Please, read carefully the instructions, thank you.

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.

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


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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

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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):

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 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, swellin

Top of Form

Benchmark – Individual Client Health History and Examination

 

1
Unsatisfactory
0.00%

2
Less than Satisfactory
75.00%

3
Satisfactory
79.00%

4
Good
89.00%

5
Excellent
100.00%

80.0 %Content

 

40.0 % Uses SBAR Format to Include All Components of the Health History (Biographical, Past Heath, Family, Symptoms) Using Appropriate Medical Acronyms and Abbreviations

With or without SBAR format, provides incomplete medical history with or without use of appropriate medical acronyms and abbreviations.

Uses SBAR format to provide all components of the health history based upon the information collected in the health history. Appropriate medical acronyms and abbreviations are absent or inconsistent.

Uses SBAR format to provide all components of the health history (biographical, past health, family, symptoms) using appropriate medical acronyms and abbreviations.

Uses SBAR format to provide all components of the health history (biographical, past health, family, symptoms) using appropriate medical acronyms and abbreviations, and relates information to the diagnoses.

Uses SBAR format to provide all components of the health history (biographical, past health, family, symptoms) using appropriate medical acronyms and abbreviations, and relates information to the diagnoses and integrates into treatment plan.

40.0 % Benchmark D5: Holistic Patient Care Competency 5.1: Understand the human experience across the health-illness continuum

Health screening and diagnosis do not demonstrate understand of the human experience across the health-illness continuum.

Health screening and diagnosis suggest minimal understanding of the human experience across the health-illness continuum.

Health screening and diagnosis demonstrate understanding of the human experience across the health-illness continuum.

Health screening and diagnosis are integrated in an understanding of the human experience across the health-illness continuum.

Health screening and diagnosis are integrated in an understanding of the human experience across the health-illness continuum and provide specific suggestions for treatment across this continuum.

10.0 %Organization and Effectiveness

 

10.0 % Mechanics of Writing (Includes spelling, punctuation, grammar, and language use

SBAR TEMPLATE – to submit issues of concern to NNLC
The SBAR (Situation-Background-Assessment-Recommendation) technique provides a framework for communication
between members of the health care team. Although this technique was original developed to target a patient-centered
condition, the NNLC will implement this technique to communicate and address critical issues to support immediate
attention and action by the committee. This SBAR tool was developed by Kaiser Permanente.

S
Situation:
What is the situation you are writing about?

• Identity self, health care site, area, title, date, etc.
• Briefly state the problem/issue, what is it, when it happened or started, and how severe.

EXAMPLE:
Author: Sharon Feldstein, Chair-Albuquerque Area Council of Nurse Executives
Date: July 10, 2008
Situation: Public Health Nursing Funded Positions

B
Background
Pertinent background information related to the situation could include the following:

• The history of problem/issue, the date of the problem/issue.
• List of current situations.
• Most recent occurrences.
• National standards, policy, regulations, standards, requirements.

EXAMPLE:
Background:
At the John P. Morgan Health Center, during FY 2008, the Public Health Nursing (PHN) department
consisted of 5 PHNs. During this time, 3 PHNs were detailed to outpatient on average 40% of their time and
supervised by the Clinical Director, which decreased the PHN Provider Productivity significantly.
The IHS Public Health Nursing scope of Practice is designed to build healthy communities by promoting
healthy behaviors and lifestyles through provision of care based on a primary prevention public health model.
The American Nurses Association Scope of Practice Model describes the practice of the PHN as placing
emphasis on primary prevention in all health promotion & health protection strategies with the focus on
population level outcome.
The GPRA objective related to the Health Promotion & Disease Prevention correlates directly with the PHN
program funding & is most effective with the PHN planning, developing, & supporting systems in the
community setting.
PHN visits are done primarily in the home, PHN specialty clinics, PHN office settings, school & community
sites with primary prevention as the focus for meeting the IHS mission.
PHN core services are divided into direct & indirect care activities listed in the RRM document with do not
cover services defined in the clinic settings supervised by another discipline.
The standard PHN position description, which is held at a minimum educational level of BSN, describes PHN
supervision directly under the DPHN & with the scope of community focused primary prevention.

A
Assessment
What is your assessment of the situation?

EXAMPLE:
Assessment: A lack of adherence to the defined standards identifie