NUR500 Health Assessment Assignment

NUR500 Health Assessment Assignment

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NUR500 Health Assessment

Health History and Physical Examination Write-up with Evidence Based Practice guidelines

Purpose: Nursing professionals need to have comprehensive in-depth assessment skills. Assessment provides health care providers (NP, MD, DO, PA) an in-depth look into an individual’s physiologic condition. Interview skills are imperative to eliciting information that will lead the provider to a complete holistic assessment, accurate diagnosis and effective treatment plan.

Directions: Each student will be completing a health history write-up in this course. Most of the content will be obtained during the lab portion of your class. The student will perform this assessment on their assigned partner in lab to assess. Students must include at least 2 screening tools discussed. After the health history is complete, students will identify and formulate 2 medical diagnoses with a plan of care ( 3 interventions) that are based on evidence.

NUR500 Health Assessment

Deliverables for this assignment include:

1. Health history write up
2. Complete comprehensive physical examination
3. 2 screening tools used/results- and plan
4. 2 Medical diagnoses with 3 evidence based interventions for each.
5. Preventative care measures (3)
6. Reference list for evidence based recommendation
7. APA style throughout paper when appropriate

Please review the rubric to ensure you are meeting the criteria for the paper.

Use your textbooks to guide your health history interview and PE write up. Components of the Complete Health History should include:

1. Biographical/demographic Data

Name:

Address:

Sex:

Age:                                       Birth date:

Marital Status:

Number of children and ages:

Current Occupation:

Religion/practice and attitude toward religion:

Race:

Ethnic origin

Level of Education/ability to read and write:

Health insurance plan:

Advanced directives: Yes/No. Need information?

Health history informant and reliability:

2. Chief Complaint:

NUR500 Health Assessment

Signs and symptoms that led patient to seek health care:

3. History of Present Illness: (use the patient’s words, subjective data, brief)

Precipitating/Palliative Factors:

Quality/Quantity

Region/Radiation/Related Symptoms:

Severity:

Timing:

Pain rating and scale used:

Effect on ADLs and other life areas:

4. Past Medical History

Childhood Illnesses: Mumps, Chickenpox, rubella, frequent ear infections, frequent streptococcal infections or sore throats, rheumatic fever, scarlet fever, pertussis, asthma

Chronic illnesses: heart disease, hypertension, diabetes, cancer, seizures

NUR500 Health Assessment

Medications: prescription, over-the-counter, and herbals

Immunizations: smallpox, measles, mumps, rubella, chickenpox, hepatitis B, diphtheria, tetanus, polio, Haemophilus influenza B (BHIB), pneumococcal vaccine, flu shot, swine flu shot, PPD, BCG

Allergies: yes/no. Type:   Response:

Food/Latex/Medication

Past Illnesses

Past surgical history: Type? When? Difficulties?

Previous Hospitalizations: When and why?

Blood transfusions:

Trauma or other serious injuries:

Recent Travel:

Military Service

5. Family History:

NUR500 Health Assessment

Pertinent specific illness in family: hypertension, strokes, ulcers, mental illness, alcoholism, epilepsy, gout, bleeding disorders, diabetes, heart disease, cancer, arthritis, ulcerative colitis.

Spouse:

Children:

Brothers:

Sisters:

Mother:

Father:

Paternal grandparents:

Maternal grandparents

6. Developmental Considerations: (Using Erikson’s stages). Briefly (one to three sentences) describe what stage patient is in and how this patient is meeting or failing to meet the criteria for this stage
7. Psychosocial Profile

Health Practices and beliefs: how does the patient perceive his/her role in maintaining his/her health? How often does the patient visit a health care provider?

Typical day: (have patient describe what he or she does in a typical day):

Diet:

Mealtimes:

Prepared by:

24 hour recall:

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