Weber, J., & Kelley, J. (2014). Health assessment in nursing (5th ed.). Philadelphia, PA: Lippincott, Williams, and Wilkins. ISBN: 978-1-4511-4280-8. . Please each question has to answer separately please .
Indian River State College
NUR 3065C – Nursing Assessment
Complete Health History
For this assignment, you are to obtain part of a complete health history on your partner/client. Your assignment must be prepared in a professional manner and must include your name, course name, instructor(s) name, and submission date. This assignment must be typewritten using 6th edition APA writing style, unless otherwise specified by the instructor(s). You are responsible for submitting your assignment by the due date at 11:55 PM. If you turn your assignment in late, an initial 5 point will be deducted from your final grade. An additional 1 point will be deducted for days 2 through 5. After that a zero will be earned. You may use chapter 2 of your book (page 19) as a guide.
The following components of the Complete Health History should be formatted and typed with the headings bold printed and in all capital letters. Subheadings can be included under each area but must be clearly defined by non-bold italic print. It should be written in Times New Roman, 12-font and double spaced. Please include a title page with the title Complete Health History Assignment and a running head titled Health History in APA format.
Your “Complete Health History” write up will be evaluated using specific competency criteria as noted in the grading rubric below. As part of the “Assessment Write Ups” (see course syllabus) which is 25% of your course grade, this assignment is worth 50 points.
*Note: The Review of Systems (ROS) will be occurring during each body system assignment.
Categories
Possible Points
Points Earned
Biographic Data:
Name, address, phone, gender, provider of history (patient or other), date of birth, place of birth, race or ethnic background, education level, occupation, support persons
11
Reason for seeking health care or chief complaint:
*Note: A simple complaint of a past issue can be used in order to effectively address the COLDSPA requirements in the history of present health concerns area. Example: headache or nasal congestion.
2
History of Present Health Concern:
Character, onset, location, duration, severity, pattern, associated factors (COLDSPA)
*Note: COLDSPA must be addressed or you will receive 0/7 for this section.
7
Medication:
Prescription, over-the-counter (OTC), complementary alternative medicine (CAM)
3
Past health history:
Birth problems, childhood illnesses, immunizations to date (do not write up to date!), surgeries, accidents, prolonged pain, allergies (food, drugs, and environmental), last menstrual period (LMP) if female
8
Family history:
Age of parents (living? deceased?), parent illnesses, grandparents’ illnesses, aunts’ and uncles’ age and illnesses, children’s age and illnesses or handicaps
*Note: Use the correct wording of paternal and maternal not mom’s side or dad’s side.
5
Lifestyle and practices/Personal Social history :
Typical day, 24-hour diet history (be specific), who purchases/prepares meals, activities on a typical day, exercise patterns and habits, sleep/rest patterns and habits, use of substances (nicotine, alcohol, recreational drugs), self-care responsibilities, social activities
9
Developmental Level:
Erickson stage (mastery?)
*Note: You may use chapter 7, page 101 for assistance.
2
APA, Grammar, follows assignment directions
3
Total Points
50