Individual Client Health History and Examination (A Direct Care Experience)

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Details:
In this coursework, you will be completing a health assessment on an older adult. To complete this coursework, do

the following:

1. Perform a health history on an older adult.

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2. Complete a physical examination of the client using the uploaded “Individual Health History and

Examination personal” resource. Use the uploaded “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. Refer to the uploaded sample”SBARtemplate” also located on the National Nurse Leadership

Council website at www.ihs.gov/NNLC/documents/resources/SBARTEMPLATE.pdf. as a guide. Document the findings of

the physical examination in the assessment worksheet.

4. Using the uploaded”Individual Health History and Examination personal” resource, provide the

physical examination findings summary with planned interventions for the client. Include any community services

in the interventions.

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