| Course | NUR 545 Advanced Health and Literacy Assessment |
|---|---|
| Module | Module 3 |
| Paper type | Comprehensive health history with health literacy findings (milestone) |
| Length | About 1,180 words, 7 pages |
| Format | APA 7 student paper |
| School | Southern New Hampshire University |
| Program | MSN |
| Updated | September 2026 |
Free sample paper for NUR 545 Module 3
Milestone One: Comprehensive Health History and Health Literacy Findings for an Adult With Newly Diagnosed Type 2 Diabetes
[Student Name]
Southern New Hampshire University
NUR 545: Advanced Health and Literacy Assessment
Milestone One
[Instructor Name]
[Date]
The organization, setting and figures below are a composite written as a model document. No real employer, client, colleague or patient is described.
Milestone One: Comprehensive Health History and Health Literacy Findings for an Adult With Newly Diagnosed Type 2 Diabetes
A comprehensive health history is the foundation of assessment, and in a patient with a new chronic disease it is also the first chance to learn how that patient takes in information. This milestone documents the history of a composite 58-year-old patient seen at a community health center after a workplace screening, following the standard structure for adult histories (Bickley et al., 2021), and records health literacy findings gathered during the same visit. The history supports a diagnosis of type 2 diabetes with several cardiovascular risk factors, and the literacy findings show that the patient will need teaching built around demonstration and a simple daily routine rather than written instructions.
Identifying Data and Source
A 58-year-old man who works nights as a warehouse order picker, referred by his employer's occupational health service. He told his own story, consistently and in detail; his adult daughter, who attended the visit at his request, added details about diet and medications.
Chief Concern
"The nurse at work said my sugar was too high and I need to see a doctor."
History of Present Illness
Three months of increased thirst, drinking "a couple of big bottles of water a shift," and waking three times each day's sleep period to urinate. Reports vision that gets "fuzzy" late in his shift, improving after sleep. Unintended weight loss of about 4 kg over the same period despite no change in eating. Denies numbness or tingling in the feet, foot sores, chest pain, shortness of breath or fainting. A random fingerstick glucose at a workplace health fair two weeks ago was 286 mg/dL. Laboratory testing ordered by occupational health last week showed a hemoglobin A1C of 8.4% and a fasting plasma glucose of 172 mg/dL. No prior diagnosis of diabetes or prediabetes. Has not taken any treatment.
Past Medical, Medication and Allergy History
A pharmacy kiosk reading last year was, in his words, "up there"; he did not follow up. Chronic low back pain from work, treated with ibuprofen 400 mg two or three times a week. No hospitalizations or surgeries. Immunizations uncertain; believes he had a tetanus shot "a long time ago." No known drug allergies.
Family History
Mother had type 2 diabetes and died at 70 after a stroke. Father had a heart attack at 61 and died at 68. One brother, 55, with high blood pressure. Daughter, 22, healthy.
Social History
Works 10 p.m. to 6:30 a.m. five nights a week; sleeps from about 8 a.m. to 2 p.m. Eats one large meal around 3 a.m. at work, usually from a vending area, and drinks two 20-ounce regular sodas per shift. Former smoker, about 20 pack-years, quit 10 years ago. Drinks four beers on weekend days. Walks extensively at work. Lives with his daughter, who helps him with mail and forms. Left school in 10th grade. Says he learns best "when somebody shows me." Employer-sponsored insurance with a pharmacy benefit.
Health Literacy Findings
Single Item Literacy Screener: when asked how often he needs someone to help him read instructions or pamphlets from a doctor or pharmacy, answered "often." Newest Vital Sign, administered in English with his permission after explaining it helps the team plan teaching: 2 of 6 correct; answered questions about ice cream servings correctly but could not calculate calories or carbohydrates for a portion.
Review of Systems
General: tired by the end of each shift; weight loss as above. Eyes: blurring as above, last eye check "years ago." Heart and vessels: denies chest pressure, a racing heartbeat or swollen ankles. Lungs: no cough; not short of breath on the warehouse stairs. Digestive: bowels regular; denies belly pain. Urinary and sexual: frequent urination as above without burning; some difficulty with erections over the past year. Muscles and joints: the long-standing low back ache. Nerves: denies numb or weak limbs and headaches. Skin: a scrape on the forearm that is slow to heal. Mood and sleep: daytime sleep is "broken" by street noise; denies feeling down.
Analysis of the History
The history supports the diagnosis of diabetes. Classic symptoms of hyperglycemia, thirst, frequent urination, weight loss and blurred vision, accompanied a random glucose above 200 mg/dL, which alone meets diagnostic criteria, and an A1C of 8.4% and fasting glucose of 172 mg/dL both exceed diagnostic thresholds (American Diabetes Association Professional Practice Committee, 2025). His age, family history and weight history point to type 2 rather than type 1 diabetes, although the weight loss is a reason to watch for insulin deficiency.
The history also identifies risks that go beyond glucose. A likely history of untreated hypertension, a father's early heart attack, a mother's stroke, 20 pack-years of past smoking and erectile difficulty suggest considerable cardiovascular risk. Regular ibuprofen use matters for kidney function and blood pressure. The night-shift schedule, single large meal and sugary drinks will shape any plan for diet and medication timing.
Priorities for the Examination
The history directs the examination that follows. Blood pressure should be measured carefully, seated and after rest, with a repeat reading, since hypertension is likely and matters as much as glucose for his long-term risk. Weight, height, body mass index and waist circumference will set a baseline. A dilated eye examination referral is needed because of blurred vision and no recent eye care, although his symptom is more likely due to shifting glucose than to retinopathy. The feet need inspection, pulses and monofilament testing even though he reports no numbness, because loss of protective sensation is often silent. The skin, including the slow-healing forearm scrape, and signs of insulin resistance such as darkened skin at the neck should be noted. Laboratory tests should include kidney function, urine albumin and a lipid panel.
What the Literacy Findings Change
The SILS answer of often and the NVS score of 2 are consistent: fewer than four correct answers on the NVS indicate possible limited literacy (Weiss et al., 2005), and his specific difficulty was with calculation, which matters for counting carbohydrates and reading glucose values. The SILS is not sensitive enough to rule literacy problems in or out on its own (Morris et al., 2006), but in this patient both tools and his own description of how he learns point in the same direction. Three changes follow. The examination visit will include demonstration rather than handouts for any self-care skill. Teaching will focus on a small number of actions tied to his work routine rather than on numbers. His daughter, with his agreement, will be included as a support, but teaching will be directed to him, since he will be managing his diabetes on shifts when she is not there.
Conclusion
This 58-year-old patient's history establishes type 2 diabetes, identifies significant cardiovascular risk and reveals a working life that will shape his treatment. His literacy findings show that he learns by being shown and struggles with calculation, so the next stage of assessment and every piece of teaching must be designed around demonstration and routine. The focused examination and SOAP note in Module 4 will complete the assessment.
References
American Diabetes Association Professional Practice Committee. (2025). 2. Diagnosis and classification of diabetes: Standards of care in diabetes 2025. Diabetes Care, 48(Suppl. 1), S27-S49. https://doi.org/10.2337/dc25-S002
Bickley, L. S., Szilagyi, P. G., Hoffman, R. M., & Soriano, R. P. (2021). Bates' guide to physical examination and history taking (13th ed.). Wolters Kluwer.
Morris, N. S., MacLean, C. D., Chew, L. D., & Littenberg, B. (2006). The Single Item Literacy Screener: Evaluation of a brief instrument to identify limited reading ability. BMC Family Practice, 7, Article 21. https://doi.org/10.1186/1471-2296-7-21
Weiss, B. D., Mays, M. Z., Martz, W., Castro, K. M., DeWalt, D. A., Pignone, M. P., Mockbee, J., & Hale, F. A. (2005). Quick assessment of literacy in primary care: The newest vital sign. Annals of Family Medicine, 3(6), 514-522. https://doi.org/10.1370/afm.405
What the NUR 545 Module 3 instructions ask for
Milestone One in NUR 545 usually asks you to document a comprehensive health history for a patient, often from a scenario your section provides, and to incorporate health literacy. Typical requirements include identifying data, chief concern, history of present illness, past medical, medication and allergy history, family and social history, review of systems and the patient's health literacy, together with a brief analysis of what the history suggests. Some sections ask you to use a specific screening tool. The milestone usually runs four to six pages in APA 7, or follows a template. Keep the patient's words in quotation marks and your interpretation out of the history sections, since graders check for that separation. Save analysis for its own section at the end, where it can draw on everything above.
How this NUR 545 Module 3 milestone one example is built
The sample documents the history of a composite 58-year-old night-shift worker with newly diagnosed type 2 diabetes. The history sections follow the standard order and keep the patient's words in quotation marks, with pertinent negatives, outside results and uncertain items recorded as such. The social history captures the night schedule, eating pattern, schooling and preferred way of learning. Literacy findings record a SILS answer and an NVS score of 2 with the specific tasks missed. The analysis applies current ADA diagnostic criteria, identifies cardiovascular risks and explains three changes the literacy findings make to the examination and teaching. Four real sources support it, including the 2025 ADA standards and the two screening tools' validation studies.
Where the NUR 545 Module 3 rubric puts the points
History milestones are generally graded on completeness, organization, accuracy of documentation, the separation of subjective data from interpretation, the integration of health literacy and the quality of the brief analysis. Completeness includes sensitive and easily skipped items, such as sexual health, substance use and over-the-counter medicines. Organization follows a recognized structure, and graders notice when present illness details drift into the review of systems. Literacy integration earns credit when results are documented factually and used to change the plan, rather than noted and forgotten. The analysis should apply current diagnostic criteria with a citation and identify risks the history reveals.
NUR 545 Module 3 help: the mistakes that cost points
History milestones often lose points by mixing interpretation into the history, by leaving out the social details that shape treatment or by recording a literacy score without saying what it means. Another frequent issue is using outdated diagnostic thresholds. Follow a standard structure, quote the patient, record pertinent negatives, capture work, food, supports and learning preferences, document literacy findings factually and finish with a short analysis that applies current criteria and explains what the literacy results change. Read the finished history once as a stranger would, checking that every abnormal finding has a follow-up. If your scenario involves a different patient or condition, we can prepare a comprehensive history and analysis around it.
Get NUR 545 Module 3 written to your instructions
Attach your scenario, the milestone template or guidelines and the rubric. A comprehensive health history with literacy findings, current diagnostic criteria and a focused analysis is ready in 24 to 48 hours, and the first one is free. The paper above is an original model document written by our desk, not a submitted student paper and not an official Southern New Hampshire University document.
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NUR 545 Module 3 questions, answered
Where can I find a free NUR 545 Module 3 Milestone One sample?
The complete milestone on this page is free to read: a comprehensive health history for a composite adult with new type 2 diabetes, literacy screening results and an analysis of what they change, with four real sources.
What sections belong in a comprehensive health history?
Identifying data and source, chief concern, present illness, past medical, medication and allergy history, family history, social history and review of systems.
How do I document health literacy in a history?
Record the tool used, how it was introduced, the result and the specific tasks the patient could or could not do, then explain how it will change care.
What are the diagnostic criteria for diabetes?
Current ADA standards include an A1C of 6.5% or higher, fasting glucose of 126 mg/dL or higher, a 2-hour oral glucose tolerance value of 200 or higher, or a random glucose of 200 or higher with classic symptoms.
Why include the patient's work schedule in the history?
Schedules shape eating, sleep and medication timing. For a night-shift worker, the treatment plan must fit the hours he is actually awake and eating.