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Pages:
1 page/≈275 words
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Level:
APA
Subject:
Health, Medicine, Nursing
Type:
Essay
Language:
English (U.S.)
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Topic:

Individual Client Health History and Examination (Essay Sample)

Instructions:

Due Date: Feb 08, 2018 23:59:59 Please the paper urgency is 16 days which is 01/08/18 and i want to know how many pages altogether. I have attached two files for this assignment.
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(dot)ihs(dot)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.
NRS-434VN-R-Functional-Health-Pattern-Assessment-Student.docx NRS-434VN-R-IndividualHealthHistoryandExaminationAssignment-Student.docx

How does the person describe current health? • What does the person do to maintain health? • What does person know about links between lifestyle and health? • How big a problem is financing health care for this person? • Can this person report his/her medications and the reason for taking them? • If this person has allergies, what does he/she do to prevent/manage them? • What does the person know about medical problems in his/her family? • Have there been any important illnesses/injuries in this person’s life? 

source..
Content:

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:


Client/Patient Initials:

Sex: female

Age: 65

Occupation of Client/Patient:

Health History/Review 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):
The patient has experienced frequent headaches, depression and anxiety

Head and Neck (pain, headaches, head/neck injury, neck pain, lumps/swelling, surgeries on head/neck, medications):
The patient complains of frequent headaches
Patient also mentioned occasional swelling of the neck

Eyes (eye pain, blurred vision, history of crossed eyes, redness/swelling in eyes, watering, tearing, injury/surgery to eye, glaucoma testing, vision test, glasses or contacts, medications):
The patient has been complaining of dryness of the eyes, with a gritty feeling and sometimes burning.

Ears (earache or other ear pain, history of ear infections, discharge from ears, history of surgery, difficulty hearing, environmental noise exposure, vertigo, medications):
There have been sometimes where the hearing comes at varying levels

Nose, Mouth, and Throat (discharge, sores or lesions, pain, nosebleeds, bleeding gums, sore throat, allergies, surgeries, usual dental care, medications):
The patient has been experiencing dryness in the mouth, nasal cavity, blocked airways due to inflammation

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 hazards/exposures, medications):
There are hard bumps on the patient's elbows, which are sometimes painful

Breasts and Axilla (pain or tenderness, lumps, nipple discharge, rash, swelling, trauma or injury to breast, mammography, breast self-exam, medications):
According to the patient, they sometimes experience breast pain

Peripheral Vascular and Lymphatic System (leg pain, cramps, skin changes in arms or legs, swelling in legs or ankles, swollen glands, medications):
The patient has had episodes of swollen feet and painful joints especially in the morning

Cardiovascular System (chest pain or tightness, SOB, cough, swelling of feet or hands, family history of cardiac disease, tire easily, self-history of heart disease, medications):
The patient has complained of having irregular heartbeats at times

Thorax and Lungs (cough, SOB, pain on inspiration or expiration, chest pain with breathing, history of lung disease, smoking history, living/working conditions that affect breathing, last TB skin test, flu shot, pneumococcal vaccine, chest x-ray, medications):
Sometimes the patient will experience chest pains when breathing

Musculoskeletal System (joint pain; stiffness; swelling, heat, redness in joints; limitation of moveme...

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