Health history of an 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 “Individual Health History and
    Examination Assignment” resource. Use “Functional Health Pattern Assessment” as a
    guideline to assist you in completing the template.
  3. Document findings of complete physical examination in Situation-Background-
    Assessment-Recommendation Format (SBAR) by using the SBAR format. Refer to the
    “SBAR Template,” located on the National Nurse Leadership Council Document the
    findings of the physical examination in assessment worksheet.
  4. Using the “Individual Health History and Examination Assignment,” provide the
    physical examination findings summary with planned interventions for the client. Include
    any community services in the interventions.
  5. APA format is not required, but solid academic writing is expected.

Health history of an older adult

In order to provide better health care, it is prudent to understand the health history of a
client before embarking on treatment. This information forms the basis on which to administer
treatment (Shannon, Long-Sutehall & Coombs, 2011). In ensuring that this information is well
captured, health practitioners use different strategies; one being the functional health pattern
assessment and situation-background-assessment recommendation formats. This paper focuses
on the history of Andrew, an old man indeed of medical attention.
Individual health history and examination history allows the medical practitioner to
capture all the relevant information about the patient. This information covers different aspects
of the clients such as biographical information, prior treatment and diagnosis among many other
aspects (Gikow & Patricia, 1987). The history of this old man is therefore presented herein.

The old man name is Andrew Alexander, a retired army officer. He was born in 1930 in
Ohio State. He is an American. He is married to one wife and has three children. His address is
567, Grin Ave. Ohio, 2345900. The financial status of Andrew is stable. He received
compensation and benefits when he retired from the army thirteen years ago. Furthermore, his
three children have stable incomes and provide financial support. The old man is concerned
about his own health and in case he feels unwell, he normally goes to the nearby hospital for
checkups and treatment. The old man has not had any severe health complications that required
him to visit a health facility. He has his own training field where he does his physical exercise
on daily basis. The physical exercise session takes duration of between 1-2 hours on daily basis.
This has helped the old man remain stable and strong. The health history the old man has had is
that he was admitted in hospital two years back and diagnosed with malaria. The client since
then has been in good health condition being able to meet all his schedules. He stated that he did
not have any allergies. He also stated that he did not undergo any screening for diseases for
quite a long period. The only time he was screened, was when he joined the army as a recruit. At
that particular moment, he had no any health complications. He also denies having any injuries
during his time of service in the army and therefore, he could not remember any time that he was
hospitalized for more than a week. Furthermore, he did not undergo any surgery and never used
alcohol in his entire life. The family health history of Andrew has had a number of people
succumbing to death due to cancer. In the last month, Andrew complained of a swelling in one
of his testicles, which made him to be suspicious prompting him to come to the health facility for
further diagnosis of what this, might be. In his entire life, he had never had such experience.
Situation-Background- Assessment- Recommendation (SBAR) template developed by
Kaiser Permanente is a good tool to clearly explain the health history of Andrew. It provides a

communication framework between the members of a health care team as well as capturing
patients detailed (Boaro et al. (2010). Therefore, it allows immediate actions to be taken to
ensure that a client receives immediate health interventions.

S Situation
The patient name is Andrew aged 83 years and is seeking medical attention at Ohio state
hospital. He reported to the facility on August 5, 2013. The client is complaining about a
swelling on one of his testicles. It is a hard swelling, which needs attention.
B Background
The client stated that the he first saw the swelling on July 3, 2013
He tried to apply a number of pharmaceutical products but the situation could not improve
prompting him to take and initiative of seeing a doctor.
Prior to this swelling, the old man was living a healthy life attending to all his schedules as
A Assessment
From the assessment of the situation, the old man is likely to be having cancer. This is one of
the early signs that manifest to those people that have prostate cancer.
Furthermore, the fact that a number of people in his family have died due to cancer, the


chances of it being cancerous are very high.
R Recommendation
Therefore, as a result of this, it is highly recommended, for the old man to be tested for
cancer as the first priority. If this is not the case, other tests should also be carried to establish
the causes of the swelling for immediate administering of medication. Incase the old man is
diagnosed with cancer, it will be appropriate to begin quick treatment such as radiotherapy to
kill the cells if in its earlier stages. However, if the disease is mature, appropriate medications
should be provided with immediate action to enhance the health of the old man.

In summary, the old man has had good health as he has only being admitted on few
occasions. He is can active old man because of his initiative of remaining stronger and healthy
through physical exercise. A swelling on his testis one month ago was diagnosed to be cancer.
The planned intervention is to ensure that the cells are eliminated before they mature. Therefore,
the old man must undergo radiotherapy. Communality is also very important in these
interventions. They need to give him support and encouragement at this moment that he will be
able to come through the condition. They can also help to contribute funds for the treatment.
They should also educate the members of the community about the disease through this
experience to reduce such cases in future and be able to promote healthy living among the old
and other members of the society.
In conclusion, it is essential, for the history of an individual to be provided before
administering medications. This aims to avoid any incidence of treating the wrong disease that

may cause harm to the clients. In this case, this old man history was essential in ensuring that
appropriate health services are provided to restore his health.


Boaro, N et al. (2010). Using SBAR to improve communication in interprofessional
rehabilitation teams, Journal of Interprofessional Care, 24(1): 111-114.
Gikow, F., & Patricia M. (1987). A New Look at the Community: Functional Health Pattern
Assessment, Journal of Community Health Nursing, 4(1):21.
Shannon, S., Long-Sutehall, T., & Coombs, M. (2011). Conversations in end-of-life care:
communication tools for critical care practitioners, Nursing in Critical Care, 16(3): 124-