Family History

Family History (to include three (3) generations for the Genogram) and lastly Lifestyle/Health Practices Data. This is time consuming so plan to complete the assignment in detail ?
Performance Objectives:
€¢ Collect subjective data to include present health concerns, past health history, family history and lifestyle/health practices related to:
o abdomen.
o neurological
o mental status
o musculoskeletal system.
o general status
Rubric
Inadequate/ Incomplete data will result in 0 points earned as listed in the rubric
o N/A and Normal/WNL is not acceptable
o Submissions must be in narrative as listed in the Lab Manual required for assignment completion

Comprehensive Data
o Subjective Data must include without omissions the Nursing Interview Guide under each topical System listed in the required Lab Manual.
Documented assessment findings should not be copied from the lab manual or text but based on your physical assessment data.

If the student uses the verbiage from the lab manual text, they should cite the text as a reference to avoid allegations of plagiarism. Five or more words copied in a row require an in-text citation. A reference to the lab manual is required in this assignment.

 
Use this rubric to guide your work on the assignment, Week 4 Subjective Data Collection. Be sure you use the Common Error guide located in week 1 of the course to avoid common documentation errors.
Components Proficient
Acceptable Incomplete Information
Documented Correct Format
Document is in the correct forma with zero to one error. Includes:
€¢ History of Present Health Concern with at least one COLDSPA per assignment
€¢ Past health history
€¢ Family history
€¢ Lifestyle/Health Practices

(25 Point) Needs improvement, 2-3 errors in documentation
(15 point) Incomplete or incorrect with 4 or more errors
(0 Points)
Data Sheet Accuracy
Data sheet is accurate with zero to one error:
€¢ Abdomen
€¢ Neurological
€¢ Mental Status
€¢ Musculoskeletal
€¢ General status
(25 point) Needs improvement, 2-3 errors in documentation
(15 point) Incomplete or incorrect with 4 or more errors
(0 point)
Covers all Lab Manual Variables
Collects complete subjective data items listed in lab manual with zero to one error.
(25 point) Needs improvement, 2-3 errors in documentation
(15 point) Incomplete or incorrect with 4 or more errors
(0 point)
Able to Document Findings Comprehensively
Able to formulate articulate comprehensive statements of the subjective data collected in narrative format with zero to one error.
(25 points) Needs improvement, 2-3 errors in documentation
(15 point) Incomplete or incorrect with 4 or more errors
(0 point)
All assignments must be submitted and complete for completion of N3425 requirements.
N3425 RN-BSN Holistic Health Assessment reduces the maximum grade by 25% for any late submissions without prior written notification and permission from the faculty based on documentation related to unavoidable situations like illness, hospitalization or death. Lack of planning or time management and work related delays will not be granted waiver of late penalty.
Subjective Data Sheet
1) Record in narrative format your subjective data findings from your client for abdomen using pages 166 (Activity E) in your lab manual and the following headings:
Current Symptoms:

Past History:

Family History:

Lifestyle and Health Practices:

2) Record in narrative format your subjective data findings from your client for musculoskeletal using page 178 (Activity E) in your lab manual and the following headings:
Current Symptoms:

Past History:

Family History:

Lifestyle and Health Practices:

3) Record in narrative format your subjective data findings from your client for nervous system using pages 189-190 (Activity E) in your lab manual and the following headings (Omit Analysis of Data section):
Current Symptoms:

Past History:

Family History:

Lifestyle and Health Practices:

4) Record in narrative format your subjective data findings from your client for mental status using pages 29-30 (Activity C) and the following headings:
Biographical Data:

Present History (with COLDSPA):

Past Health History:

Family History:

Lifestyle and Health Practices:

5) Record in narrative format your subjective data findings from your client for general status using page 45 (Activity D) in your lab manual and the following headings (this may be copied from week 1 assignment):
Present History (with COLDSPA):

Past History:

Family History:

Lifestyle and Health Practices:

References

 
Name: Sample for format only-do not use this template for your week 1 assignment Date:
Overview: Subjective Data Collection
In this assignment, you will find an adult person from whom to collect holistic health assessment data over the course of five weeks and conduct a subjective assessment. You will follow the nursing process as well as the steps outlined in the course. Documentation is to be completed on this template.
Must Read: WRITER THIS IS A SAMPLE DOCUMENT REMEMBER THE WORD COLDSPA STANDS FOR
These questions follow the same pattern as the Lab Manual and will help you collect organized Subjective Data for the topics completed each week. Please follow the order of Current Symptoms with COLDSPA for each complaint, followed by Past History (Medical and Surgical), and followed by Family History (to include three (3) generations for the Genogram) and lastly Lifestyle/Health Practices Data. This is time consuming so plan to complete the assignment in detail ?
Performance Objectives:
€¢ Collect subjective data to include present health concerns, past health history, family history and lifestyle/health practices related to:
o Collect assessment data of childbearing woman
Rubric
Inadequate/ Incomplete data will result in 0 points earned as listed in the rubric
o N/A and Normal/WNL is not acceptable
o Submissions must be in narrative as listed in the Lab Manual required for assignment completion

Comprehensive Data
o Subjective Data must include without omissions the Nursing Interview Guide under each topical System listed in the required Lab Manual.
Documented assessment findings should not be copied from the lab manual or text but based on your physical assessment data.

If the student uses the verbiage from the lab manual text, they should cite the text as a reference to avoid allegations of plagiarism. Five or more words copied in a row require an in-text citation. A reference to the lab manual is required in this assignment.

 
Use this rubric to guide your work on the assignment, Sample Subjective Data Collection. Be sure you use the Common Error guide located in week 1 of the course to avoid common documentation errors.
Components Proficient Acceptable Incomplete Information
Documented Correct Format
Document is in the correct forma with zero to one error. Includes:
€¢ History of Present Health Concern with at least one COLDSPA per assignment
€¢ Past health history
€¢ Family history
€¢ Lifestyle/Health Practices

(25 Point) Needs improvement, 2-3 errors in documentation
(15 point) Incomplete or incorrect with 4 or more errors
(0 Points)
Data Sheet Accuracy
Data sheet is accurate with zero to one error:
€¢ Assessment of childbearing woman
(25 point) Needs improvement, 2-3 errors in documentation
(15 point) Incomplete or incorrect with 4 or more errors
(0 point)
Covers all Lab Manual Variables
Collects complete subjective data items listed in lab manual with zero to one error.
(25 point) Needs improvement, 2-3 errors in documentation
(15 point) Incomplete or incorrect with 4 or more errors
(0 point)
Able to Document Findings Comprehensively
Able to formulate articulate comprehensive statements of the subjective data collected in narrative format with zero to one error.
(25 points) Needs improvement, 2-3 errors in documentation
(15 point) Incomplete or incorrect with 4 or more errors
(0 point)
All assignments must be submitted and complete for completion of N3425 requirements. ANY LATE SUBMISSION OF ASSIGNMENTS WILL RECEIVE A MAXIMUM GRADE REDUCED TO 25% AS LATE PENALTIES. THE LATE PENALTIES MAY BE AVOIDED BY COMMUNICATING WITH YOUR COACHES VIA EMAIL. LATE PENALTIES ARE NOT APPLICABLE IF THE STUDENT HAS MADE PRIOR ARRANGEMENTS FOR LATE SUBMISSION WITH THE COACHES.

Subjective Data Sheet
1) Record in narrative format your subjective data findings from your client for assessment of childbearing woman using pages 230-231 (Activity C) in your lab manual and the following headings:
Current Symptoms:
J.S. reports 17 pound weight gain with pregnancy, denies upper respiratory or cold symptoms, denies stomach or bowel problems, nausea or vomiting with pregnancy, reports burning with urination:
C: burning with urination
O: 2 days ago
L: urinary, on stopping stream
D: times 2 days
S: rates 9/10 on pain scale, it hurts so much
P: complains of frequency and every time urinates
A: associated symptoms are frequency, stinging, and pain, denies bloody urine. Affects the client as she reports unable to sleep last night due to frequent trips to the bathroom.
Denies vaginal discharge, bleeding, or leaking any fluids. Client reports no psychological problems associated with pregnancy. Denies changes to breasts.
Past History:
Denies past pregnancy. LMP was August 5, 2013, denies bleeding since this time. No birth control used during pregnancy or within the last year. Reports no history of infertility, reproductive surgeries, or abnormal Pap smears. Reports diagnosed with a STD at age 18 and was treated with antibiotics at the time. Reports blood type B+; medical history positive for broken femur at age 12 due to skiing accident, denies hospitalizations or previous surgeries except for wisdom teeth removal as teen.
Family History:
J.S. denies family history of birth defects. Ethnic background is Hispanic. Reports family history of Factor V in maternal grandmother, mother, 2 maternal aunts, and 1 cousin. Paternal grandmother and father with HTN and pacemakers. Denies family history of lung disease, diabetes, asthma, cancer, mental retardation, or sickle cell disease.
Lifestyle and Health Practices:
Client is 24 years old, takes multivitamin prescribed by OB, denies other medications or use of alcohol or cigarettes. Denies street drug use and reports family members have not stated she has a problem with any social habits. 24 hour diet includes: breakfast had one Greek yogurt, 1 piece wheat toast with jam, 8oz orange juice and one cup of coffee; for lunch at turkey sandwich on wheat, banana, and bottle of water; dinner 2 pork tacos, rice, beans, small salad; denies snacking during pregnancy. Client reports she drinks about 6 8 oz water bottles per day. Baseline weight reported at 120 and current weight 137 per client. Reports she walks 20 minutes every evening; client is a medical assistant and had medical assistant certification. Works day shift 8am-4pm full time. Denies exposure to radiation or chemicals, denies risk of toxoplasmosis and does not have exposure to cats. Client is married to spouse who works full time as financial analyst; reports husband is supportive of pregnancy. Reports no family nearby but has close friends. No other children in home.

References
Weber, J., Kelly, J., & Sprengle, A.D. (2014). Lab Manual for Health assessment in nursing (5th ed.) Philadelphia, PA: Lippincott Williams & Wilkins.