Individual Client Health History and Examination
NRS-434V Week 5 Benchmark Assignment – Individual Client Health History and Examination (A Direct Care Experience)
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 athttps://www.ihs.gov/nnlc/includes/themes/newihstheme/display_objects/documents/resources/SBARTEMPLATE.pdfas 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.
APA format is not required, but solid academic writing is expected.
This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.
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)
Surface errors pervasive enough that they impede communication of meaning. Inappropriate word choice and/or sentence construction used.
Frequent and repetitive mechanical errors distract the reader. Inconsistencies in language choice (register), sentence structure, and/or word choice are present.
Some mechanical errors/typos are present, but are not overly distracting to the reader. Correct sentence structure and audience-appropriate language are used.
Prose is largely free of mechanical errors, although a few may be present. A variety of sentence structures and effective figures of speech are used.
Writer is clearly in command of standard, written, academic English.
10.0 %Format
10.0 % Research Citations (In-text citations for paraphrasing and direct quotes, and reference page listing and formatting, as appropriate to assignment)
- Create a letterhead. The name of the office is The Peoples Clinic. The address is 1000 N. Lake, Chicago, IL 00001-0000.
- The name of the patient is Jane Doe.
- Only lab results can be released to her husband John Doe.
- Jane’s birthdate is October 12, 1970.
Their address is 1000 North Street, Aurora, IL 00001-0000View less »Feb 08 2019 12:53 PM
1 Approved Answer
siva answered on February 08, 20193 Ratings, (9 Votes)1
HEALTH ASSESSMENT – WELL OLDER ADULT
DEMOGRAPHICS:
Initials: DOB: Marital Status: Married
Gender: Ethnicity/Culture: Caucasian
Health Insurance: Blue Chip Medicare Dental Insurance:_______________
CURRENT HEALTH STATUS:
JH considers him self to be a somewhat health person besides his illness and hospitalization 2 years ago. To stay healthy, JH admits to exercising regularly and being aware of his diet. He admits to visiting a health care provider regularly and attends cardiac rehab twice per week. JH admits that his health has been very good over the past year as he continues to recover from his heart disease. In early 2012, he had been hospitalized for two months with an infection around his heart. Patient admits to smoking in the past but quit two years ago. He continues to drink a couple glasses of red wine at dinner everyday. Patient takes a prescription medication for his Blood Pressure along with OTC antacids and allergy medications but does not remember the names. JH is allergic to pollen, walnuts, dust and mold. He admits to being UTD on all medications including influenza, shingles, hepB and pneumococcal. Patient wears his seat belt every time he is in the care and has never had any accidents nor been involved in one. He denies knowing first aid/CPR.
FUNCTIONAL HEALTH PATTERNS:
ACTIVITY/EXERCISE:
JH attends cardiac rehab twice a week, exercising on the recumbent bike, hand weights and sometimes the treadmill. He does not like using the treadmill. His leisure activates used to include skiing but since his hospitalization he has slowed down on this activity. He now enjoys sailing in the summertime. JH has a shoulder pad prosthesis since the amputation of his right clavicle/ scapula for osteosarcoma in 1962. He denies needing a cane, walker or wheelchair.
SLEEP/REST :
JH admits to sleeping 6.5-7 hours per night and wakes up feeling rested. He denies napping during the day. He retires at 9:30pm and awakens at 4:45am. He denies any problems with sleeplessness and the used of sleep aids.
CARDIOVASCULAR/RESPIRATORY:
BP:120/60 Radial Pulse:_________ Rhythm: A-fib/flutter
Respirations: 18
JH admits to chest pain and SOB. He denies cough, distended neck veins, edema, cyanosis and varicosities.
NEUROMUSCULAR/COGNITION:
JH speaks English. He claims he used to have bad migraines but doesn’t anymore. He has had 2-3 seizures a couple years ago but has been sense treated. Patient admits to having balance problems in the past. He wears glasses for reading. JH denies problems with dizziness, speech impediment, walking and visual problems. He does not use a hearing aid. UTA date of last hearing or eye exam. He denies any problem with memory.
NUTRITIONAL/METABOLIC:
Height: 6’2.5” Weight 165 lbs
JH eats three full meals a day and denies snacking. He admits to not drinking enough water. He does not have dentures but has crowns. His last dental exam was a couple months ago. He denies weight loss and weight gain. JH is allergic to walnuts. He denies GI bleeding, difficulty swallowing, nausea, vomiting, anorexia and bulimia.
SELF-PERCEPTIONS/COPING/
JH’s friends would describe him as friendly, positive and sometimes funny. His source of strength and hope comes from God and his family and friends. He attends church at least once a week but often times multiple times per week.
PH admits that his health problems have affected his skiing but he has not stopped completely. He denies feelings of anger, fear, anxiety and depression but says the biggest negativity in his life is his impatience. He deals with this but just brushing it off and occasionally swearing. The only significant loss/change in this life was his hospitalization two years ago. If he could changes one thing to improve his quality of life it would be to be more generous.
CULTURAL ASSESSMENT
Patient denies his cultural background affecting his health care needs. He is Caucasian with his cultural background being English and Irish. His family shows they care by giving hugs and kisses.
ILLNESS BELIEFS AND CUSTOMS
JH said that people become ill when they are ill or when there is a lot of tension. When he is sick, he likes to pray, relax and tries to be patient, When his loved ones are sick he prays for them, cares for them and is there for them.
INTERPERSONAL RELATIONS
JH defines his family as terrific. He has four adult kids and a wife of 47 years. He denies specific duties for men women and children in a family. Growing up both him and his wife disciplined the children but now they live alone and take care of themselves and their families. JH admits that the most important aspect of life is leading a good life full of gratitude. There are no topics not discussed in their household. In his home they only speak English. JH is a self-employed attorney. He admits to finances influencing his life. He graduated form law school. His wife and three of his children graduated from college one having his doctorate.
NUTRITIONAL ASSESSMENT
