1.- Functional Health Pattern Assessment 2.- Individual Health History Examination Assignment

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Heath History and Examination - Older adult

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.

SBAR template https://www.ihs.gov/nnlc/includes/themes/responsiv...

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Functional Health Pattern Assessment (FHP) Pattern of Health Perception and Health Management: • How does the person describe current health? • What does the person do to maintain health? • What does person know about links between lifestyle and health? • How big a problem is financing health care for this person? • Can this person report his/her medications and the reason for taking them? • If this person has allergies, what does he/she do to prevent/manage them? • What does the person know about medical problems in his/her family? • Have there been any important illnesses/injuries in this person’s life? Nutritional-Metabolic Pattern: • Is this person well-nourished? • How does this person’s food intake compare with recommended food intake? • Does this person have any disease that affects nutritional/metabolic function? Pattern of Elimination: • Are the person’s excretory functions within normal range? • Does the person have any disease of the digestive system, urinary system, or skin? Pattern of Activity and Exercise: • How does this person describe his/her weekly pattern of: Activity/Leisure?--Exercise/Recreation? • Does this person have any disease that affects his/her: Cardio/Respiratory System?--Musculoskeletal System? Cognitive/Perceptual Pattern: • Does this person have any sensory deficits? If yes, are they corrected? • Can this person express himself/herself clearly and logically? • What is this person’s level of education? • Does this person have any disease that affects mental or sensory functions? • If this person has pain, describe it and its causes. Pattern of Sleep and Rest: • Describe this person’s sleep/wake cycle. • Does this person appear physically rested and relaxed? Pattern of Self-Perception and Self-Concept: • Is there anything unusual about this person’s appearance? • Does this person seem comfortable with his/her appearance? • Describe this person’s feeling state. Role-Relationship Pattern: • How does this person describe his/her various roles in life? • Has, or does this person presently have positive role models for these roles? • Which relationships are most important to this person at this time? • Is this person presently going through any changes in role or relationships? If yes, describe changes. Sexuality – Reproductive Pattern: • Is this person satisfied with his/her situation related to sexuality? • Does this person have any disease/dysfunction of the reproductive system? • Is this person satisfied with his/her plans regarding children? Pattern of Coping and Stress Tolerance: • How does this person cope with difficult situations/problems? • Do these coping mechanism/actions help or make things worse? • Has this person had any treatment for emotional distress? © 2016. Grand Canyon University. All Rights Reserved. Pattern of Value and Beliefs: • What principles did this person learn as a child that are still important to him/her? • Does this person identify with any social, religious, ethnic, regional, cultural, or other groups? • What support systems does this person currently have? © 2016. Grand Canyon University. All Rights Reserved. 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: Occupation of Client/Patient: Sex: Age: 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): Head and Neck (pain, headaches, head/neck injury, neck pain, lumps/swelling, surgeries on head/neck, medications): 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): Ears (earache or other ear pain, history of ear infections, discharge from ears, history of surgery, difficulty hearing, environmental noise exposure, vertigo, medications): Nose, Mouth, and Throat (discharge, sores or lesions, pain, nosebleeds, bleeding gums, sore throat, allergies, surgeries, usual dental care, medications): Skin, Hair and Nails (skin disease, changes in color, changes in a mole, excessive dryness or moisture, itching, bruising, rash or lesions, recent hair loss, changing nails, environmental hazards/exposures, medications): Breasts and Axilla (pain or tenderness, lumps, nipple discharge, rash, swelling, trauma or © 2016. Grand Canyon University. All Rights Reserved. injury to breast, mammography, breast self-exam, medications): Peripheral Vascular and Lymphatic System (leg pain, cramps, skin changes in arms or legs, swelling in legs or ankles, swollen glands, medications): Cardiovascular System (chest pain or tightness, SOB, cough, swelling of feet or hands, family history of cardiac disease, tire easily, self-history of heart disease, medications): Thorax and Lungs (cough, SOB, pain on inspiration or expiration, chest pain with breathing, history of lung disease, smoking history, living/working conditions that affect breathing, last TB skin test, flu shot, pneumococcal vaccine, chest x-ray, medications): Musculoskeletal System (joint pain; stiffness; swelling, heat, redness in joints; limitation of movement; muscle pain or cramping; deformity of bone or joint; accidents or trauma to bones; back pain; difficulty with activity of daily living, medications): Gastrointestinal System (change in appetite – increase or loss; difficulty swallowing; foods not tolerated; abdominal pain; nausea or vomiting; frequency of BM; history of GI disease, ulcers, medications): Genitourinary System (recent change, frequency, urgency, nocturia, dysuria, polyuria, oliguria, hesitancy or straining, urine color, narrowed stream, incontinence, history of urinary disease, pain in flank, groin, suprapubic region or low back): Physical Examination (Comprehensive examination of each system. Record findings.) Neurological System (exam of all 12 cranial nerves, motor and sensory assessments): Head and Neck (palpate the skull, inspect the neck, inspect the face, palpate the lymph nodes, palpate the trachea, palpate and auscultate the thyroid gland): Eyes (test visual acuity, visual fields, extraocular muscle function, inspect external eye structures, inspect anterior eyeball structures, inspect ocular fundus): © 2016. Grand Canyon University. All Rights Reserved. Ears (inspect external structure, otoscopic examination, inspect tympanic membrane, test hearing acuity): Nose, Mouth, and Throat (Inspect and palpate the nose, palpate the sinus area, inspect the mouth, inspect the throat): Skin, Hair and Nails (inspect and palpate skin, temperature, moisture, lesions, inspect and palpate hair, distribution, texture, inspect and palpate nails, contour, color, teach selfexamination techniques): Breasts and Axilla (deferred for purpose of class assignment) Peripheral Vascular and Lymphatic System (inspect arms, symmetry, pulses; inspect legs, venous pattern, varicosities, pulses, color, swelling, lumps): Cardiovascular System (inspect and palpate carotid arteries, jugular venous system, precordium heave or lift, apical impulse; auscultate rate and rhythm; identify S1 and S2, any extra heart sounds, murmur): Thorax and Lungs (inspect thoracic cage, symmetry, tactile fremitus, trachea; palpate symmetrical expansion;, percussion of anterior, lateral and posterior, abnormal breathing sounds): Musculoskeletal System (inspect cervical spine for size, contour, swelling, mass, deformity, pain, range of motion; inspect shoulders for size, color, contour, swelling, mass, deformity, pain, range of motion; inspect elbows for size, color, contour, swelling, mass, deformity, pain, range of motion; inspect wrist and hands for size, color, contour, swelling, mass, deformity, pain, range of motion; inspect hips for size, color, contour, swelling, mass, deformity, pain, range of motion; inspect knees for size, color, contour, swelling, mass, deformity, pain, range of motion; inspect ankles and feet for size, color, contour, swelling, mass, deformity, pain and © 2016. Grand Canyon University. All Rights Reserved. range of motion): Gastrointestinal System (contour of abdomen, general symmetry, skin color and condition, pulsation and movement, umbilicus, hair distribution; auscultate bowel sound;, percuss all four quadrants; percuss border of liver; light palpation in all four quadrants– muscle wall, tenderness, enlarged organs, masses, rebound tenderness, CVA tenderness): Genitourinary System (deferred for purpose of this class) FHP Assessment Cognitive-Perceptual Pattern: Nutritional-Metabolic Pattern: Sexuality-Reproductive Pattern: Pattern of Elimination Pattern of Activity and Exercise: Pattern of Sleep and Rest: Pattern of Self-Perception and Self-Concept: Summarize Your Findings (Use format that provides logical progression of assessment.) Situation (reason for seeking care, patient statements): © 2016. Grand Canyon University. All Rights Reserved. Background (health and family history, recent observations): Assessment (assessment of health state or problems, nursing diagnosis): Recommendation (diagnostic evaluation, follow-up care, patient education teaching including health promotion education): © 2016. Grand Canyon University. All Rights Reserved.
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Running Head: HEALTH HISTORY AND EXAMINATION

Health History and Examination
Name
Instructor
Institutional Affiliation
Date

1

HEALTH HISTORY AND EXAMINATION

2

Health History and Examination

Student Name:

Date: August 3, 2018

Client/Patient Initials: N.A.C

Sex: Female

Age: 55

Occupation of Client/Patient: High school teacher
Health History/Review of Systems
(Complete and systematic review of systems)
Neurological System: The patient complains of having headaches at least twice a week. She
frequently feels dizzy especially in the evening after a long day at work. N.A.C has no history of
head injuries, tremors and convulsions. However, she complains of numbness accompanied with
tingling during the night (Swartz, 2014).
Head and Neck: The patient has no history of head/neck injury and has never experienced neck
pain. She however complains of frequent headaches and often takes paracetamol to ease the pain.
N.A.C also has no lumps in the neck and has never undergone neck surgeries.
Eyes: The patient wears reading glasses but feels that her vision is getting worse. She however
has no medical history of eye pain or diplopia. Her eyes are watery when she is exposed to too
much light.
Ears: The patient has difficulties hearing and sometimes wears a hearing aid. She also complains
of earache once a month but uses ibuprofen to ease the pain. N.A.C has no history of surgery or
ear infections.
Nose, Mouth, and Throat: The patient sometimes experiences nosebleeds and bleeding gums. To
address the bleeding gums problem, N.A.C practices good oral hygiene. She also experiences

© 2018. Grand Canyon University. All Rights Reserved.

HEALTH HISTORY AND EXAMINATION

3

sore throat especially when she has a viral infection such as flu. N.AC has no history of lesions
and has never had surgeries in the nose, throat, and mouth
Skin, Hair and Nails: The patient denies ever having a skin disease, itching, skin rash, or a mole
in the skin. She however reports that she had experienced recent hair loss and her fingernails
have ridges (Swartz, 2014).
Breasts and Axilla: The patient denies feeling any pain in her breast and has no lumps, rash, or
swelling. She reports that she had a mammography in May this year. She also states that she
always performs a self-breast examination at least twice a month. N.A.C has no history of injury
to the breast and has never taken any breast pain medications
Peripheral Vascular and Lymphatic System: The patient sometimes experiences leg pain and
cramps when she wears high-heels shoes. She has never had swollen glands or witnessed skin
changes in her arms or legs. She does not take any medications.
Cardiovascular System: The patient often experiences chest pain especially during winter season.
She also feels tired easily and coughs a lot during the cold season. Her family has a history of
cardiovascular disease as her grandmother and mother both died of this illness. She takes
nitroglycerin to relax her heart arteries and aspirin to ease the pain chest.
Thorax and Lungs: The patient experiences chest pain and cough especially during the cold
season. She also reports of having pain on inspiration. Her family has a history of lung disease.
The patient however does not smoke. She has never had a chest x-ray and only takes pain killers
to ease the chest pain.
Musculoskeletal System: N.A.C complains of having joint pains and redness in joins which
limits her movement. She has never had trauma to bones or deformity of joints. The patient takes
pain relievers medications to ease the joint pains. The joint pains also cause her to have

© 2018. Grand Canyon University. All Rights Reserved.

HEALTH HISTORY AND EXAMINATION

4

difficulties handling heavy loads.
Gastrointestinal System: The patient cites that she had ulcers but after taking medications, the
illness was cured. She reports that her appetite has not changed and doesn’t have difficulties
when swallowing food. She denies having any abdominal pain or nausea.
Genitourinary System: The patient cites that she wakes up at least three times at night for
voiding. She states that her urine color is pale yellow and has no history of urinary disease. She
denies having pain in the lower back (Swartz, 2014).
Physical Examination
(Comprehensive examination of each system. Record findings.)
Neurological System: The cranial nerves II-XII of the patient are normal. Furthermore, the motor
and sensory examination of the lower and upper extremities is also normal. The reflexes appear
normal and proportional bilaterally in both extremities.
Head and Neck: The neck moves easily without any resistance. The anterior and posterior
cervical is normal. The supra-clavicular as well as the sub-mandibular appear to be normal. The
cervical adenopathy is normal. Jugular venous pressure is measured as 9 cm with patient at 44
degrees (Forbes, Watt, 2015).
Eyes: The assessment of the visual acuity shows the result of 20/50 with corrective lenses. The
ocular is symmetrical and the sclera is yellow in color. The patient’s conjunctiva is red in color
and the structures of the pupil and iris are round and symmetric. The patient’s ...


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