Health history and physical assessment

Requirements to Follow/grading rubric

To 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.

Rubric

NR304 RUA: Health History and Physical Assessment Guidelines (Sept20)

NR304 RUA: Health History and Physical Assessment Guidelines (Sept20)

Criteria Ratings Pts

This criterion is linked to a Learning OutcomeHealth History: Subjective Data

Required criteria

1. Demographic data

2. Reason for care (why they are in the facility)

3. Present illness (PQRST of current illness)

4. Perception of health

5. Past medical history (including medications, allergies, and vaccinations and immunizations)

6. Family medical history

7. Review of systems

8. Developmental considerations

9. Cultural considerations

10. Psychosocial considerations

11. Presence or absence of collaborative resources (community, family, groups, and healthcare system)

30.0 pts

Highest Level of Performance

Includes 11 requirements for section.

28.0 pts

High Level of Performance

Includes 9-10 requirements for section.

23.0 pts

Satisfactory Performance

Includes 5-8 requirements for section.

15.5 pts

Unsatisfactory Performance

Includes 1-4 requirements for section.

0.0 pts

Not Present

No requirements for this section presented.

30.0 pts

This criterion is linked to a Learning OutcomePhysical Examination: Objective Data

Required criteria

1. From NR302:

o HEENT (head, eyes, ears, nose, and throat)

o Neck (including thyroid and lymph chains)

o Respiratory system

o Cardiovascular system

2. From NR304:

o Neurological system

o Gastrointestinal system

o Musculoskeletal system

o Peripheral vascular system

30.0 pts

Highest Level of Performance

Includes 8 requirements for section.

28.0 pts

High Level of Performance

Includes 7 requirements for section.

23.0 pts

Satisfactory Performance

Includes 4-6 requirements for section.

15.5 pts

Unsatisfactory Performance

Includes 1-3 requirements for section.

0.0 pts

Not Present

No requirements for this section presented.

30.0 pts

This criterion is linked to a Learning OutcomeNeeds Assessment

Required criteria

1. 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 pts

Highest Level of Performance

Includes 4 requirements for section.

18.0 pts

High Level of Performance

Includes 3 requirements for section.

15.0 pts

Satisfactory Performance

Includes 2 requirements for section.

7.5 pts

Unsatisfactory Performance

Includes 1 requirement for section.

0.0 pts

Not Present

No requirements for this section presented.

20.0 pts

This criterion is linked to a Learning OutcomeReflection

Required criteria

1. 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 pts

Highest Level of Performance

Includes 9 requirements for section.

9.0 pts

High Level of Performance

Includes 7-8 requirements for section.

8.0 pts

Satisfactory Performance

Includes 5-6 requirements for section.

4.0 pts

Unsatisfactory Performance

Includes 1-4 requirements for section.

0.0 pts

Not Present

No requirements for this section presented.

10.0 pts

This criterion is linked to a Learning OutcomeStyle and Organization

Required criteria

1. 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 pts

Highest Level of Performance

Includes 6 requirements for section.

9.0 pts

High Level of Performance

Includes 5 requirements for section.

8.0 pts

Satisfactory Performance

Includes 4 requirements for section.

4.0 pts

Unsatisfactory Performance

Includes 1-3 requirements for section.

0.0 pts

Not Present

No requirements for this section presente

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