture, excessive sweating, relationship between appetite and weight, diabetes, abnormal hair distribution.

FUNCTIONAL ASSESSMENT (Including Activities of Daily Living) (15 points)

Self-Esteem/Self-Concept: Education (last grade completed, other significant training),
financial status (income adequate for lifestyle and/or health concerns),
value-belief system (religious practices and perception of personal strengths).

Activity/Exercise: Note
ability to perform ADLs: independent or needs assistance with feeding, bathing, hygiene, dressing, toileting, bed-to-chair transfer, walking, standing, or climbing stairs. Any use of wheelchair, prostheses, or mobility aids?

Record leisure activities enjoyed and the exercise pattern (type, amount per day or week, method of warm-up session, method of monitoring the body’s response to exercise).

Sleep/Rest: Sleep patterns, daytime naps, any sleep aids used.

Interpersonal Relationships/Resources: Social roles: “How would you say you get along with family, friends, and co-workers?”

Spiritual Resources:
Faith

: “Does religious faith or spirituality play an important part in your life?
Yes/No Do you consider yourself to be a religious or spiritual person?”
Yes/No

Influence

: “How does your religious faith or spirituality influence the way you think about your health or the way you care for yourself?”
Their answer here.

Community

: “Are you a part of any religious or spiritual community or congregation?”
Yes/No
Address

: “Would you like me to address any religious or spiritual issues or concerns with you?”
Their answer here.

Coping and Stress Management: Kinds of stresses if life, especially in the past year, any change in lifestyle or any current stress, methods tried to relieve stress, and whether these have been helpful.

Personal Habits: Tobacco, “Do you smoke cigarettes (pipe, use chewing tobacco)?” “At what age did you start?” “How many packs do you smoke per day?” “How many years have you smoked?” Record the number of packs smoked per day (PPD) and duration (e.g., 1 PPD x 5 years). Then ask, “Have you ever tried to quit?” and “How did it go?” to introduce plans about smoking cessation.

Alcohol: Ask whether the person drinks alcohol. If yes, ask specific questions about the amount and frequency of alcohol use: “When was your last drink of alcohol?” “How much did you drink that time?” “Out of the past 30 days, about how many days would you say that you drank alcohol?” “Has anyone ever said you had a drinking problem?”
If the person answers “no” to drinking alcohol, ask the reason for his decision (psychosocial, legal, health). Any history of alcohol treatment? Involvement in recovery activities? History of family member with problem drinking?

Illicit or Street Drugs: Ask specifically about marijuana, cocaine, crack cocaine, amphetamines, heroin, pain killers like OxyContin or Vicodin, and barbiturates. Indicate frequency of use and how usage has affected work or family.

Environment/Occupational Hazards: Housing and neighborhood (living alone, knowledge of neighbors), safety of area, adequate heat and utilities, access to transportation, and involvement in community services. Note environmental health, including hazards in workplace (asbestos, inhalants, chemicals, or repetitive motion). Wear any protective equipment? Aware of any health problems now that may be related to work exposure? Geographic exposures including travel or residence in other countries, including time spent abroad during military service.

ANALYSIS OF DATA (8 points)

Review the collected subjective data and identify the PRIORTY body system for the client and state the rationale for selecting the system.

This section is directly related to you identified priority health issue that you identified on page 1 (Present Health: (chronological account of one priority health issue))

· Priority System:

· Rationale for Selecting this System:

List two (2) Teaching/Learning needs related to the PRIORITY system listed above.

REFLECTION (20 points and 4 points for APA) –
Separate Document (2-3 pages, APA format – 7th edition – please refer to your resources for additional APA guidelines.)

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:

Address these in the order that they are written here – you can use a paragraph (or more) for each of these questions in your paper.

REMEMBER TO MAINTAIN HIPPA

· How did you prepare yourself and the patient for the interview?

· Describe the environment in which the interview took place.

· Describe the therapeutic communication techniques utilized during the interview.

· 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?

· What went well?

· Was there information you wished you had obtained?

· How will you alter your approach next time?

Include a reference page with textbook citation.

1
Running head: HEALTH HISTORY

Health History

Samantha Candela

Chamberlain College of Nursing

NR 302: Health Assessment

2/12/2016

Professor Moersch

This study source was downloaded by 100000792604172 from CourseHero.com on 09-27-2022 14:53:34 GMT -05:00

https://www.coursehero.com/file/15013831/NR-302-RUA/

2
HEALTH HISTORY

Health History Assessment

I choose to do a health assessment on a family friend. I will use AH has her initials.

Demographic Data

AH is 63 years old, a female, Caucasian, and lives in a house. She lives in a rural area

where she lives alone but has family close by.

Perception of Health

To her healthy means being in good health, getting regular exercise, and eating nutritious

food. Unhealthy to her means not being in good health, overweight, and eating bad foods. She

feels like she is between healthy and unhealthy. She is not in the best health, exercises once a

week, and eats good most of the time. She would like to increase her health and the amount of

exercise she gets.

Past Medical History

Her past medical history includes degenerative disc disease, high blood pressure,

hyperlipemia, depression, anxiety, COPD, asthma, emphysema, diverticulitis, and osteoporosis.

Her past surgical history includes neck and back surgery, removal of gallbladder, removal of

cataract, and hysterectomy. The medications she takes daily include a Spiriva inhaler, allegra,

valium, Zoloft, gabapentin, Lopressor, and protonix.

Family Medical History

Both of her parents had high blood pressure, which lead to her high blood pressure. Her

mother had asthma, which increased her chance of having it. Her father had lung cancer from

smoking cigarettes. Her mother was anemic and had to have a lot of blood transfusions.

Review of Systems

This study source was downloaded by 100000792604172 from CourseHero.com on 09-27-2022 14:53:34 GMT -05:00

https://www.coursehero.com/file/15013831/NR-302-RUA/

3
HEALTH HISTORY

The only skin issue that she has is eczema. Her hair has some grey in it and her nails are

fine. She doesn’t have any headaches, head injury, or dizziness. She has some pain in her neck

when she turns her head to the right. She doesn’t have any lymphatic issues. She has decreased

vision and had some cataracts. She wears eyeglasses and had cataract removal surgery in June

2015. She doesn’t have any earaches or infections and her hearing is good. She has allergies to

pollen and dust but no other major sinus issue. Her mouth and throat look good, no mouth pain,

sore throat, toothaches, or lesions. She has asthma and emphysema, which causes her to have

shortness of breath. Even with her breathing problems she can still take care of herself, cook, and

clean. Her only heart related use is high blood pressure and she controls that with medication and

controls her salt intake.

Developmental Considerations

She has had asthma since she was a little girl and this has caused her some issues

growing up. She couldn’t play sports and play with friends for long because she would start

having trouble breathing. She did not have many friends growing up and had trouble with

weight; she always thought that her asthma caused this.

Cultural Considerations

Growing up she was always interested in going to church but her family wasn’t very

religious. She always wanted to study her bible and her father would always have mean

comments to say to her. This made it hard for her to go to church and be able to have a religious

connection.

Psychosocial Considerations

She lost her husband almost a year ago and has had trouble with wanting to be social. She

doesn’t like to attend social events because that was something her and her husband always used

This study source was downloaded by 100000792604172 from CourseHero.com on 09-27-2022 14:53:34 GMT -05:00

https://www.coursehero.com/file/15013831/NR-302-RUA/

4
HEALTH HISTORY

to do together. Her children are great about coming to visit her. At least one of them comes by

daily and they have a weekly family night.

Collaborative Resources

Her family helps her by visiting everyday and going to any doctor appointments with her.

She has a group of friends that go to church every Sunday together then go to lunch afterward.

Her neighbor and her get together a few days of the week and walk to get exercise.

Reflection

This interaction helped me to practice some of the skills I learned in health assessment.

We were able to talk about her medical history well since I know a lot of the medical terms and

she also does because of how much she has had to be at hospitals. During the review of systems

she had trouble understanding some of the questions I asked but we overcame it by me

explaining each subject. I now realized I should have asked her more about any cultural issues.

This study source was downloaded by 100000792604172 from CourseHero.com on 09-27-2022 14:53:34 GMT -05:00

https://www.coursehero.com/file/15013831/NR-302-RUA/

5
HEALTH HISTORY

References

American Psychological Association. (2010). Publication manual of the American Psychological

Association (6th ed.). Washington, DC: Author.

Jarvis, C., Tarlier, D., Pelt, L. V., Andrews, M. E., & Jarvis, C. (n.d.). Physical examination and

health assessment (7th ed.).

This study source was downloaded by 100000792604172 from CourseHero.com on 09-27-2022 14:53:34 GMT -05:00

https://www.coursehero.com/file/15013831/NR-302-RUA/
Powered by TCPDF (www.tcpdf.org)

https://www.coursehero.com/file/15013831/NR-302-RUA/

http://www.tcpdf.org

NR302 Health Assessment I
RUA: Health History Guidelines

NR302_Health_History_Guidelines_V7 Revised:Mar/22 1

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 1: Explain expected client behaviors while differentiating between normal findings variations, and abnormalities. (PO

1)
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)
CO 5: 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 responsibility involved in conducting a comprehensive health assessment and providing

appropriate documentation. (POs 6 & 7)

Due date: Your faculty member will inform you when this assignment is due. The Late Assignment Policy applies to
this assignment.

Total points possible: 100 points

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.
a. 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.

b. Inform the individual that information obtained will be kept confidential and do not use identifying information
within the assignment.

c. There are three parts to this assignment.
2. Include the following sections when completing the assignment

a. Health History Assessment (50 points/50%)
1) Demographics
2) Perception of Health

NR302 Health Assessment I
RUA: Health History Guidelines

NR302_Health_History_Guidelines_V7 Revised:Mar/22 2

3) Past Medical History
4) Family Medical History
5) Review of Systems
6) Developmental Considerations- use Erikson’s Stages of Psychosocial Development- which stage is your

participant at and give examples of if they have met or not met the milestones for that stage.
7) Cultural Considerations- definition, cultural traditions, cultural viewpoints on healing/healers, traditional and

complementary medicine, these are examples but please add more
8) Psychosocial Considerations- support systems-family, religious, occupational, community these are examples

but please add more
9) Resources to Improve Health- give examples of resources available to improve the health of the participant

such as community, nutritional recommendations, healthcare, spiritual, etc.
b. Reflection (40 points/40%)

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.

a) Describes 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?

a) How did you overcome them?
b) 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?

3. Style and Organization (10 Points/10%)
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.

For writing assistance, visit the Writing Center.
Please note that your instructor may provide you with additional assessments in any form to determine that you fully
understand the concepts learned in the review module.

NR302 Health Assessment I
RUA: Health History Guidelines

NR302_Health_History_Guidelines_V7 Revised:MAR/2

Grading Rubric
Criteria are met when the student’s application of knowledge within the paper demonstrates achievement of the outcomes for this assignment.

Assignment Section and
Required Criteria

(Points possible/% of total points available)

Highest Level of
Performance

High Level of
Performance

Satisfactory
Level of

Performance

Unsatisfactory
Level of

Performance

Section not
present in

paper

Health History Assessment
(70 points/70%)

70 points 66 points 52 points 35 points 0 points

Required criteria
1. Demographics
2. Perception of Health
3. Past Medical History
4. Family Medical History
5. Review of Systems
6. Developmental Considerations
7. Cultural Considerations
8. Psychosocial Considerations
9. Collaborative Resources

Includes 9
requirements for
section.

Includes 7-8
requirements for
section.

Includes 5-6
requirements
for section.

Includes 1-5
requirements for
section.

No requirements
for this section
presented.

Reflection
(20 points/20%)

20 points 18 points 16 points 10 points 0 points

Required criteria
1. Reflect on your interaction with the

interviewee holistically.
a) Describes 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?
a) How did you overcome them?

Includes 7
requirements for
section.

6 requirements
for section.

Includes 5
requirements for
section.

Includes 1-4
requirements for
section.

No requirements
for this section
presented.

NR302 Health Assessment I
RUA: Health History Guidelines

NR302_Health_History_Guidelines_V7 Revised:MAR/2

Assignment Section and
Required Criteria

(Points possible/% of total points available)

Highest Level of
Performance

High Level of
Performance

Satisfactory
Level of

Performance

Unsatisfactory
Level of

Performance

Section not
present in

paper

b) 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?

Style and Organization
(10 points/10%)

10 points 8 points 4 points 0 points

Required criteria
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.

Includes no fewer than 3 requirements
for section.

Includes no fewer
than 2
requirements for
section.

Includes 1
requirements for
section.

No requirements
for this section
presented.

Total Points Possible = 100 points

Purpose
Preparing the assignment

Company

Terms

We Accept