Guidelines for Course Project Milestone 1:Health HistoryPurposeThe student will obtain a health history on a willing, non-related, adult participant in order to generate written documentation that is clear and accurate.Course OutcomesThis assignment enables the student to meet the following course outcomes:CO #3: Utilize effective communication when performing a health assessment. (PO #3)CO #4: Identify teaching/learning needs from the health history of an individual. (PO #2)CO #5: Explore the professional responsibilities involved in conducting a comprehensive health assessment and providing appropriate documentation. (PO #6)PointsThis assignment is worth a total of 175 points.Due DateThe Course Project Milestone 1: Health History assignment is to be submitted to the Dropbox by Sunday, 11:59 p.m. MT at the end of this Week 4. The guidelines and grading rubric may be found in Doc Sharing. Post questions to the Q&A Forum. Contact your instructor if you need additional assistance.DisclaimerThe focus of this assignment is on communicating details within the written client record. When taking a health history on an actual client, it is essential that the information is accurate. Please inform the person you are interviewing that they do NOT need to disclose information that they wish to keep confidential. If the interviewee decides not to share information, please write, âDoes not want to disclose.âDirections1. Find an adult who is not related to you who is willing to let you take a health history.2. Download the NR305_Milestone1_Form from Doc Sharing. You will type your answers directly into this Word document. Your paper does NOT need to follow APA formatting, however, you are expected to be clear in your communication by using correct medical terminology, grammar and spelling.3. Review the examples in Chapter 10 of your textbook to gain insight into how to document the health history. Avoid words like frequently, improved, increased, decreased, good, poor, normal, or WNL as they may have different meanings for different people. Instead, document the specific data that led you to these conclusions, e.g., 3x/day instead of âfrequently,â or consuming 4 servings of vegetables/day instead of âincreasedâ vegetable servings.4. Save the file by clicking âSave asâ and adding your last name to the file name, e.g., âNR305_Milestone1_Form_Smithâ5. Submit the completed form to the Dropbox by Sunday, 11:59 p.m. MT at the end of Week 4. Please post questions in the weekly Q & A Forums so the entire class may view the answers.Grading Research Topics – CriteriaCategoryPoints%DescriptionBiographical Data106Date of health history, clientâs initials, age, date of birth, birthplace, gender, marital status, race, religion, occupation, health insurance information, source of information, and the reliability of the source. Do NOT include identifying information such as phone numbers, address, etc.Present Health History/ Illness159Reasons for seeking care, health patterns, and health goals.Health Beliefs and Practices159Health beliefs and practices including factors that influence their healthcare decisions, related traits, habits or acts that affect a clientâs health.Medications159Use of prescription medications, over-the-counter medications and/or any herbals. Include name, dose, purpose, duration, frequency and desired or undesired effects of each of the medications.Past History159Childhood diseases, immunizations, allergies, blood transfusions, major illnesses, injuries, hospitalizations, labor and deliveries, surgeries, and use of alcohol, tobacco and illicit drugs.Emotional History159Includes information about any mental, emotional, or psychiatric health problems.Family History159Review of health history of the father, mother, sibling(s) and grandparents to determine if any genetic or familial patterns of health or illness might affect current health status.Psychosocial/ Occupational History159Includes information about occupational history, educational level, and financial background.Roles and Relationships159Information about the clientâs roles and relationships; including identifying a significant other and support systems (friends, neighbors, club members, clergy, church members and members of the healthcare team)Ethnicity and Culture106Clientâs ethnicity and culture, and physical and social characteristics that influence healthcare decisions.Spirituality53Clientâs religious and spiritual needs. (Spirituality refers to the individualâs sense of self in relation to others and a higher being.)Self-Concept53Includes information on how they view their self-worth and plans for the future.Review of Systems2012Focus is to uncover current and past information about each body system and its organs. Ask about the system function and any abnormal signs or symptoms, paying attention to gathering information about the functional patterns of each system.Clarity of writing53Content is organized logically and clearly understandable. Documentation is clear and accurate. Words like frequently, improved, increased and decreased not used, instead provide specific examples.Total175 pts100%A quality paper will meet or exceed all of the above requirements.Grading Paper Writing Service – Topic Examples – RubricAssignment Research Topics – CriteriaExceeds Minimum RequirementsMeets Minimum RequirementsPartially Meets or Does Not Meet Minimum RequirementsBiographical Data10 pointsAll required criteria included. No errors.10 pointsNo more than one required elements missing8 pointsMore than two required elements missing.0-7 pointsPresent Health History/Illness15 pointsAll required criteria included. No errors.12-15 pointsNo more than three required elements missing5-11 pointsMore than three required elements missing.0-4 pointsHealth Beliefs and Practices15 pointsAll required criteria included. No errors.12-15 pointsNo more than three required elements missing5-11 pointsMore than three required elements missing.0-4 pointsMedications15 pointsAll required criteria included. No errors.12-15 pointsNo more than three required elements missing5-11 pointsMore than three required elements missing.0-4 pointsPast History15 pointsAll required criteria included. No errors.12-15 pointsNo more than three required elements missing5-11 pointsMore than three required elements missing.0-4 pointsEmotional History15 pointsAll required criteria included. No errors.12-15 pointsNo more than three required elements missing5-11 pointsMore than three required elements missing.0-4 pointsFamily History15 pointsAll required criteria included. No errors.12-15 pointsNo more than three required elements missing5-11 pointsMore than three required elements missing.0-4 pointsPsychosocial/ Occupational History15 pointsAll required criteria included. No errors.12-15 pointsNo more than three required elements missing5-11 pointsMore than three required elements missing.0-4 pointsRoles and Relationships15 pointsAll required criteria included. No errors.12-15 pointsNo more than three required elements missing5-11 pointsMore than three required elements missing.0-4 pointsEthnicity and Culture10 pointsAll required criteria included. No errors.10 pointsNo more than one required elements missing8 pointsMore than two required elements missing.0-7 pointsSpirituality5 pointsAll required criteria included. No errors.5 pointsNo more than one required elements missing4 pointsMore than two required elements missing.0-3 pointsSelf-Concept5 pointsAll required criteria included. No errors.5 pointsNo more than one required elements missing4 pointsMore than two required elements missing.0-3 pointsReview of Systems20 pointsAll required criteria included. No errors.16-20 pointsNo more than three required elements missing did not include information about functional patterns of each system.10-15 pointsMore than three required elements missing. Total body systems and/or functional patterns missing.0-9 pointsClarity of writing5 pointsOrganized logically and written clearly with good structure4-5 pointsLacks some organization & clarity. Uses words such as frequently, increased, decreased.2-3 pointsLacks logical organization; difficult to read. Uses words such as frequently, increased, decreased.0-1 pointsTotal Points Possible = 175 pointsCourse Project Milestone 1: Health History FormYour Name: Date:Your Instructorâs Name:Directions: Refer to the Milestone 1: Health History guidelines and grading rubric found in Doc Sharing to complete the information below. This assignment is worth 175 points, with 5 points awarded for clarity of writing, which means the use of proper grammar, spelling and medical language.Type your answers on this form. Click âSave asâ and save the file with the assignment name and your last name, e.g., âNR305_Milestone1_Form_Smithâ When you are finished, submit the form to the Milestone #1 Dropbox by the deadline indicated in your guidelines. Post questions in the Q&A Forum or contact your instructor if you have questions about this assignment.Disclaimer:The focus of this assignment is on communicating details within the written client record. When taking a health history on an actual client, it is essential that the information is accurate. Please inform the person you are interviewing that they do NOTneed to disclose information that they wish to keep confidential. If the interviewee decides not to share information, please write, âDoes not want to disclose.âBIOGRAPHICAL DATA (10 pts)Date:Initials:Age:Date of birth:Birthplace:Gender:Marital status:Race:Religion:Occupation:Health insurance:Source of information:Reliability of source of information:PRESENT HEALTH HISTORY/ILLNESS (15 pts)Reason for seeking care:Health patterns:Health goals:HEALTH BELIEFS AND PRACTICES (15 pts)Beliefs and practices:Factors influencing healthcare decisions:Related traits, habits or acts:MEDICATIONS (15 pts)Prescription medications:Over-the-counter medications:Herbals:PAST HISTORY (15 pts)Childhood diseases:Immunizations:Allergies:Blood transfusions:Major illnesses:Injuries:Hospitalizations:Labor and deliveries:Surgeries:Use of alcohol:Use of tobacco:Use of illicit drugs:EMOTIONAL HISTORY (15 pts)Mental, emotional or psychiatric problems:FAMILY HISTORY (15 pts)Father:Mother:Siblings:Grandparents:PSYCHOSOCIAL/ OCCUPATIONAL HISTORY (15 pts)Occupational history:Educational level:Financial background:ROLES AND RELATIONSHIPS (15 pts)Significant others:Support systems:ETHNICITY AND CULTURE (10 pts)Ethnicity and culture:Physical and social characteristics that influence healthcare decisions:SPIRITUALITY (5 pts)Religious and spiritual needs:SELF-CONCEPT (5 pts)View of self-worth:Future plans:REVIEW OF SYSTEMS (20 pts)Skin, hair, nails:Head, neck, related lymphatics:Eyes:Ears, nose, mouth, and throat:Respiratory:Breasts and axillae:Cardiovascular:Peripheral vascular:Abdomen:Urinary:Reproductive:Musculoskeletal:Neurologic:Guidelines for Course Project Milestone 2:Nursing Diagnosis and Care Plan AssignmentPurposeThis activity will be a continuation of the Milestone 1: Health History that you submitted in Week 4. In this part of the assignment you will take the information you gathered, analyze the data, and develop a nursing care plan.Course OutcomesThis assignment enables the student to meet the following course outcomes:CO #3: Utilize effective communication when performing a health assessment. (PO #3)CO #4: Identify teaching/learning needs from the health history of an individual. (PO #2)CO #5: Explore the professional responsibilities involved in conducting a comprehensive health assessment and providing appropriate documentation. (PO #6)PointsThis assignment is worth a total of 250 points.Due DateThe assignment is to be submitted to the Dropbox by Sunday, 11:59 p.m. MT at the end of Week 6.Post questions to the weekly Q & A Forum. Contact your instructor if you need additional assistance.See the Course Policies regarding late assignments. Failure to submit your paper to the Dropbox on time may result in a deduction of points.Directions1. Download the NR305_Milestone2_Form from Doc Sharing. You will type your answers directly into this Word document. Your paper does NOT need to follow APA formatting; however, you are expected to use correct grammar, spelling, syntax and write in complete sentences.2. Save the file by clicking âSave asâ and adding your last name to the file name, e.g., âNR305_Milestone2_Form_Smithâ3. Submit the completed form to the Dropbox by Sunday, 11:59 p.m. MT at the end of Week 6. Please post questions in the weekly Q & A Forums so the entire class may view the answers.Grading Research Topics – CriteriaCategoryPoints%DescriptionANALYZE THE DATAAreas for focused assessment3012Provide an overview of those areas of strength and weakness noted on the Health Assessment, Health History. Do not go into detail in this section.Clientâs strengths3012Expand on areas identified as strengths related to the person’s overall health. Support your conclusions with data from the textbook.Areas of concern3012Expand on areas previously identified as abnormal and those that place the person at health risk. Support your observations with data from the textbook.Health teaching topics3012What health education needs have you identified? Support your statements with facts from the Health History and information from your textbook.NURSING CARE PLANDiagnosis3012Write one nursing diagnosis that reflects a priority need for this person. Types of diagnoses include an illness, risk for illness or a wellness diagnosis.Plan3012Write one goal and one measurable expected outcome related your nursing diagnosis. Write my Essay Online Writing Service with Professional Essay Writers – Explain why this goal and outcome is a priority. Include cultural consideration of the client. For example, African Americans are at higher risk for hypertension and any prehypertensive blood pressure readings should be addressed.Intervention3012Write as many nursing orders or nursing interventions that you need in order to achieve the outcome. Provide the rationale for each intervention listedEvaluation3012You wonât have an opportunity to carry out your care plan so you cannot evaluate the effectiveness of your nursing orders/interventions. Instead comment on what you would look for in order to evaluate your effectivenessCLARITY OF WRITING104Use proper grammar, spelling and medical languageTotal250 pts100%A quality paper will meet or exceed all of the above requirements.Grading Paper Writing Service – Topic Examples – RubricAssignment Research Topics – CriteriaAOutstanding or highest level of performanceBVery good or high level of performanceCCompetent or satisfactory level of performanceFPoor or failing or unsatisfactory level of performanceAnalyze the DataAreas for focused assessment30 pointsIdentifies all strengths and weaknesses27-30 pointsOverlooks no more than 1 strength and/or 1 weakness25-26 pointsOverlooks more than 1 strength and 1 weakness22-24 pointsOverlooks more than 2 strengths and 2 weakness areas; item not included0-21Clientâs strengths30 pointsUses textbook (cites source) to validate all traits identified as strengths27-30 pointsUses textbook (cites source) to validate all but 1 trait identified as a strength25-26 pointsUses source to validate strengths, but not the textbook22-24Does not validate identified strengths0-21Areas of concern30 pointsUses textbook (cites source) to validate all traits identified as concerns27-30 pointsUses textbook (cites source) to validate all but 1 trait identified as a concern25-26 pointsUses source to validate concerns, but not the textbook22-24Does not validate identified concerns0-21Health teaching topics30 pointsIdentifies all areas of knowledge deficit contained in Health History; validates findings using textbook (cites source)27-30 pointsIdentifies all but 1-2 knowledge deficits contained in Health History; validates findings using textbook (cites source)25-26 pointsFails to identify 3 areas of knowledge deficit contained in Health History; validates findings using textbook (cites source)22-24Does not validate findings with textbook0-21Nursing Care PlanDiagnosis30 pointsDiagnosis properly written in NANDA terms and reflects an illness, risk for illness or a wellness diagnosis.27-30 pointsDiagnosis not written in NANDA terms or does not reflect an illness, risk for illness or a wellness diagnosis.25-26 pointsDiagnosis not written in NANDA terms and does not reflectan illness, risk for illness or wellness diagnosis.22-24Diagnosis is not documented0-21Plan30 pointsGoal realistic; outcome measurable and timed. Cultural considerations are identified and addressed.27-30 pointsGoal realistic but outcome not measurable or timed. Cultural considerations are mostly addressed25-26 pointsGoal somewhat realistic; outcome not measurable or timed. Cultural considerations are barely addressed.22-24Goal is not documented; cultural considerations are not adequately addressed0-21Intervention30 pointsInterventions will aid in achievement of outcome; sound, rationale provided27-30 pointsInterventions will aid in achievement of outcome; rationale provided but not necessarily sound25-26 pointsInterventions incomplete and rationale provided but not necessarily sound22-24Interventions will not support outcome achievement; no rationale provided0-21Evaluation30 pointsResearch Topics – Criteria listed to thoroughly evaluate effectiveness of health education27-30 pointsResearch Topics – Criteria listed mostly evaluates effectiveness of health education25-26 pointsResearch Topics – Criteria listed partially evaluates effectiveness of health education22-24No evaluation criteria listed0-21CLARITY OF WRITING10 pointsNo grammar, spelling, or syntax errors. Writes logically in complete sentences.10 pointsNo more than 2 errors of any type8-9 points2-3 errors of any type6-7 points3 or more errors of any type0-5 pointsTotal Points Possible = 250 pointsCourse Project Milestone #2: Nursing Diagnosis and Care Plan FormYour Name: Date:Your Instructorâs Name:Directions: Refer to the Milestone 2: Nursing Diagnosis and Care plan guidelines and grading rubric found in Doc Sharing to complete the information below. This assignment is worth 250 points, with 10 points awarded for clarity of writing, which means the use of proper grammar, spelling and medical language.Type your answers on this form. Click âSave asâ and save the file with the assignment name and your last name, e.g., âNR305_Milestone2_Form_Smithâ When you are finished, submit the form to the Milestone 2 Dropbox by the deadline indicated in your guidelines. Post questions in the Q&A Forum or contact your instructor if you have questions about this assignment.1: Analyze Assessment Data:Based on the health history information, identify the following:A. Areas for focused assessment (30 points)Provide a brief overview of those areas of strength and weakness noted from Milestone 1: Health History.B. Clientâs strengths (30 points)Expand on areas identified as strengths related to the person’s overall health. Support your conclusions with data from the textbook.C. Areas of concern (30 points)Expand on areas previously identified as abnormal and those that place the person at a health risk. Support your observations with data from the textbook.D. Health teaching topics (30 points)Identify health education needs. Support your statements with facts from the Health History and information from your textbook.2: Nursing Care PlanNext, plan your care based on your analysis of your assessment data:A. Diagnosis (30 points)Write one nursing diagnosis that reflects a priority need for this person. Remember a wellness diagnosis is a possibility.B. Plan (30 points)Write one goal and one measurable expected outcome related to your nursing diagnosis. Write my Essay Online Writing Service with Professional Essay Writers – Explain why this goal and outcome is a priority. Include cultural considerations for this client.C. Intervention (30 points)Write as many nursing orders or nursing interventions that you need in order to achieve the outcome. Provide the rationale for each intervention listed.D. Evaluation (30 points)You will not carry out your care plan so you cannot evaluate the effectiveness of your nursing interventions. Instead, comment on what you would look for in order to evaluate your effectiveness.
Important components of the psychiatric interview
Assignment Write a brief explanation (1 page) of three important components of the psychiatric interview and why you consider these elements important. Explain the psychometric properties of the rating scale you were assigned (Positive and negative symptom scale). Explain when it is appropriate to use this rating scale with clients during the psychiatric interview and […]
