Individual Client Health History and Examination

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 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
    As a guide. Document the findings of the physical examination in the assessment
  4. 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.
  5. APA format is not required, but solid academic writing is expected.
    This assignment uses a grading rubric. Instructors will be using the rubric to grade the
    assignment; therefore, students should review the rubric prior to beginning the assignment
    to become familiar with the assignment criteria and expectations for successful completion
    of the assignment.
    I live in Mineral Wells,Tx76067

Individual Client Health History and Examination

Date: 25 th May, 2014
Situation: Individual Client Health History and Examination: a direct care experience involving
an elderly patient
The elderly people that were assessed were from Cuba. The assessment revealed that the
healthcare issues of the elderly in general need to be taken more seriously by the healthcare
workers as well as the community. The assessment involved checking a wide array of areas that

were of great concern. A lot of observations were made and the major ones included the

  1. There was observation of poor hygiene, ADL deficit’s signs, and disheveled appearance.
  2. In the seriously ill patients, the rectal temperature was assessed and it was expected to be
    high due to blunted immune response (Wilde & University of Manchester, 2012). In such
    cases, it was recommended that the patient should consume a lot of roughage and
    vitamins. These would be obtained from intake of proper foods. More particularly, the
    patient was advised to take more of vitamin C since this has a huge role in boosting the
    immune system.
  3. There was observation of weight fluctuations during every visit. This was aimed at
    identifying any weight loses early and establishing if there was any pattern.
  4. The patients were also assessed for signs of trauma and malnutrition. Some of the
    traumas that were under keen observation included falls, neglect, and elder abuse. In such
    cases, the community health worker recommended intake of balanced diet and promoting
    intake of adequate quantities of foods. Moreover, the elderly were to be under the care of
    empathetic caregivers who would help in minimizing cases of falls, abuse, and neglect.
  5. There were tests to assess visual fields, visual acuity, extra ocular movements for stroke,
    cataracts’ lens exam, and fundoscopy for diabetic retinopathy, hypertension, and
    glaucoma. In a majority of the cases, these tests were positive (Wilde & University of
    Manchester, 2012).
  6. There was gross auditory acuity and otoscopy so as to identify potent reversible
    disequilibrium and hearing loss causes (ruptured tympanic membrane, serious otitis
    media, and cerumen impaction).


  1. There was also assessment of age-associated pulmonary pathology and age-related
    pulmonary physiology changes. Often, these lead to rales which might not indicate
    pulmonary edema or pneumonia. In this regard, there is a need that a baseline exam is
    documented during a time that the patient is well and suffering from no slight illness. If
    the patient has localized wheezes, this may be an indication of an obstructed bronchial
    lesion or carcinoma.
  2. Palpating tumors may be easier due to less fibrocystic disease and atrophy. In this regard,
    there is a need to note that men have higher tendencies of suffering from malignancy or
  3. Patients that are incapable of lying flat (cardiopulmonary disease or kyphoscoliosis) may
    give the notion of a distension. The commonly recurring pulmonary hyperaeration as well
    as the mentioned phenomena may make the liver edge be palpable beneath the costal
    margin in the absence of hepatomegaly. This should be assessed through percussion.
    Usually, palpation assessed aortic aneurysm or urinary retention (the bladder may be
    percussed as well). The femoral, inguinal, and ventral hernias have to assessed for
    reducibility. Normally, the sigmoid colon is mostly palpable and there may be presence
    of a fecal impaction as a lower quadrant mass on the left.
  4. The following should also be assessed; uterine, prolapsed, vaginal or adnexal neoplasm,
    estrogen deficit, and infections. In osteoarthritic patients, the lithotomy position produces
    discomfort. As an alternative, there can be the lateral decubitus position on the left with
    the right hip being flexed more compared to the left. Elderly women should have a pap
    smear done. Speculum examination can be difficult and painful as a result of vaginal
    stenosis and atrophic changes (Rosdahl & Kowalski, 2012).

A majority of the findings and observations have a cause and can be explained. For
Medications; mostly, iatrogenic illnesses are commonly a result of excessive dosages and
Functional status assessment; as far as the physical and history assessments in the elderly are
concerned, there should be a keen regard for deficits in instrumental and basic daily living
activities. The systems that are involved in physical examination should be assessed. In addition,
reversible conditions which can upgrade function should be looked for, for example, treating
arthritis for better dressing capability.
Review of systems; musculoskeletal pain or stiffness, cognitive impairment, headache, weight
change, and sexual dysfunction among others were all common.
Social history; a majority of the elderly had a careless life and were still holding onto their
culture and beliefs.
Nutritional history; there were malnutrition cases which needed dietetic consultations. The
elderly had concerns about the available foods and foods of choice. If the diet was never
favorable, the result was health issues (Linsley, Kane & Owen, 2011).

  1. A basic nutritional assessment can identify the patients who are at risk of being
    malnourished and who need dietetic consultation referral.
  2. A home visit is important. A care plan should be adapted and a social worker should be
    involved. A primary care evaluation should aim at uncovering all essential care


  1. There should be a thorough assessment of cardiovascular illness.
  2. A ‘paper bag test’ is useful in knowing the medications that a patient is taking (Linsley,
    Kane & Owen, 2011).
  3. Daily living activities should be assessed thoroughly.



Linsley, P., Kane, R., & Owen, S. (2011). Nursing for public health: Promotion, principles, and
practice. Oxford: Oxford University Press.
Rosdahl, C. B., & Kowalski, M. T. (2012). Textbook of basic nursing. Philadelphia: Wolters
Kluwer Health/Lippincott Williams & Wilkins.
Wilde, D. J., & University of Manchester. (2012). Finding meaning in out-of-body experiences:
An interpretative phenomenological analysis. University of Manchester.

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