Individual Client Health History And Examination

n 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.pdfhttps://www.ihs.gov/nnlc/includes/themes/
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.
Functional Health Pattern Assessment (FHP)

Pattern of Health Perception and Health Management:

1. How does the person describe current health?

1. What does the person do to maintain health?

1. What does person know about links between lifestyle and health?

1. How big a problem is financing health care for this person?

1. Can this person report his/her medications and the reason for taking them?

1. If this person has allergies, what does he/she do to prevent/manage them?

1. What does the person know about medical problems in his/her family?

1. Have there been any important illnesses/injuries in this person’s life?

Nutritional-Metabolic Pattern:

1. Is this person well-nourished?

1. How does this person’s food intake compare with recommended food intake?

1. Does this person have any disease that affects nutritional/metabolic function?

Pattern of Elimination:

1. Are the person’s excretory functions within normal range?

1. Does the person have any disease of the digestive system, urinary system, or skin?

Pattern of Activity and Exercise:

1. How does this person describe his/her weekly pattern of:

Activity/Leisure?–Exercise/Recreation?

0. Does this person have any disease that affects his/her:

Cardio/Respiratory System?–Musculoskeletal System?

Cognitive/Perceptual Pattern:

1. Does this person have any sensory deficits? If yes, are they corrected?

1. Can this person express himself/herself clearly and logically?

1. What is this person’s level of education?

1. Does this person have any disease that affects mental or sensory functions?

1. If this person has pain, describe it and its causes.

Pattern of Sleep and Rest:

1. Describe this person’s sleep/wake cycle.

1. Does this person appear physically rested and relaxed?

Pattern of Self-Perception and Self-Concept:

1. Is there anything unusual about this person’s appearance?

1. Does this person seem comfortable with his/her appearance?

1. Describe this person’s feeling state.

Role-Relationship Pattern:

1. How does this person describe his/her various roles in life?

1. Has, or does this person presently have positive role models for these roles?

1. Which relationships are most important to this person at this time?

1. Is this person presently going through any changes in role or relationships? If yes, describe changes.

Sexuality – Reproductive Pattern:

1. Is this person satisfied with his/her situation related to sexuality?

1. Does this person have any disease/dysfunction of the reproductive system?

1. Is this person satisfied with his/her plans regarding children?

Pattern of Coping and Stress Tolerance:

1. How does this person cope with difficult situations/problems?

1. Do these coping mechanism/actions help or make things worse?

1. Has this person had any treatment for emotional distress?

Pattern of Value and Beliefs:

1. What principles did this person learn as a child that are still important to him/her?

1. Does this person identify with any social, religious, ethnic, regional, cultural, or other groups?

1. What support systems does this person currently have?

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