Analyzing Health History Guidelines

Explain expected client behaviors while differentiating between normal findings, variations, and abnormalities. (PO
1)
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)
Recognize the influence that developmental stages have on physical, psychosocial, cultural, and spiritual
functioning. (PO 1)
Utilize effective communication when performing a health assessment. (PO 3)
Demonstrate beginning skill in performing a complete physical examination, using the techniques of inspection,
palpation, percussion, and auscultation. (PO 2)
Identify teaching/learning needs from the health history of an individual. (POs 2 and 5)
Explore the professional responsibility involved in conducting a comprehensive health assessment and providing
appropriate documentation.
Follow these guidelines when completing this assignment.
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
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
1) Demographics
2) Perception of Health

Health History Guidelines
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
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?