Details: In this assignment, you will be completing a health assessment on an ol
ID: 247531 • Letter: D
Question
Details:
In this assignment, you will be completing a health assessment on an older adult. To complete this assignment, do the following:
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).
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.
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.
Document the findings of the physical examination in the assessment worksheet.
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.
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.
You are not required to submit this assignment to Turnitin.
Student.docx NRS-434VN-R-IndividualHealthHistoryandExaminationAssignment-
Explanation / Answer
Health assessment of an older adult:
health history:
Name: apparao
Age:75 years.
Sex:male.
Marital status: married.
chief complaints:
(Ideally in patient own words) present of the symptoms.
Patient complaint about: Weakness,sleep disturbances,joint pain,uneaseness,chest pain.
present illness:
presence of new symptoms: depression, tiredness, legs cramps, excessive urination.he explained about previous heart Surgery.
past history:
prevous medical history: patients had surgery of bypass graft.
No history of communicable diseases in the childhood.
Patient had immunization of (based on universal immunization schedule).
Patient having allergies of antibiotics.
social history:
Birthplace: apparo born in Kakinada in south in India.he completed matriculation.he got married at age of 19 years old.
He worked in sugar factory as a machine operator.he retired at the age of 60.
Hobbies: interested in agriculture work in free time.
Habits: smoking,rarely drinking (alcohol).
He had regularly pattern of sleep and excercise.
family history:
father had history of type 2 diabetes.
(Presence of disease with recognised family importance in first degree type 2 diabetes,tuberculosis, cancer hypertension allergy ,heart disease, neurological or psychiatric disease arthritis ,osteoporosis ,bleeding tendency ,similar presenting symptoms and family members).
Reviews of systems:
General: height and weight.loose of weight in old patient.
Lymphatic: asess for blood glucose levels.
Skin: loose wrinkle skin or scaly in some people.
Head : identify if an symmetry in stroke patients.
Eyes: loss of near vision,eye pain.
Ears: hearing loss.
Nose and sinuses:examine any nasal polyps.examine sinus for if any enlargement.
Mouth and throat:
Neck: straight and normal.
Breast: normal in pattern.
Respiratory: dyspnea, chronic cough.
Cardiac: shortness of breath, orthopenia.
Gastrointestinal: constipation.
Urinary: urinary frequency, urinary incontinence.
male reproductive: loss of sexual interest.check for prostate nodules.
Neurological: syncope,transient loss of power.
Endocrine: blood sugar values in diabetes patients.
Hematology.: Based on blood examination ( complete blood tests).
physical examination :
general appearance:
Vital signs: T- 98.6f, P- 60 bpm,R - 16 bpm, Bp- 150/90.
skin: loose wrinkle skin.check for lesions or basal cell carcinoma and malignant melanoma.
lymph nodes: no enlargement.
head: no lesions or infection.normal pattern.
eyes: impaired visual acuity.
ears: hearing loss in left ear.
nose: identify if any polys in nose.
mouth: remove inspect the denture.check for mucosal drynes.
throat:peridontal disease noted.
lungs: clear,chronic cough .
abdomen: gastritis.
extrimities: check muscles and joints in upper and lower.
musculoskeletal:check for muscle wasting.
neurological:perform mental status examination.
Activities of daily living:
The patient is able to perform self care activities are eating,bathing, toileting,transfering,feeding.how much assistance need for client.
laboratotytest:
Serum albumin to help determine protein and immune status.
Serum cholesterol to determine risk level for CVD.
Blood glucose monitoring in diabetes.
Haemoglobin to evaluate anaemia.
Interventions:
Screening for health problems: alchol misuse ,blood pressure,depression,type 2 diabetes.
Counseling:
1) avoid alchol.
2) healthy diet.
3) regular physical activity.
4)house hold members trained in CPR.
5) counseling to family members regarding care of patient.
6) regular dental care.
7) maintain personal hygiene.
8) explain in safety precautions in fire arm .
9) regular health check-up.
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