health Assessment

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Question Description

In this assignment, you will be completing a health assessment on an older adult. To complete this assignment, do the following:

  1. Perform a health history on an older adult. Students who do not work in an acute setting may "practice" these skills with a patient, community member, neighbor, friend, colleague, or loved one. (If an older individual is not available, you may choose a younger individual).
  2. Complete a physical examination of the client using the "Health History and Examination" assignment resource. Use the "Functional Health Pattern Assessment" resource as a guideline to assist you in completing the template.
  3. Document findings of complete physical examination in Situation-Background-Assessment-Recommendation (SBAR) format. Refer to the sample SBAR Template located on the National Nurse Leadership Council website at https://www.ihs.gov/nnlc/includes/themes/newihstheme/display_objects/documents/resources/SBARTEMPLATE.pdf as a guide.
  4. Document the findings of the physical examination in the assessment worksheet.
  5. Using the "Health History and Examination" assignment resource, provide the physical examination findings summary with planned interventions for the client. Include any community services in the interventions.

APA format is not required, but solid academic writing is expected.

This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.

The individual health history and examination form is attached .

Tutor Answer

Lessermaster
School: UIUC

Attached.

Health History and Examination

Health Assessment of the Head, Neck, Eyes, Ears, Nose, Mouth, Throat, Neurological
System, and the 12 Cranial Nerves Skin, Hair, Nails, Breasts, Peripheral Vascular
System, Lymphatics, Thorax, Heart, Lungs, Musculoskeletal, Gastrointestinal, and
Genitourinary Systems

Save this form on your computer as a Microsoft Word document. You can expand or shrink each
area as you need to include relevant data for your client.

Student Name:

Date:

Client/Patient Initials:

Sex:

Age:

Occupation of Client/Patient:
Health History/Review of Systems
(Complete and systematic review of systems)
Neurological System (headaches, head injuries, dizziness, convulsions, tremors, weakness,
numbness, tingling, difficulty speaking, difficulty swallowing, etc., medications):
➢ The patient denies any possibilities of head injuries, headaches, convulsions, tremors,

© 2011. Grand Canyon University. All Rights Reserved.

numbness, tingling, challenges in speaking and swallowing food and drinks.
➢ Patient denies taking any medication in connection to her neurological system.
➢ The patient states that when she wakes up, she has to take a moment because of dizziness.

Head and Neck (pain, headaches, head/neck injury, neck pain, lumps/swelling, surgeries on
head/neck, medications):
➢ Patient denies any challenges in the head and neck. However, the patient asserts that she
normally accompany herself with a special pillow because her neck normally get sore
when she uses a wrong pillow.
➢ The patient denies taking medication.

Eyes (eye pain, blurred vision, history of crossed eyes, redness/swelling in eyes, watering,
tearing, injury/surgery to eye, glaucoma testing, vision test, glasses or contacts, medications):
➢ The patient states that she has a bad history of dry macular degeneration and it is being
well managed and controlled.
➢ Patient utilizes the special eye drops for her eye condition
➢ The client puts on corrective lenses and admits to blurred vision frequently.
➢ Negative glaucoma testing on 23rd February 2014
➢ Eye surgery in connection to the muscular degeneration on 18th August 2013.

Ears (earache or other ear pain, history of ear infections, discharge from ears, history of

© 2011. Grand Canyon University. All Rights Reserved.

surgery, difficulty hearing, environmental noise exposure, vertigo, medications):
➢ The patient denies possibility of ear problems.
➢ The last ear infections were over 10 years ago.
➢ No particular discharge was noted from the ears.

Nose, Mouth, and Throat (discharge, sores or lesions, pain, nosebleeds, bleeding gums, sore
throat, allergies, surgeries, usual dental care, medications):
➢ Pink lips, mucous membranes pink and moist.
➢ No discharge or foul odor eminent
➢ No history of nose bleeding, bleeding gums, allergies or surgeries on the nose, mouth or
throat.
➢ Lymph nodes hardly palpable
➢ The client had four wisdom teeth removed at the age of 20
➢ The patient admits that she flosses daily, and also brushes her teeth twice a day with
sensodine.
➢ No noted dentures
➢ No missing teeth

Skin, Hair and Nails (skin disease, changes in color, changes in...

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Review

Anonymous
awesome work thanks

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