Health History

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.

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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) Read more at https://en.wikipedia.org/wiki/Medical_history

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)

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