What is the goal of a complete health history?

HEALTH HISTORY ASSIGNMENT

 

This project is worth 10% of your overall grade. This project is to be done individually. This assignment is designed to introduce students to the concept of collecting accurate, detailed, subjective data through the interview process. Each student will conduct a functional health assessment and interview a family member and create a nursing care plan responding to one concern in the “patient’s” presentation.

 

This assignment will assist you to meet the following learning objectives:

 

  1. Obtain a holistic health history using appropriate interviewing skills.
  2. Develop focused assessment skills relevant to the growth and development of the individual.
  3. Review and analyze data using critical thinking, practice judgment and diagnostic reasoning.
  4. Document and report findings using correct terminology.

 

Preparing for the interview:

  • Review Chapter 5 The Complete Health History in Jarvis textbook (2019)

 

Interview:

The family member should be informed that:

  • Any information collected will be kept private and confidential
  • Information will be shared with your professor for marking purposes
  • There will be no personal identity information shared with the professor.
  • The interview should take between 45 -60 minutes.
  • The interviewed person should feel free to decline to answer any questions they do not wish to discuss

 

Format:

  • Title Page (APA format)
  • Content shouldn’t exceed 4 pages (excludes title page, reference page, form)
  • Content passed page 4 will not be graded
  • Reference page
  • Health History form attached as a template.
  • The paper can be written in first person format e.g. “I interviewed a 60-year-old….”

 

Assignments must be submitted to Turn It In by the due date indicated by your professor. Unless otherwise negotiated prior to the assignment due date, late submissions will be subject the policy for non-negotiable submissions as indicated in the Practice Nursing Handbook 6.2 Assignment Procedures.

 

Students are responsible for keeping a copy of their original assessment notes as well as their paper.

 

*Make sure not to include any identifiers*.

 

Instructions:

 

  1. Complete the Health History Form.

Print the health history form from Blackboard under “Health History Assignment” and complete the form with a willing and healthy adult individual/family member.

 

  1. Introduce the Assignment and the ‘Patient’ Interviewed

What is this assignment for? What is the goal of a complete health history? (Do not forget to cite Jarvis to define the purpose of the assignment)

Provide a quick summary of your ‘patient’ (Do not give names) For example, demographics and reasons for seeking care. (1/4 page)

 

  1. Summarize Your Findings (in APA format)

After gathering information about your “patient’s” health, critically think about the information you recorded. The database is used to make a judgement of a diagnosis about the health status of an individual. Summarize the findings. Go through each category of the form (e.g., biographical data, reason for seeking care, review of systems, etc.) and discuss the most pertinent information. (1 page)

 

  1. Provide 2 Nursing Diagnoses

After providing a summary of your “patient”, provide 2 examples of nursing diagnoses from your analysis and the risk factors that lead to this diagnostic conclusion. (This can be its own subheading with bullet points of the 2 nursing diagnoses) (1/4-1/2 page)

*Use Your Nursing Diagnosis Textbook

 

Example of a Nursing Diagnosis: Insomnia related to lifestyle disruptions as evidenced by difficulty falling asleep and short sleep duration.

 

  1. Health Promotion Plan

Chose the priority nursing diagnosis (one client issue) and rationalize why this is the most important one. Then, discuss a health promotion plan (at least 2 interventions) for this individual regarding the health problem/concern. Make sure you remain in your scope of practice (i.e., you can’t order medications) (1 page).

Tip: Think SMART goals.

Must include: 2 scholarly references (in APA format) in this section to rationalize the health promotion plan

 

  1. Attach Health History Form as Appendix

Attach your completed health history form (from step 1) as an appendix to your paper.