Complete a health assessment on an older adult. Requirements: 1. Perform a health history on an older adult. Students who do not work in an
Complete a health assessment on an older adult.
Requirements:
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 as a guideline to assist you in completing the template.
3. Document findings of complete physical examination in Situation-Background-Assessment-Recommendation (SBAR) format.
4. Document the findings of the physical examination in the assessment worksheet.
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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 Save this form on your computer as a Microsoft Word document You can expand or shrink each area as you need to include relevant data for your client Student Name Date ClientPatient Initials Sex F Age 65 Occupation of ClientPatient 1 Health HistoryReview of Systems Complete and systematic review of systems Neurological System headaches head injuries dizziness convulsions tremors weakness numbness tingling difficulty speaking difficulty swallowing etc medications Headaches dizziness difficulty swallowing Head and Neck pain headaches headneck injury neck pain lumpsswelling surgeries on headneck medications No pain Eyes eye pain blurred vision history of crossed eyes rednessswelling in eyes watering tearing injurysurgery to eye glaucoma testing vision test glasses or contacts medications Blurred vision Ears earache or other ear pain history of ear infections discharge from ears history of surgery difficulty hearing environmental noise exposure vertigo medications No discharge from ears and no history of ear pains Nose Mouth and Throat discharge sores or lesions pain nosebleeds bleeding gums sore throat allergies surgeries usual dental care medications Skin Hair and Nails skin disease changes in color changes in a mole excessive dryness or moisture itching bruising rash or lesions recent hair loss changing nails environmental hazardsexposures medications No pain Breasts and Axilla pain or tenderness lumps nipple discharge rash swelling trauma or injury to breast mammography breast selfexam medications No pain Peripheral Vascular and Lymphatic ...
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Authors: Michael Sullivan III
5th Edition
978-0134135373, 134133536, 134135377, 978-0134133539
