In this paper, we present an Individual clients health history examination on the basis of Gordon's Functional Health Pattern Assessment. 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. (If an older individual is not available, you may choose a younger individual). 2. Complete a physical examination of the client using the "Individual Health History and Examination Assignment" resource. Use "Functional Health Pattern Assessment" as a guideline to assist you in completing the template. 3. Document findings of complete physical examination in Situation-Background-Assessment-Recommendation Format(SBAR) by using the SBAR format. Refer to the "SBAR Template," located on the National Nurse Leadership Council website at http://www.ihs.gov/medicalprograms/nnlc/documents/SBARTEMPLATE.pdf as a guide. Document the findings of the physical examination in a Word document. 4. Using the "Individual Health History and Examination Assignment," provide the physical examination findings summary with planned interventions for the client. Include any community services in the interventions.
¶ … patient's general health been? - The Patient, Mr. Jones has generally been good but with frequent cases of heart complications. The situation has been deteriorating over time.
Any colds in past years that required absences from work?-None
Most important things you do to keep healthy? -- regular jogging exercise and being a vegetarian
Accidents (home, work, driving)?-Twice when the patient experienced a heart attack
In past, has it been easy to find ways to follow suggestions from physicians or the nurses? Yes
F. If appropriate: what do you think caused the illness? I believe the illness was caused by the kind of lifestyle that I had (smoking and eating high cholesterol meals while also leading a sedentary life)
g. If necessary: outline the things important to you in your health care? How can we be most helpful? I require hypertensives and advice on how to live a healthy life
Examination -- the general health appearance is frail. There is a need for immediate therapy
NUTRITIONAL-METABOLIC PATTERN
1. History
a. Typical daily food intake?-The typical daily food intake includes bread and coffee, milk, meat chops, broccoli, steak, vegetables such as cabbages and tea.
b. Typical daily fluid intake? The typical fluid intake includes at least 4 liters of water, milk intake as well as soda.
c. Weight loss or gain? The patient has over the years been gaining wait owing to a sedentary lifestyle
d. Appetite? The appetite for this patient has been incredible.
e. Food or eating problems. None f. Heal well or poorly? Heals well granny Skin problems: None
h. Dental problems? Has had 2 premolars removed via root canal operation.
2. Examination
a. Skin: Always moist
b. Oral mucous membranes: Normal color, always moist and healthy.
c. Teeth: The teeth are generally white in color with some discoloration of the molars .two premolars had previously been extracted due to cavity and infection of surrounding tissue.
d. Actual weight -- the patient weighs 104 Kilograms and is 179 cm tall.
e. Temperature -- the temperate is 37 degrees Celsius
f. Intravenous feeding -- none whatsoever
ELIMINATION PATTERN
1. History
a. Bowel elimination pattern? No elimination problems. No retention problems.
b. Urinary elimination pattern? The patient has an increased rate of urinations.
c. Excessive perspiration? Yes with a slight odor
2. Examination -- the patient is diabetic due to the presence of excessive sugar in his blood.
ACTIVITY-EXERCISE PATTERN
1. History
a. Sufficiency of energy for desired or required activities? Yes
b. Exercise pattern? Regular jogging exercise in the neighborhood.
c. Spare-time (leisure) activities? Fishing. Perceived ability (code for level) for:
Functional Level Codes:
Level 0: full self-care
Level I: requires use of equipment or device
Level II: requires assistance or supervision from another person
Level III: requires assistance or supervision from another person and equipment or device
Level IV: is dependent and does not participate
+++ The functional level is Level):Full self-care
2. Examination
g. Blood pressure-High
h. General appearance-is good
SLEEP-REST PATTERN
1. History
a. Generally rested as well as ready for daily activities after sleep? Yes
b. Sleep onset problems? None
c. Rest-relaxation periods? Sleeps more than 8 hours at night with daily siestas in the afternoon.
2. Examination
The patient has a satisfactory sleep-rest pattern.
COGNITIVE-PERCEPTUAL PATTERN
1. History
a. Hearing difficulty? None
b. Vision? Short sighted
c. Any change in memory lately? Yes
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