Health History Report Document Week

Week 7

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. 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

Category

Description

Health History

Provide a comprehensive health history narrative that includes: demographic data; perception of health; past medical history; family medical history; review of systems; developmental considerations; cultural considerations; psychosocial considerations; and collaborative resources.

Reflection

Reflect on the interaction with the interviewee holistically. Consider the interaction in its entirety: include the environment, your approach to the individual, time of day, and other features relevant to therapeutic communication and the interview process (if needed, refer to your text for a description of therapeutic communication and the interview process). Be sure your reflection addresses each of these questions: How did your interaction compare to what you have learned? What went well? What barriers to communication did you experience? How did you overcome them? Were there unanticipated challenges to the interview? Was there information you wished you had obtained? How will you alter the approach next time?

Grammar, Spelling, Clarity of Thought

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Week 7 Health History Report Document
Week 7 Health History Report Document

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. 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

Category

Description

Health History

Provide a comprehensive