For this paper, you do not need to follow any particular format and you do not need to include references as HIPAA would forbid referencing the subject. However, follow these guidelines:

  • Typed, double spaced using Word (Office 2007 or 2010)
  • Include your name on it
  • Use headings as appropriate(see below) and format them uniformly throughout the paper.
  • Use correct spellings and grammar; the majority of the assignment grade will be based on the content covered, but points will be deducted for misspellings and grammatical errors.
  • Refer to the HIPAA rules listed in the syllabus for information to omit. If you have a question about including any piece of information, contact the course instructor.
  • Submit the completed assignment as a file upload through the Canvas Assignments tool.
Refer to the attached document for specific assignment guidelines and components to be addressed, and the attached rubric for grading specifics.

Canvas will alert me when the assignment is submitted, and will show you a confirmation of submission. I will provide individual feedback on each paper.

Supporting Materials

B344 Assignment1_Adult_Health_History.docPreview the documentView in a new window

b344 rubric complete adult health history rubric.docPreview the documentView in a new window

 

Rubric

Complete Adult Health History
Complete Adult Health History
Criteria Ratings Pts
Introductory Paragraph
Exceeds Standard

5.0 pts

Meets Standard

4.0 pts

Below Standard

3.0 pts

No Marks

0.0 pts

5.0 pts
Present Health/History of Present Problems(s)
Exceeds Standard

5.0 pts

Meets Standard

4.0 pts

Below Standard

3.0 pts

No Marks

0.0 pts

5.0 pts
Past Health
Exceeds Standard

15.0 pts

Meets Standard

12.0 pts

Below Standard

10.0 pts

No Marks

0.0 pts

15.0 pts
Family History
Exceeds Standard

15.0 pts

Meets Standard

12.0 pts

Below Standard

10.0 pts

No Marks

0.0 pts

15.0 pts
Review of Systems
Exceeds Standard

15.0 pts

Meets Standard

12.0 pts

Below Standard

10.0 pts

No Marks

0.0 pts

15.0 pts
Functional, personal and social history
Exceeds Standard

15.0 pts

Meets Standard

12.0 pts

Below Standard

10.0 pts

No Marks

0.0 pts

15.0 pts
Conclusion
Exceeds Standard

5.0 pts

Meets Standard

4.0 pts

Below Standard

3.0 pts

No Marks

0.0 pts

5.0 pts
Reflection
Exceeds Standard

15.0 pts

Meets Standard

12.0 pts

Below Standard

10.0 pts

No Marks

0.0 pts

15.0 pts
Writing
Exceeds Standard

10.0 pts

Meets Standard

9.0 pts

Below Standard

8.0 pts

No Marks

0.0 pts

10.0 pts
Total Points: 100.0
 

Running head: ADULT HEALTH HISTORY 1

ADULT HEALTH HISTORY

9

This is how the Running head should appear on page 1, it is different on all other pages – please review. Please remember the running head after the colon cannot be more than 50 characters, including spaces. Your title in the running head may be shortened due to this.

Adult Health History

First and Last Name

Indiana University Southeast

Adult
Health History

This
documentation is a comprehensive health history of TJ, a 45 year old male who lives

in Indiana. TJ has been married for 25 years. He and his wife have two daughters who are 21

and 22. The oldest daughter has a masters in elementary education and teaches in the Greater

Clark school corporation. She has been married for two
years and she and her husband are

expecting their first child in May. The youngest daughter is finishing her senior year of nursing

school at the University of Louisville. TJ denied having any cultural, religious or spiritual values

that would inhibit him from participating in this interview. TJ denies any exposure to domestic

partner violence or sexual abuse. The interview took place in TJ’s living room. The setting was

very nice, quiet, comfortable, and free from distractions.

Present Health/History of Present Problem(s
)

TJ reports no present health issues.

.

Past Health

Childhood illnesses

TJ denies having measles, mumps, or rubella (MMR
), and pertussis. He did report

having chicken pox at age six. Many episodes of strep throat (denies knowledge of rheumatic

fever), tonsillectomy at age nine.

Accidents or injuries

Bike wreck in third grade, broken collar bone and pulled growth center from humerous.

Laid in traction for three weeks at hospital. Doctor was not sure if damage to growth plate would

cause long term issues. Arm grew at normal rate and size, no problems.

Serious or chronic illnesses


Denies any history of serious or chronic illnesses.

Hospitalizations

Only hospitalization was in 1979 when shoulder was broken as documented under

“Accidents and injuries”. No long term complications.

Operations

Surgery to repair collar bone and growth center in 1979. No long term complications

Obstetrical history

Does not apply.

Immunizations

Has documented history of the following vaccines: MMR, polio, diphtheria-tetanus-and

pertussis (Dtap), and varicella. Denies having hepatitis A or B, meningococcal vaccine, human

papilloma virus, haemophilus influenza type B, pneumoc

Running head: APA GUIDELINES
1

APA GUIDELINES 2

1) Never assume the reader knows what abbreviation represents. Always type the word first with abbreviations in (), then you may use the abbreviation throughout the paper. Measles, mumps, and rubella (MMR).

2) Header will be used in every APA paper, no exceptions. 1st page header is different from all other pages.

3) Numerals <10 are spelled out unless it used in a date, height, weight, etc.

4) Introduction does NOT warrant header. (Page 27, Section 2.05)

5) First page is cover page with the header at top of page with page number. Title of the paper, your name, and university is in the upper first half of the paper. NOTHING else is on the cover page!

6) Second page should be the start of your paper. The title is always centered on the second page unless an abstract is required. THERE IS NO abstract required for this course. With that being said, the second page should have the title of your paper, then the introduction. Remember do NOT include INTRODUCTION at top of page as APA states the intro does not warrant a title!

7) Headers are used in APA. First page should have this in the header: Running head: TITLE OF PAPER (no more than 50 characters including spaces) flush left with page number flush right.

8) The header for all pages after page 1: TITLE OF PAPER flush left with page number flush right.

9) First line of every paragraph is indented.

10) First level headers are bolded, centered. No lines underneath, colons, bullets.

11) Second level headers are bolded, flush left. No lines underneath, colons, bullets.

12) Third level headers are bolded, flush left with indent and period at end. Comments start immediately after period.

13) Double space, Times Roman New Font, 12 inch pica, one inch margins all the way around.

14) To remove the extra space that seems to appear in some papers (especially after a paragraph), highlight the text, click on review, line spacing, and remove the line after the paragraph (you may also need to remove the line before the paragraph.

15) If the requirement is for a six page paper, APA format: the first page is the title page, pages two, three, four, and five are filled with the text (evidenced based research), and page six is the reference page. Make sure you adhere to the required page limit.

For those of you that this is your first class that requires APA …keep your papers, correct

5

B344: Comprehensive Health Assessment

Week 1/Module 1 Student Notes

Module 1 covers Jarvis chapters 1 – 9. The assigned chapters are 3, 4, 5, 8 & 9; these notes will concentrate on the chapters not assigned. Even though some chapters are not assigned, I may refer you to specific information in them in these student notes.

Chapter 1: Evidence-Based Assessment

· Understand subjective vs. objective data (p. 2)

· Review first-level, second-level, and third-level priority problems (p. 5-6)

· In this text, they refer to first-level priority problems as ‘ABC plus V’, referring to Airway, Breathing, Cardiac/Circulation, and Vital sign concerns (high fever, high or low BP, etc.)

· Know the 4 types of databases (p. 7-8):

· Complete/Total Health Database: this is made up of the complete health history (which you will be performing for your first assignment) and a full physical examination

· Focused, or Problem-centered Database: a limited database targeting a specific problem

· Follow-up Database: the evaluation of a specific problem, used for short-term or chronic problems

· Emergency Database: the rapid collection of data, often done while lifesaving measures are being implemented, such as those obtained in the ED

Chapter 2: Cultural Competence/Cultural Care

· You can review this chapter as desired; it will not be tested over

· HOWEVER: Nurses should be asking the client if there are cultural, spiritual, or religious values they have so the nurse can provide optimum care!!!

Chapter 3: The Interview

This is an assigned chapter, and one you will be using for your complete health history, so do read it. I will draw your attention to a few things:

· Note the material on empathy and active listening (p. 30)

· Review external factors: the physical setting (privacy, interruptions), equal-status seating, dress, and note-taking (p. 30-31)

· Review open-ended vs. closed or direct questions (p. 32-33)

· Review the 9 types of verbal responses (facilitation, silence, reflection, empathy, clarification, confrontation, interpretation, explanation, and summary) (p. 33-34)

· Note that part of the complete health history assignment will include a self-assessment, where you will evaluate things like the interview environment, and your use of questions and verbal responses

· Do note the 10 traps of interviewing (p. 35-36); these also apply to general patient care, and so are good to keep in mind

· Review the nonverbal skills (appearance, posture, etc.)

· For the section on Developmental Competence (starting on p. 37), quickly read through the sections on children- we will refer back to this information later when doing the pediatric developmental/nutritional assessment. Do pay attentio

1

B344: Comprehensive Health Assessment

Week 2/Module 2 Student Notes

Module 2 reading assignment is chapters 10, 11, 12 & 13.

Chapter 10: Pain Assessment: The Fifth Vital Sign

This chapter goes into great detail on pain, but just know the basics:

· Difference between nociceptive and neuropathic pain

· Types of pain: acute vs. chronic

· Infants feel pain, and pain does not diminish in older adults; pain is not a normal part of aging

· Note the types of information to obtain about pain (p. 164)

· Most often pain is measured using a rating scale, such as the 0-10 scale, or a faces scale for preverbal or nonverbal patients

· Note Table 10-2 (p. 172) for info on nociceptive and neuropathic pain

Chapter 11: Nutritional Assessment

Things to concentrate on for this chapter:

· Know the discussion on 24-hour food recall and food diaries (p. 180)

· Note MyPyramid info on p. 181; this information is no longer accurate. The MyPyramid.com website has been replaced by http://www.MyPlate.gov , there you will find information that will be useful for the pediatric nutritional assessment

· Note Table 11-5: clinical signs of malnutrition

· Note the ranges for interpreting BMI for adults and children on p. 187 (pink portion of the page)

· Other nutritional measures: waist-to-hip ratio and waist circumference, skinfold thickness, and mid-upper arm circumference

· Routine labs used include serum glucose and glycosylated hemoglobin (HbA1c), hemoglobin and hematocrit, cholesterol and triglycerides, serum proteins or serum albumin

· Note p. 194 on the obesity epidemic in this country; the current generation of children are the first in recorded history to have a predicted shorter life span than their parents, and this is due to the dramatic rise in obesity, especially among children. For more startling info, go to: www.cdc.gov; under ‘Multimedia & Tools’, click on ‘BMI Calculator’. Here, under ‘Related Links’, click on ‘Overweight & Obesity’; here, click on Obesity Data & Statistics (More button); finally, click on ‘Trends by State, 1985 – 2009. Watch how obesity has changed in this country since the 1980’s.

· In the text’s Abnormal Findings section, read about obesity, marasmus, and kwashiorkor; also know the basics of Metabolic Syndrome on p. 200.

Chapter 12: Skin, Hair and Nails

This is the first body system. All chapters begin with a review of structure and function. Review this content to better understand assessment and findings. Thi