Benchmark Individual Client Health History And Examination
Benchmark Individual Client Health History And Examinationview Rubri
Perform a health history on an older adult. 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 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.
Paper For Above instruction
The process of conducting a comprehensive health history and physical examination on an older adult is fundamental in nursing practice, serving as the basis for effective health assessments, diagnoses, and care planning. This paper delineates the steps involved, integrates applicable frameworks such as the Functional Health Pattern Assessment, and underscores the importance of documentation through the SBAR format to ensure clear communication among healthcare providers.
Introduction
Older adults often present with complex health needs due to physiological changes, chronic conditions, and social factors. As such, an initial step is obtaining a thorough health history, including past medical history, medication use, dietary habits, alcohol and tobacco use, and psychosocial factors such as support systems and mental health status. The health history not only provides insight into existing health issues but also guides the physical examination and subsequent interventions (Bickley, 2017).
Health History Collection
When interviewing an older adult, establishing rapport and ensuring privacy foster open communication. Elements of the health history should encompass:
- Demographic information: age, gender, occupation, living arrangements
- Chief complaints and history of present illness
- Past medical and surgical history
- Medication history, including over-the-counter and herbal supplements
- Allergies
- Functional status and activities of daily living (ADLs)
- Social and environmental factors
- Psychosocial health including mood, cognition, and support systems (Jonsen et al., 2018).
In practice settings where access to older adults might be limited, students may opt to conduct assessments with a younger individual or a community member, practicing the skills necessary for thorough health history collection.
Physical Examination Using the Functional Health Pattern
Applying the Gordon’s Functional Health Patterns provides a structured approach to physical assessment, focusing on areas such as:
- Health perception-health management pattern
- Nutritional-metabolic pattern
- Elimination pattern
- Activity-exercise pattern
- Sleep-rest pattern
- Cognitive-perceptual pattern
- Self-perception/self-concept pattern
- Role-relationship pattern
- Sexuality-reproductive pattern
- Coping-stress tolerance pattern
- Values-beliefs pattern
This comprehensive review ensures that subtle signs of deterioration or illness are detected early (Gordon, 2014).
Documenting Findings Using SBAR
The SBAR framework enhances communication clarity by systematically organizing assessment data into:
- Situation: concise statement of the problem
- Background: relevant health history and context
- Assessment: current findings from physical examination
- Recommendation: suggested actions or interventions
For example, if the physical exam reveals decreased mobility and balance issues, the SBAR might be:
Situation: The client demonstrates increased risk of falls due to gait instability.
Background: The patient is an 80-year-old with a history of osteoporosis and recent mobility decline.
Assessment: Physical exam shows unsteady gait, weakness in lower extremities, and postural imbalance.
Recommendation: Implement fall risk interventions, schedule physiotherapy, and evaluate home safety.
Physical Examination Findings and Interventions
The physical exam should encompass vital signs, general appearance, head and neck assessment, cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal, neurologic, skin, and functional assessments. Findings guide tailored interventions:
- Address medication management if adverse effects are observed
- Implement nutritional support if malnutrition signs are evident
- Initiate fall prevention strategies for mobility issues
- Facilitate community resources, such as home health services, social support programs, or physical therapy.
For instance, if decreased activity tolerance and balance issues are identified, recommended interventions might include balance training exercises, medication review, and community-based fall prevention programs (Tinetti et al., 2012).
Conclusion
Thorough health histories and physical examinations are essential in managing older adult health. Using structured frameworks like Gordon’s patterns and documentation tools such as SBAR enhances assessment accuracy and interprofessional communication. Incorporating community services ensures holistic, patient-centered care aimed at improving quality of life in aging populations.
References
Bickley, L. S. (2017). Bates' Guide to Physical Examination and History Taking. Wolters Kluwer.
Gordon, M. (2014). Manual of Nursing Diagnosis. Jones & Bartlett Learning.
Jonsen, A. R., Siegler, M., & Winslade, W. J. (2018). Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine. McGraw-Hill Education.
Tinetti, M. E., Kumar, C., & Claus, E. (2012). Designing health care for the elderly: tailoring interventions to frailty. JAMA, 308(11), 1133–1134.
[Additional references from peer-reviewed journals and authoritative sources can be added as appropriate.]