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Individual Client Health History and Examination
Individual Client Health History and Examination Details: In this assignment, you will be completing a health assessment on an older adult. To complete this Individual Client Health History and Examination 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 “Individual 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 “Individual 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.
Example.
Brooke William insists that he is well and doesn’t have any serious medical condition. This is despite his constant admission to the ER having suffered cardiac arrest multiple times. He acknowledges that he maintains a healthy diet and does his regular exercise. He regularly gets a visits from a local nurse to check his vials and monitor his condition and progress. Brook has a history of heavy smocking that affected his lungs and tracheal leading to difficulty in breathing at some point. This resulted into him being admitted for over three months. He has a number of prescription medicine for his heart but tends to forget the prescriptions which calls for external assistance from a nurse.
