Health History Assessment: Collecting Objective and Subjective Data

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 

Course Outcomes: This assignment enables the student to meet the following course outcomes:

1. Explain expected client behaviors while differentiating between normal findings, variations, and abnormalities.

2. Utilize prior knowledge of theories and principles of nursing and related disciplines to integrate clinical judgment in professional decision-making and implementation of nursing process while obtaining a physical assessment.

3. Recognize the influence that developmental stages have on physical, psychosocial, cultural, and spiritual functioning. 

4. Utilize effective communication when performing a health assessment.

5. Identify teaching/learning needs from the health history of an individual. 

6. Explore the professional responsibilities involved

The Health History Worksheet can be used to help you organize the Family Medical History information you will obtain from the Adult Participant (document link is on the Assignment page). The use of this tool is optional. There are three parts to this assignment.

1. Health History Assessment

Using the following components of a health history assessment and your textbook for explicit details about each category, complete a health assessment/history on an individual of your choice. The person interviewed must be 18 years of age or older and should NOT be a family member or close friend. The purpose of this restriction is to avoid any tendency to anticipate answers or to influence how the questions are answered. Your goal in choosing an interviewee is to simulate the interaction between you and an individual for whom you would provide care. It is important that you inform the person of your assignment and assure him/her that the information obtained will be kept confidential. Please be sure to avoid the use of any identifiers in preparing the assignment. Health History components to be included:

a) Demographics

b) Perception of Health

c) Past Medical History

d) Family Medical History

e) Review of Systems

f) Developmental Considerations

g) Cultural Considerations

h) Psychosocial Considerations

i) Collaborative Resources

2. Reflection

Reflection is used to intentionally examine our thought processes, actions, and behaviors in order to evaluate outcomes. Provide a written reflection that describes your experience with conducting this Health History.

a) Reflect on your interaction with the interviewee holistically.

I. 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 to the interview process (if needed, refer to your text for a description of therapeutic communication and of the interview process).

b) How did your interaction compare to what you have learned?

c) What went well?

d) What barriers to communication did you experience?

I. How did you overcome them?

II. What will you do to overcome them in the future?

e) Were there unanticipated challenges to the interview?

f) Was there information you wished you had obtained?

g) How will you alter your approach next time?