nursing project and need support to help me learn.
Students will demonstrate knowledge of interviewing skills, the components of a health history, recording the
history data, and assigning three priorities after reviewing the data. A health history will be completed and submitted according to the grading rubric and course schedule. Students will submit a detailed subjective health history of a volunteering adult over 50 on the provided form. Students should not give identifying data on the patient – only the demographics requested in the grading rubric.
The health history assignment is SUBJECTIVE – interviewing and questioning the patient.
Each student will complete a comprehensive health history following the rubric provided below:
Comprehensive health history is all subjective data. Consider the health history a chance for the patient to tell their story.
Find a friend or relative to complete an entire health history.
After completing, a detailed health history, students will document the results of the health history APA7.
Steps for the Health History:
Subject Criteria Possible Points
Gender, age, ethnicity, and other social demographics as indicated (self-pay, Insurance)
Use the patient’s own words—one or more symptoms or concerns cause the patient to seek care.
Elaborate on the chief complaint; describes how each symptom developed.
Includes the patient’s thoughts and feelings about the illness.
History of Present Illness
Appropriate dimensions of cardinal symptoms are listed (including location, severity, quality, setting, chronology, aggravating/alleviating, and associated manifestations)
HPI narrative flows smoothly in a logical fashion
For those who favor mnemonics, the 8 dimensions of a medical problem can be easily recalled using OLD CARTS (Onset, Location/radiation, Duration, Character, Aggravating factors, Relieving factors, Timing and Severity).
Past Medical History
Lists childhood illnesses
Lists adult illnesses with dates for at least three categories: medical, surgical, and psychiatric.
Includes health maintenance practices such as immunizations, screening tests, lifestyle issues, and home safety.
Current Health Status
Summary of general health status related to the present illness.
Narrative and Genogram
https://genopro.com/genogram/medical/Links to an external site.
Outlines or diagrams of age and health or age and cause of death of siblings, parents, grandparents, and children.
Documents the presence or absence of specific illnesses in the family (e.g., hypertension, coronary artery disease)
The family pedigree shows at least three generations and involves the use of standardized symbols, which mark individuals affected with a specific diagnosis to allow for easy identification.
Risk assessment based on family history
Family history of a known or suspected genetic condition
Ethnic predisposition to certain genetic disorders
Consanguinity (blood relationship of parents)
Multiple affected family members with the same or related disorders
Earlier than expected age of onset of disease
Diagnosis in less-often-affected sex
Past Surgical History
Were they ever operated on, even as a child?
What year did this occur?
Were there any complications?
Have they ever smoked cigarettes? If so, how many packs per day and for how many years? If they quit, when did this occur?
Do they drink alcohol? If so, how much per day and what type of drink?
Any drug use, past or present, should be noted.
Work, family, friends, community support systems,
Do they participate in intercourse? With persons of the same or opposite sex?
Are they involved in a stable relationship?
Do they use condoms or other means of birth control?
Married? The health of the spouse? Divorced? Past sexually transmitted diseases?
Do they have children? If so, are they healthy? Do they live with the patient?
What sort of work does the patient do?
Have they always done the same thing? Do they enjoy it?
If retired, what do they do to stay busy? Any hobbies?
Review of systems (ROS)
Documentation of the presence or absence of common symptoms related to each major body system.
Consider asking a series of questions going from “head to toe.”
The questions asked to reflect an array of standard and critical clinical conditions (heart disease, diabetes, arthritis)
These disorders would only be recognized if the patient were explicitly prompted.
Gastrointestinal and Urinary
Prevention and Health Promotion
At least one prevention activity.
At least three health promotion recommendations.
APA Guidelines & Writing Style
APA (title page, margins, page numbers, headings, subheadings, citations); spelling; writing straightforward, concise, and professional.
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