Details: In this assignment, you will be completing a health assessment on an ol

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.

NRS-434VN-R-Functional-Health-Pattern-Assessment-Student.docx NRS-434VN-R-IndividualHealthHistoryandExaminationAssignment-Student.docx

Explanation / Answer

I made a complete history and physical examination of Mr. John who is 65 years old.

Name : Mr. John

Sex : Male

Age : 65 years

Occupation: Retired from Military service.

Health History: Patient has pain and swelling in both knees. He is not allergic to any medications. His daily activities have become decreased. His weight has gained to 5lbs recently with little appetite. His range of motion was limited. He is known the case of hypertension for the past 10 years and he is on regular medication.

Review of the system:

Head and Neck:

Mild headache present rarely. No history of neck pain.

Eyes and Nose:

His Left eye is slightly blurred vision since past 18 months and is seeking medical attention.

Ears:

No history of any ear infection or discharge.

Throat and Tongue:

No swelling, lump, are present in the throat.

Cardiovascular system:

He is known as the case of hypertension.

Gastrointestinal system:

Stomach upset, cramping pain present due to the intake of analgesics. Normal bowel habits. Appetite has reduced.

Renal system:

Normal bladder habits. No history of any urinary infection.

Neurological system:

Patient has fatigue and unexplained weakness from last 6 months. Mild headache present rarely.

Respiratory system:

No history of respiratory infection. Shallow breathing if he strains or climbing stairs.

Musculoskeletal system:

Has pain and swelling on both knees.

Situation:

I am calling about Mr. John having a problem on his knees.

I have assessed the person personally.

Vital signs show BP: 140/80mmHg. Pulse: 84 Resp: 22 Temp: 98.4F

I am concerned the patient blood pressure is little high.

Background:

He has the primary diagnosis of osteoarthritis.

He has the medical history of hypertension.

Mental status: oriented and conscious Neuro changes: fatigue and weakness

Lung sounds: clear Pulse oximetry: 96% on room air.

GI changes: Stomach upset, decreased appetite.

Weight gained up to 5 lbs. Skin: Redness around the knees.

Musculoskeletal system: Joint stiffness and unable to maintain gait for a long time.

Pain level/ location/status: severe pain in both knees relieved with analgesics.

Assessment:

I think the patient is suffering from osteoarthritis.

Recommendation:

I suggest

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