Health History and physical Assessment

Requirements to Follow/grading rubricTo recognize the interrelationships of subjective data (physiological, psychosocial, cultural/spiritual values, and developmental) and objective data (physical examination findings) in planning and implementing nursing care.To reflect on the interactive process that takes place between the nurse and an individual while conducting a health assessment and a physical examination.RubricNR304 RUA: Health History and Physical Assessment Guidelines (Sept20)NR304 RUA: Health History and Physical Assessment Guidelines (Sept20)Criteria Ratings PtsThis criterion is linked to a Learning OutcomeHealth History: Subjective DataRequired criteria1. Demographic data2. Reason for care (why they are in the facility)3. Present illness (PQRST of current illness)4. Perception of health5. Past medical history (including medications, allergies, and vaccinations and immunizations)6. Family medical history7. Review of systems8. Developmental considerations9. Cultural considerations10. Psychosocial considerations11. Presence or absence of collaborative resources (community, family, groups, and healthcare system)30.0 ptsHighest Level of PerformanceIncludes 11 requirements for section.28.0 ptsHigh Level of PerformanceIncludes 9-10 requirements for section.23.0 ptsSatisfactory PerformanceIncludes 5-8 requirements for section.15.5 ptsUnsatisfactory PerformanceIncludes 1-4 requirements for section.0.0 ptsNot PresentNo requirements for this section presented.30.0 ptsThis criterion is linked to a Learning OutcomePhysical Examination: Objective DataRequired criteria1. From NR302:o HEENT (head, eyes, ears, nose, and throat)o Neck (including thyroid and lymph chains)o Respiratory systemo Cardiovascular system2. From NR304:o Neurological systemo Gastrointestinal systemo Musculoskeletal systemo Peripheral vascular system30.0 ptsHighest Level of PerformanceIncludes 8 requirements for section.28.0 ptsHigh Level of PerformanceIncludes 7 requirements for section.23.0 ptsSatisfactory PerformanceIncludes 4-6 requirements for section.15.5 ptsUnsatisfactory PerformanceIncludes 1-3 requirements for section.0.0 ptsNot PresentNo requirements for this section presented.30.0 ptsThis criterion is linked to a Learning OutcomeNeeds AssessmentRequired criteria1. Based on the health history and physical examination findings, determine at least two health education needs for the individual. Remember, you may identify an educational topic that is focused on wellness.2. Support the identified health teaching needs selected with evidence from two current, peer-reviewed journal articles.3. Discuss how the interrelationships of physiological, developmental, cultural, and psychosocial considerations will influence, assist, or become barriers to the effectiveness of the proposed health education.4. Describe how the individual’s strengths (personal, family, and friends) and collaborative resources (clinical, community, and health and wellness resources) effect proposed teaching.20.0 ptsHighest Level of PerformanceIncludes 4 requirements for section.18.0 ptsHigh Level of PerformanceIncludes 3 requirements for section.15.0 ptsSatisfactory PerformanceIncludes 2 requirements for section.7.5 ptsUnsatisfactory PerformanceIncludes 1 requirement for section.0.0 ptsNot PresentNo requirements for this section presented.20.0 ptsThis criterion is linked to a Learning OutcomeReflectionRequired criteria1. 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 went well?4. What barriers to communication did you experience?5. How did you overcome them?6. What will you do to overcome them in the future?7. Were there unanticipated challenges to the interview?8. Was there information you wished you had obtained?9. How will you alter your approach next time?10.0 ptsHighest Level of PerformanceIncludes 9 requirements for section.9.0 ptsHigh Level of PerformanceIncludes 7-8 requirements for section.8.0 ptsSatisfactory PerformanceIncludes 5-6 requirements for section.4.0 ptsUnsatisfactory PerformanceIncludes 1-4 requirements for section.0.0 ptsNot PresentNo requirements for this section presented.10.0 ptsThis criterion is linked to a Learning OutcomeStyle and OrganizationRequired criteria1. Writing reflects synthesis of information from prior learning applied to completion of the assignment.2. Grammar and mechanics are free of errors.3. Able to verbalize thoughts and reasoning clearly.4. Use appropriate resources and ideas to support topic.5. Adheres to APA recommendations for title page, running head, headings, in-text citations, and reference page.6. HIPAA protocols followed.10.0 ptsHighest Level of PerformanceIncludes 6 requirements for section.9.0 ptsHigh Level of PerformanceIncludes 5 requirements for section.8.0 ptsSatisfactory PerformanceIncludes 4 requirements for section.4.0 ptsUnsatisfactory PerformanceIncludes 1-3 requirements for section.0.0 ptsNot PresentNo requirements for this section presente

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