HEALTH ASSESSMENT RUA PAPERE

ChamberlainCollege of Nursing NR302 Health Assessment I

Health History Worksheet

This worksheet is used to assist the student in gathering and organizing information when conducting a health history.

Birthdate:

Death date:

Occupation:

Education:

Primary language:

Health summary:

Birthdate:

Death date:

Occupation:

Education:

Primary language:

Health summary:

Birthdate:

Death date:

Occupation:

Education:

Primary language:

Health summary:

Birthdate:

Death date:

Occupation:

Education:

Primary language:

Health summary:

Birthdate:

Death date:

Occupation:

Education:

Primary language:

Health summary:

Birthdate:

Death date:

Occupation:

Education:

Primary language:

Health summary:

Birthdate:

Death date:

Occupation:

Education:

Primary language:

Health summary:

Birthdate:

Death date:

Occupation:

Education:

Primary language:

Health summary:

Birthdate:

Death date:

Occupation:

Education:

Primary language:

Health summary:

Birthdate:

Death date:

Occupation:

Education:

Primary language:

Health summary:

Birthdate:

Death date:

Occupation:

Education:

Primary language:

Health summary:

Family Member

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Paternal grandfather First and last initials:

Birthdate:

Death date:

Occupation:

Education:

Primary language:

Health summary:

Paternal grandmother First and last initials:

Father First and last initials:

Father’s siblings- Summary of any significant health issues

Maternal grandfather First and last initials:

Maternal grandmother First and last initials:

Mother First and last initials:

Mother’s siblings- Summary of any significant health issues

Adult Participant First and last initials:

Adult participant’s siblings Summary of any significant health issues

Adult participant’s spouse/significant other First and last initials:

Adult participant’s children- Up to 4 children

Child # 1 first and last initials:

Child #2 first and last initials:

Child #3 first and last initials:

Child #4 first and last initials:

An example

Birthdate:

Death date:

Occupation:

Education:

Primary language:

English

Health summary:

Family Member	Description
Paternal grandfather First and last initials:	RL
	Birthdate:	1921
	Death date:	1981
	Occupation:	Retired as a coal miner
	Education:	6th grade
	Primary language:		English
	Health summary:	He was diagnosed with chronic lung disease, diabetes, and hypertension. He died from a heart attack.
Paternal grandmother First and last initials:	ML
1932
1998
House wife
Does not want to disclose
Diagnosed with chronic lung disease from smoking cigarettes. Died from heart failure.

This example points to common problems among this generation on both sides of the Adult Participant’s family. Consider the potential implications this would have for the Adult Participant’s health status.

NR302_Health_History_Worksheet April 2014

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NR302Health Assessment I

RUA: Health History Guidelines

NR302_RUA_Health_History_Guidelines_V5_Final 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 and 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 and 5)
CO 7: Explore the professional responsibility involved in conducting a comprehensive health assessment and providing

appropriate documentation. (POs 6 and 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. 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).

d. The use of this tool is optional. There are three parts to this assignment.
2. Include the following sections when completing the assignment.

a. Health History Assessment (70 points/70%)
1) Demographics
2) Perception of Health

NR302 Health Assessment I
RUA: Health History Guidelines

NR302_RUA_Health_History_Guidelines_V5_Final 2

3) Past Medical History
4) Family Medical History
5) Review of Systems
6) Developmental Considerations
7) Cultural Considerations
8) Psychosocial Considerations
9) Collaborative Resources

b. 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.

a) 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?

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?

c. 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 (APA, formatting, or grammar), visit the APA Citation and Writing page in the online library.

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.

https://library.chamberlain.edu/APA

NR302 Health Assessment I
RUA: Health History Guidelines

NR302_RUA_Health_History_Guidelines_V5_Final 3

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 1-4
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) 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?

a) How did you overcome them?

Includes 7
requirements for
section.

Includes 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_RUA_Health_History_Guidelines_V5_Final 4

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
requirement for
section.

No requirements
for this section
presented.

Total Points Possible = 100 points

Purpose
Preparing the assignment

2

NR302

Required Health History Assessment – 100 points

Student Name:

1. Biographical Data

Name: Osamudiamen Imuentiyan

Address: 2242 CHICAGO, IL

Phone: 773-*****4 Gender: MALE

Birth Date: 04/19/1992 Birthplace: NIGERIA

Age: 29

Marital Status: SINGLE

Occupation: STYLIST Religion: CHRISTIANITY

Race/Ethnic origin: AFRICAN AMERICAN Employer: SELF EMPLOYED

Source and Reliability: Information obtained from the patient; Subjective data collected, the most reliable information that can be obtained

Reason for seeking care: Patient sought care to aid in the Health History Assessment assignment

Present Health or History of Present Illness (HPI): The patient is currently 29 years old, presenting with no current illness. The patient verbalizes that he believes he is in good health

Perception of Own Health: To the patient, he is in good health. The patient states that he goes to the gym regularly, (2-3 times/week) and tries to eat healthily but enjoys fast food. The patient also admits to smoking occasionally but claims that it aids in his anxiety and depression

Past Health:

Childhood illness: Patient denies any childhood illnesses

Serious/Chronic illness: Patient denies any serious/chronic illnesses

Accident/Injuries: Patient reports having suffered from a lesion on the left lateral calf from a piece of glass while taking out the garbage

Hospitalizations: Patient reports being hospitalized for depression and anxiety

Operations: Patient denies any operations performed

Obstetric History: N/A G: 0 T: 0 P: 0 A: 0 L: 0

The course of pregnancy: N/A

Immunizations: Patient reports vaccinations for pertussis, MMR, HepA, HepB, Tetanus, Diphtheria, ProQuad, Polio, and Influenza

Last examination date: Patient said he could not recall but it has been a little over 1 year to date

Allergies: Patient denies any known allergies (NKA/NKDA)

Reaction: N/A Any treatment: N/A

Current Medications: Patient reports taking Venlafaxine and Clonazepam

Family History

Heart Disease: Present in paternal grandmother, states that brother has a heart murmur

Stroke- None to the patient’s knowledge

Sickle cell: None to the patient’s knowledge

Diabetes: Father has Type II diabetes

Blood Disorder: Sister has iron-deficient anemia

Breast/Ovarian Cancer: Patient states that he thinks that his paternal great grandmother passed away from breast cancer; ultimately unsure; Patient denies knowing of any cancer in the family

Cancer (other) – Lung Cancer: Paternal grandfather passed away from lung cancer; skin Cancer – Father had the skin removed from the nose that presented with melanomas

Allergies- Mother allergic to pollen, damp, and dust (patient states mother developed allergies after being pregnant), Maternal grandmother allergic to pollen, Maternal grandfather allergic to cats (pet dander)

Arthritis: Patient states that his mother presented with arthritis

General Overall Health State:

Height Weight BMI

5ft 7inches. 65. 22.4

Skin: Patient denies history of rash, eczema, psoriasis, hives, lesion, and so on

Hair: Patient denies any history of recent hair loss, change in texture and brittleness

Nails: Patient denies a history of change in nail’s texture, shape, and color that suggest any infection

Head: The patient denies a history of unusually frequent or severe headache, injury, dizziness (syncope), or vertigo.

Eyes: The patient denies a history of vision impairment or has a history of eye pain rather, redness or swelling, watering or discharge, glaucoma, or cataracts. However, patients claimed that there is a history of cataracts and astigmatism in his family (mother had cataracts and astigmatism)

Ears: Patient denies a history of earaches, infections, discharge, and its characteristics, he also denies having tinnitus or vertigo in the past

Nose and Sinuses: The patient agreed to a history of being allergic to cold and that he often comes up with flu-like symptoms, such as sinus pain, severe cold, nasal obstruction, and sometimes nosebleeds during the winter season.

Mouth and Throat: The patient denies frequent sore throat, having a toothache, and mouth lesion. The patient denies dysphagia. The patient denies tonsillectomy, the patient denies alteration in taste. The patient agrees to have bleeding gum during the fall and winter season

Breast: The patient denies any tenderness in the breast, patient denies the presence of any lumps, patient denies any sign of nipple discharges, patient denies rashes, patient reports no history of breast disease or any form of surgical procedure on the breast

Respiratory System: The patient denies any history of respiratory diseases such as asthma, emphysema, bronchitis, TB, chest pain with breathing, noisy breathing, shortness of breath. The patient agrees to have a cough during the fall and winter season. Patient denies any release of sputum, Patient denies hemoptysis, the patient also denies any known exposure to toxins or excessive pollution, ‘Except for living in the fine city of Chicago” When asked how much activity predisposes the patient to shortness of breath, the patient stated he works out so often, only a vigorous physical activity would cause him shortness of breath.

Cardiovascular System: The patient denies a history of cardiac diseases such as chest pain, palpitation, hypertension, coronary heart disease, and anemia. The patient also denies tightness/fullness in the chest, the patient denies dyspnea on exertion. The patient denies paroxysmal nocturnal dyspnea, the patient denies cyanosis, the patient denies any edema, the patient denies orthopnea, the patient denies nocturia. The patient denies any history of a heart murmur. Patient denies anemia

Peripheral Vascular System: The patient denies a sense of coldness, numbness, and tingling, swelling of legs, varicose veins, or complications that may arise from it, discoloration in hands or feet, intermittent claudication, thrombophlebitis, ulcers.

Gastrointestinal System: Patient states he has a very huge appetite as a result of his active lifestyle. Patient report up to 1to 3 bowel movement daily; moderately soft stools present. The patient denies any noticeably recent changes in stool constituency (black tarry stool or melena). The patient denies any unusual flatulence. The patient reported that he is lactose intolerant. The patient denies ingestion. The patient agrees to be nauseated sometimes but denies pain in association with eating. The patient denies a history of abdominal diseases such as liver or gallbladder, ulcer, jaundice, appendicitis, colitis, and rectal condition such as hemorrhoids and fistula.

Urinary System: Patient states frequency of urination is about 1-4 times daily, patient states nocturia to be rare, patient denies dysuria, polyuria, or oliguria. The patient denies urinary urgency, the patient denies straining. The patient denies incontinence, the patient state no history of urinary tract infections, renal diseases, patient denies having pain in the flank, groin, suprapubic region, or lower back.

Genital System: The patient denies any abnormal discharge, the patient denies any knowledge of contracting sexually transmitted diseases, the patient denies any scrotal or testicular pain, the patient denies any genital ulcers. Patient denies any erectile dysfunction

Sexual Health: Patient reports that he is single but uses condoms regularly, patient denies any knowledge of contact with a partner with any STIs

Musculoskeletal System: The patient denies a history of arthritis/gout, the patient denies the presence of any deformity, patient denies any limitation of motion, patient denies any pain, stiffness, or inflamed joints, patient denies any noise associated with joint motion. The patient report muscle pain associated with high levels of exercise “Often after my rigorous and strenuous physical activities” the Patient denies any gait problems/problems with coordinated activities. The patient denies any cramps, the patient denies weakness in muscles, the patient denies any history of back pain or disk disease. Patient denies stiffness in back or limitation in back motion,

Neurologic System: The patient denies any history of seizure or neurological disorders. The patient denies a history of stroke, fainting, or blackouts, patient denies any tremor, patient denies coordination problems, patient denies any weakness in motor function, paralysis, numbness/tingling associated with sensory function, patient confirms having unproved nervousness and patient confirmed it all started a few years ago, stating “It’s a fair part of my anxiety” I am learning to manage it through meditation” Patient confirms having mood swing occasionally. The patient confirms depression and a history of mental health including anxiety disorder and denies having hallucinations.

Hematologic System: The patient denies excessive bruising, the patient denies lymph node swelling, the patient states no abnormal bleeding tendency of skin/mucous membranes, the patient denies exposure to toxic agents/radiation. Patient denies any history of blood transfusion

Endocrine System: Patient denies a history of thyroid disease, patient denies history of diabetes symptoms (such as polyuria, polydipsia, or polyphagia), patient denies change in skin pigmentation or texture, patient denies any intolerance to heat and cold, patient denies diaphoresis, patient denies unevenly hair distribution, Patient confirms nervousness, patient denies tremors or any hormonal imbalances that require therapy.

Developmental considerations: patient denies having developmental disorders/abnormalities. Patient states, “My anxiety used to make school difficult, and my medications make me feel drowsy at times”

Cultural considerations: The patient refers to himself as a “Typical African Man” embodying many cultures. Patient states he prefers local African dish and delicacies

Psychosocial considerations: Patient states that anxiety and depression have made it difficult to socialize sometimes, but that he is generally ongoing

Collaborative resources that could be recommended for any teaching/learning needs the client may have (Consider the client’s age as well as any cultural, lifespan, or psychosocial concerns. Think about Community, Family, Groups, and/or Health Care System resources)

Health promotion techniques that will promote emotional/mental health- since the patient states he often has anxiety and loves being alone.

Health promotion for constant screening and checkups

Health promotion for eyes: make sure of yearly vision check-ups and eyes are revaluated.

Health promotion for lifestyle changes related to smoking and diet

Community events would be a great way to utilize resources to achieve the patient’s health promotion goals. Communities can hold health functions or free testing for certain health concerns like blood pressure, diabetic checks, and physical examinations. The patient could attend therapy sessions held by the community collaborating with local nurses and health professionals.

REFLECTION – 40 points

My patient and I had a spectacular interactive session outside the church premises after Sunday service. The interactive session with my patient was quite detailed and it highly important to inform the patient beforehand, that this physical assessment is going to be very detailed and will not perform it when the patient is distracted. The interview was kind of challenging because it took me a long time to convince the patient to be as free as possible when expressing himself. The interview was successful as the patient became super relax and free when questions about the review of systems were asked, as the patient gave clear and concise responses in this capacity, which may not have been the case in a real-life scenario. One of the reasons I believed the interview was successful is because I utilized therapeutic communication tools which entail, maintaining eye contact, actively listening to the patient, focusing, summarizing, paraphrasing, the use of open and close-ended questions as at when necessary and whatnot. I also made sure to any barriers to communication, however, I couldn’t completely eradicate it from the patient’s angle, as friends and family came in and intercepted the exercise on a few occasions. I was able to overcome by asking a couple of questions where the patient had to adopt the data and judiciously have a rethink regarding answers given., free from distraction, and duress. Subsequently, if given another opportunity to interview a patient, a quite and a more secluded environment would be highly beneficial or better. The unpredictable contest was having the patient answer questions like a non-medical practitioner that kind of amazed me since the client was a healthcare practitioner I thought otherwise. I wish I was more detailed when asking “OLD CARTS” about each constructive item on the review of the system, however, this information is subjective to every single point the patient can remember. The fact that the patient is a close family friend that I already have established a relationship with, creating a rapport wasn’t necessary. The basic tip for collecting data is getting your patient to trust and have confidence in you, that will prompt him/her to give accurate responses to your question, the other tip is that the patient being interviewed mustn’t be hurried or subjected to undue pressure in the course of the interview process. Subsequently, my next approach will be interviewing someone that is not familiar with me in other for me to understand clearly how to build a nurse to patient relationship.