Assignment: Health History On An Older Adult

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Assignment: Health History On An Older Adult

Assignment: Health History On An Older Adult

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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 “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. Refer to the sample SBAR Template located on the National Nurse Leadership Council website at as a guide.

4. Document the findings of the physical examination in the assessment worksheet.

5. 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.

This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.

When patients are older, acquiring thorough medical and family history, as well as information on social situations and lifestyle, is critical to providing quality care.


Different interviewing strategies may be required depending on the needs of older patients. 
The suggestions below might assist you in gathering comprehensive history of current and previous issues, family history, medications, and socioeconomic status.


These proposals will take less time than they look. 
Some only require one time commitment. 
Other health care professionals in the office or at home may be able to assist with data collection. 
You might want to collect full life and medical history from elderly patients as part of their regular office appointments, and utilize each visit to add to and update the information.


few suggestions


When gathering the medical history of older patients, you may need to be extra adaptable. 
Here are some ideas for making the most of your time and theirs:


If at all possible, acquire preliminary data prior to the session. 
If time allows, request earlier medical records or mail forms that the patient or family member can complete at home. 
Use large print and leave enough space between items for users to respond to make your questionnaires easy to read. 
In the waiting room, filling out questionnaires should be quick.


Allow the patient to relate his or her experience only once, not to another member of staff and then to you. 
This approach might be exhausting for elderly folks who are unwell.


Place yourself in comfortable position and face the patient at eye level. 
Use active listening skills to answer with short phrases like “I see” and “all right.”


Be open to deviate from the standard interview format. 
If you extract the patient’s past medical history shortly after the major complaint, before performing comprehensive evaluation of the current disease, you may be able to comprehend the patient’s condition more rapidly.


Make an effort to ask open-ended questions that invite more detailed response. 
If the patient is having problems replying, have yes-or-no or simple-choice questions ready.


Remember that the interview can be valuable in and of itself. 
Despite the fact that you visit lot of patients every day, you can be the only one with whom your patient is socially engaged on that particular day. 
It’s critical that you pay attention. 
Giving your patient the opportunity to share their worries to someone who is interested can be therapeutic and can help to build trust.


Identify current issues.


Patients in their later years are more likely to suffer number of chronic illnesses. 
They may present with unclear complaints or odd symptoms. 
It may be more beneficial to think in terms of current issues rather than major complaint. 
“Tell me, what is upsetting you the most?” you can begin the session by asking your patient.


COVID-19 poses the greatest risk of severe illness to the elderly. 
Severe illness might also be exacerbated by certain medical disorders. 
Learn how to keep older people and those at increased risk from contracting COVID-19.


Pose inquiries.


“Is there anything else?” you might inquire. 
This question, which you may need to ask multiple times, aids in getting all of the patient’s issues out in the open at the start of the appointment. 
An older patient may seek medical attention as result of concerns expressed by family members or caretakers.


The most important worry may not be the first one stated, especially if the topic is delicate. 
If there are too many concerns to cover in one appointment, you and the patient can decide to address some now and others later.


Encourage the patient (and his or her caretakers) to bring written list of concerns and questions with them to the appointment.


Talk to your elderly patient about his or her medications.


In older persons, pharmaceutical side effects, interactions, and overuse can lead to serious consequences. 
It’s critical to figure out the prescription and over-the-counter medications older people are taking, as well as how frequently they take them. 
Internists, cardiologists, urologists, and rheumatologists are among the many doctors who prescribe drugs to the elderly.


Remember to inquire about any other treatments the patient may be utilizing, such as nutritional supplements, complementary cures, or teas. 
Remind patients that it is critical for you to be aware of all over-the-counter medications they are taking, such as pain relievers or eye drops.


Patients should bring list of all their drugs, including prescriptions, over-the-counter medications, vitamins, supplements, herbal medicines, topicals, liquids, injectables, and inhalants, as well as how much and how often they take each. 
You could also recommend that they bring everything in bag with them. 
Find out how the patient takes each prescription and double-check that he or she is taking it as prescribed.


Examine the patient’s medical alert ID bracelet or necklace to see if one is worn (or if one is required). 
MedicAlert Foundation International is one of the many sources.
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