NRS 434V Week 5 Assignment 1 (Benchmark): Individual Client Health History and Examination

In this assignment, you will be completing a health assessment on an older adult. 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. 
2. Complete a physical examination of the client using the “Individual Health. History and Examination Assignment” resource. Use the “Functional Health Pattern Assessment” resource in completing the template.
3. Document findings of complete physical examination in “SBAR” format. 
4. Document the findings of the physical examination in the assessment worksheet.
5. Using the “Individual Health History & Exam. Assignment” resource, provide the physical examination findings summary with planned interventions for the client.
   

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Health History and Examination

Health_Assessment of the Head, Neck, Eyes, Ears, Nose, Mouth, Throat, Neurological System, and the 12 Cranial Nerves Skin, Hair, Nails, Breasts, Peripheral Vascular System, Lymphatics, Thorax, Heart, Lungs, Musculoskeletal, Gastrointestinal, and Genitourinary Systems

Health History/Review of Systems: (Complete and systematic review of systems)

1. Neurological System:
2. Head and Neck:
3. Eyes:
4. Ears:
5. Nose, Mouth, and Throat:
6. Skin, Hair and Nails:
7. Breasts and Axilla:
8. Peripheral Vascular and Lymphatic System:
9. Cardiovascular System:
10. Thorax & Lungs:
11. Musculoskeletal System:
12. Gastrointestinal System:
13. Genitourinary System:
    

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Physical Examination: (Comprehensive examination of each system. Record findings.)

1. Neurological System:
2. Head and Neck:
3. Eyes:
4. Ears:
5. Nose, Mouth, and Throat:
6. Skin, Hair and Nails:
7. Breasts and Axilla:
8. Peripheral Vascular and Lymphatic System:
9. Cardiovascular System:
10. Thorax and Lungs:
11. Musculoskeletal System:
12. Gastrointestinal System:
    

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FHP Assessment:

1. Cognitive-Perceptual Pattern:
2. Nutritional-Metabolic Pattern:
3. Sexuality-Reproductive Pattern:
4. Pattern of Elimination:
5. Pattern of Activity and Exercise:
6. …… of Sleep and Rest:
7. Pattern of Self-Perception and Self-Concept:
   

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Summarize Your Findings: (Use format that provides logical progression of assessment.)

1. Situation:
2. Background:
3. Assessment:
4. Recommendation:
   

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Reference