Description
Benchmark
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:
- 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).
- 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.
- 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.
- Document the findings of the physical examination in the assessment worksheet.
- 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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Explanation & Answer
Attached.
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
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HEALTH HISTORY AND EXAMINATION
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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
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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 ...