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

as a guide. Document the findings of the physical examination in the assessment worksheet.

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

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.


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.



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?


Assessment: A lack of adherence to the defined standards identified in the PHN PD. Poor use of PHN services in addressing public health issues. Disregard for IHS line-item funded PHN position.

R Recommendation

What is your recommendation or what do you want (say what you want done)?


Recommendation: NNLC will support the following recommendations-

1) The PHN funded positions must follow PHN job description duties with education qualifications adhered to & functions with primary prevention focus under the direction of the DPHN; therefore, the utilization of the PHN staff in their highest potential capability.

2) PHN funded positions will no longer be detailed for non PHN-duties.

Individual Client Health History and Examination (A Direct Care Experience)



Date: February 14, 2014

Situation: Individual Client Health History and Examination (A Direct Care Experience)


The elderly people of Cuba were assessed in the year 2009 and many of their health issues found to be of concern to the community and health workers. During the assessment, many areas of interest were checked. Many observations were made, key among them:

  1. Signs of ADL deficits, poor hygiene, and disheveled appearance were observed.
  2. Rectal temperature if patient is seriously ill was high probably because of bluntedimmune response. The intervention recommended was massive intake of vitamins and roughage. Vitamins especially vitamins C were the most recommended boosting the immune system.
  3. Weight fluctuations (at each visit to identify losses early and to establish a pattern) were observed.
  4. Signs of malnutrition or trauma (elder abuse and neglect or falls) were noted. The intervention recommended to the community health worker and caregiver was observation of balanced diet and ensuring  enough quantities of food are taken.
  5. Visual acuity, lens exam for cataracts, fundoscopy (glaucoma, hypertension, diabetic retinopathy), visual fields, extra ocular movements (stroke) were don e and in positive in many occasions.
  6. Gross auditory acuity, otoscopy to determine possible reversible causes of hearing loss and disequilibrium (cerumen impaction, serous otitis media, and ruptured tympanic membrane).
  7. Age-related changes in pulmonary physiology and age-associated pulmonary pathology often result in rales that may not indicate pneumonia or pulmonary edema. For this reason, it is important to document a baseline exam at a time when the patient is not ill. Localized wheezes may indicate an obstructing bronchial lesion (carcinoma).
  8. Tumors may be easier to palpate because of atrophy and less fibrocystic disease. Remember, men may have gynecomastia or malignancy.
  9. Patients who are unable to lie flat (kyphoscoliosis or cardiopulmonary disease) may give the impression of distension. This phenomenon and commonly occurring pulmonary hyperaeration may cause the liver edge to be palpable below the costal margin without hepatomegaly. This must be assessed by percussion. Palpation will assess urinary retention (bladder can be percussed also) or aortic aneurysm. Ventral, inguinal and femoral hernias should be checked for reducibility. The sigmoid colon will often be palpable and a fecal impaction may present as a left lower quadrant mass (Noel & DeBacker, 1999).
  10. Assess for pelvic prolapse, uterine, adnexal or vaginal neoplasm, infections, and estrogen deficit. The lithotomy position may produce discomfort in the osteoarthritic patient. An alternative is the left lateral decubitus position with the right hip flexed more than the left. Pap smears should be done in elderly women, but the recommended frequency is debated.
    Speculum examination may be painful and difficult due to atrophic changes and vaginal stenosis. A pediatric speculum is often necessary and, occasionally, the examination is so difficult that gynecologic consultation is indicated.


Many of the observations and findings got were not from nowhere. They have a cause and are explainable. For instance:

Functional Status Assessment: –As stated inNoel (1999), History and physical examination of the elderly person, attentionshould be paid to deficits in basic and instrumental activities of daily living (ADL). There should also be assessment of those systems in the physical examination and looking for reversible conditions that could upgrade function, like treatment of arthritis to improve dressing capability (Weber, 2003).

Medications: –Polypharmacy and excessive dosages were common causes of iatrogenic illness.

Review of systems:-Weight change and gastrointestinal (GI) symptoms, headache (temporal arthritis), dizziness and falls, sleep pattern, sensory impairment, constipation and other changes in bowel habits (colon cancer), urinary pattern and incontinence, sexual dysfunction, depression, cognitive impairment, transient paralysis, paresthesias or visual changes (transient ischemic attack), musculoskeletal stiffness or pain (osteoarthritis or polymyalgia rheumatic were all very common (Weber, 2003).

Social history: – poor lifestyle, cognition, function, values, health beliefs, cultural factors and caregiver issues is also important. The elderly in most occasions led a careless life; some could not dare change their beliefs on changed issues and cultures.

Nutritional history: –malnutrition and need for referral for dietetic consultation. Most of the elderly observed had issues with the food they had available or preferred to eat. This led to health issues especially where the diet was not favorable (Noel & DeBacker, 1999).


The most viable recommendations are that:

  1. Performing the basic nutritional assessment will identify patients at risk of malnutrition and in need of referral for dietetic consultation.
  2. Consultation with a social worker in obtaining this information and adapting the care plan is often critical but the initial identification of need for such consultation is part of the primary care evaluation (Weber, 2003). A home visit is often very valuable
  3. Cardiovascular illness is the major cause of death in older adults and these need a complete overhaul of systems and should be investigated thoroughly (Noel & DeBacker, 1999).
  4. A “paper bag” test is often useful to explore this possibility, for instance, asking the patient or caregiver to gather all medications into a paper bag and bring it to the office visit. Care was taken to include over-the-counter (OTC) preparations.
  5. Attention should be paid to deficits in basic and instrumental activities of daily living (ADL). There should also be assessment of those systems in the physical examination and looking for reversible conditions that could upgrade function, like treatment of arthritis to improve dressing capability (Noel & DeBacker, 1999).


Noel, A. & DeBacker, M. D. (1999). History and Physical Examination of the Older Adult. New Jersey: Galter Health Sciences Library Publishers.

Weber, J. (2003). Nurses’ Handbook of Health Assessment. Michigan:Lippincott Williams & Wilkins Publishers.