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:
CO1. Explain expected client behaviors while differentiating between normal findings, variations, and abnormalities.

CO2. 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.
CO3. Recognize the influence that developmental stages have on physical, psychosocial, cultural, and spiritual
functioning.
CO4. Utilize effective communication when performing a health assessment.
CO6. Identify teaching/learning needs from the health history of an individual.
CO7. Explore the professional responsibilities involved in conducting a comprehensive health assessment and
providing appropriate documentation.

Pulling together your RUA

• There are three parts to the NR 302 RUA. The health history assessment is worth 50 points. Your reflection is worth 40 points. And last but certainly not least, the style and organization of your paper is worth 10 points.
• Be sure to look at the NR 302 Health Assessment I RUA Health History Guidelines before you start this assignment. Pay close attention to the rubric…it is how your paper will be graded.
• Write up your health assessment findings using a narrative format which means full sentences put together in a paragraph. NO BULLET POINTS! As indicated, you can include a quote from the person you interviewed but be sure to cite it correctly.
• For the Demographics section, you will need to include the person’s initials, date of birth, age at the time of the interview, gender, race, relationship status and occupation.
• In the Perception of Health section, you want to address how the person defines health, how they feel about their current health status and if they have any concerns. You will need to include their health goals for the present as well as in the future. You could also include how they see their healthcare providers helping them with these goals.
• In the Past Medical History section, you will need to include childhood illnesses, accidents/injuries, serious or chronic illnesses, hospitalizations, operations, immunizations, last examination date, allergies with the reaction and all current medications including nonprescription/OTC medications, herbal medications and supplements. If the person is female, you will need to include their obstetric history also.
• For the Family Medical History section, you can use a pedigree or genogram such as the sample in your textbook on page 49 or you can write it out. Either way, you will need to include the gender, relationship and age of the immediate blood relatives in at least three generations of the person you interviewed. Consider including the aunts/uncles, nieces/nephews and cousins as well. The medical condition of each person along with any significant health information should be included in this section. Be sure to identify anyone in the family with the specific diseases.
• The Review of Systems is all subjective data. There should be absolutely positively no objective findings here. This is the place for the patient to tell the healthcare provider what is or is not present in each area.
• Under developmental considerations, you will indicate the person’s stage of cognitive development using Piaget’s theory as well as their stage of psychosocial development using Erickson’s theory.
• In the cultural considerations section, you will identify any religious or spiritual beliefs and practices that the person follows. You will need to identify any dietary restrictions and if there are any restrictions on medical procedures/interventions that can be done.
• Living situation, leisure activities, exercise pattern, sleep pattern and perceived level of stress should be identified in the psychosocial considerations portion of the paper. You will want to include how these things are helping or hindering the person from reaching their health goals.
• In the collaborative resources section, you will identify the presence or absence of resources from the family, community and healthcare providers/system. You will want to address how the presence or absence of these resources has affected the person and their ability to meet their health goals.
• In the reflection part of the RUA, you will have the opportunity to share how things went as you conducted the health history interview. Don’t be skimpy or superficial here when you are answering the questions. You need to write more than “everything went well and I had no problems.” Really spend some time thinking about the entire process, what you learned from it and what you definitely want to do next time around as well as what you want to make sure you don’t do again.
• How you put your paper together is just as important as what you have included in the paper. Check for misspelled words. Make sure that you are writing complete sentences. Read over the paper and see if there is logic flow or is everything all over the place.