Health assessment PDF

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Individual Health Assessment Form GENERAL SURVEY: Physical Appearance/Hygiene: General appearance: Gender: Male Apparent age: Late 50s, early 60s Ethnic group: White, Caucasian. Not Hispanic or Latino Does client appear healthy: Appears to be in in good health, no identifiable concerns upon general survey. May take part in moderate physical activity. Even skin tone, fitting for ethnic background. No signs of lesions or bruises. Good hygiene and dressed appropriately for the weather and season Is client well-groomed or disheveled: Client is well-groomed and seems able to take part in ADLs. Body Structure: Observe general stature. Is height appropriate for apparent age: Clients height is appropriate for reported age, remains tall and lengthy Does the client appear well nourished, with weight appropriate for height: Client appears to be well nourished and receiving adequate intake for his age group. Weight is appropriate for his height. No prominent signs of age-related degeneration Note the position or posture. Is it comfortable and relaxed: Client is sitting upright in relaxed and comfortable manner Are there any obvious deformities: Client does not appear to have any obvious deformities. Body Movement: Observe the client’s movement. Does the client walk with ease: The client walks with some ease and stated recent symptoms of lower lumbar pain Is the gait balanced and smooth: Gait is relatively balanced and smooth, minor deficit likely due to previously stated lumbar pain Do there appear to be any limitations to range of motion: Client appears to have some limitations to range of motion upon lateral rotation Are there any involuntary movements: Client does not display any involuntary movements Are they using any assistive devices: No assistive devices are being used by the client. Emotional/Mental Status and Behavior: Note the general expression of the client. Is the client alert: Client is alert and oriented; he is aware of what I am performing and is able to actively participate in providing answers Do they appear well rested or tired: Client appears to be well rested Does the client converse appropriately: Client converses appropriately; no apparent speech deficits, even rhythm and tone Is the behavior appropriate for situation: Client’s behavior is appropriate and consistent for the situation Is the dress appropriate for the weather: Client is dressed appropriately for the weather.

Health History Biographical data: D.M. Client Initials: ____________ 66 Age: ________ Married Marital status: _____________ 03/10/1954 Birth date: _____________________ Number of dependents: ___________________ 2 Educational level: ________________________ Gender: ______ Master’s degree M Retired Occupation: ____________________________________________________________ White Yes, Medicare Ethnicity/nationality: _____________________ Health insurance _________________ Source of history/reliability: Self, seems reliable _____________________________________________________________________

Present health history: Current medical conditions/chronic illnesses: Hypertension Current medications: Losartan (Cozaar), Metoprolol, Hydrochlorothiazide Medication/food/environmental allergies: Client does not report any allergies to medication, food, or environmental agents

Past health history: Childhood illnesses: Client reports having chickenpox (age 10) Hospitalizations/Surgeries: Prostate cancer, 2009, routine radiation therapy (3 mo.) Accidents/injuries: Client reports severe laceration from fence wiring in April of 2013 while out of state. Treated at local medical center. No scar remaining. Denies any head injuries with loss of consciousness, fractures, motor vehicle accidents, burns, or falls. Major diseases or illnesses: Prostate cancer in 2009; received ongoing radiation for 3mo.

Immunizations: x x x x Tetanus _______ Diphtheria ________ Pertussis ________ Mumps ________ x x x Rubella __ __ Polio _____________ Hepatitis B ______ Influenza _______ x Varicella ______ Other ______________________________________________ N/A x

Recent travel/military services: None Date of last examinations: Physical examination __________ 9/19

1/15 2017 Vision ___________ Dental ___________

Grandfather

Family History

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Prostate cancer Smoker Deceased, aged 82 Natural causes

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Grandmother

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Mother Deceased, aged 79 Natural causes

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________

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F

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Decreased, aged 84 Natural causes

er -

Hypertension Deceased, aged 89 Natural causes

________ ___

___ Brother -

Client

Living, aged 71

Review of Systems General health status: Client reports to be “in good health for his age.” He did confirm feelings of fatigue and pain, along with occasional night sweats. He denied any unexplained fever, weakness, problems sleeping, and changes in weight. Integumentary: Skin: Skin is pink and warm. No lesions noted. Client states he has been experiencing some changes in his skins texture – seborrhea. He confirms the use of sunscreen but says he does not receive a lot of sun exposure. Client denies changes in color, excessive bruising, itching, lesions, sores that do not heal, or changes in moles. Hair: Hair is distributed normally throughout the body. Client reports no recent hair loss or changes in texture. Nails: Nails are smooth and hard, no signs of clubbing. Client states he does experience nail splitting and cracking often, “especially doing yardwork.” Client denies any changes in color or texture HEENT: Head: Head is symmetric, round, smooth; no signs of lesions or scalp conditions. Client reports having mild headaches 2x a week. No recent head trauma, injury, history of concussion, dizziness, or loss of consciousness reported. Neck: Neck is symmetric and in line with head. Client reports occasional neck stiffness in the morning, causing mild pain. No sign of lymph node enlargement or swelling masses in the neck. Eyes: No signs of discharge or abnormal widening. Pupils are equal and round. They seem to accommodate. Client reports no recent changes in vision, eye pain, injury, itching,

excessive tearing, floaters, or abnormal reactions to light. Client does confirm difficulty reading and uses non-prescription reading glasses occasionally. Ears: No signs of drainage or cerumen. Client states that he does not remember his last hearing test; reports progressive hearing loss but notes that “it is nothing too serious.” Client does not report any ear pain, drainage, vertigo, infection, ringing, or excessive wax; client does not use hearing aids. Nose, Nasopharynx, Sinuses: Nose is symmetric, no deviation in septum or obstruction. Client reports “nightly snoring.” Also confirms sneezing and mild change in smell. Client denies nasal discharge, frequent nosebleeds, nasal obstruction, postnasal drip, allergies, use of recreational drugs, and sinus pain or infection. Mouth/Oropharynx: Lips are pink and smooth. Mouth equal bilaterally. Client confirms recent sore throat from a cold and bleeding of the gums during brushing. Client denies any mouth sores, hoarseness, changes in voice quality, dysphagia, or changes in taste. Client does not use dentures or bridges. Respiratory: Client’s breathing appears to be unlabored and even. Normal chest contour. Doesn’t appear to have any respiratory distress. Client confirmed he experiences shortness of breath and night sweats. Does not remember their last chest x-ray and stated he had his last PPD years ago. Denies frequent colds, pain with breathing, cough, coughing up blood, and wheezing. Client is not a smoker but did “about 10 years ago.” Cardiovascular: Client states that he experiences occasional chest pain along with shortness of breath. Client does not recall having an EKG done. Denied any palpitations, edema, coldness of extremities, color changes in hands and feet, hair loss on legs, leg pain with activity, paresthesia, or sores that do not heal. Breasts: Bilateral breasts, normal size, symmetric. Client noted no lesions, masses, or lumps within the region. Denied any recent pain, nipple discharge, swelling, changes in appearance, cystic breast disease, breast cancer, breast surgery, or change in size. Client states he does not perform BSE and “does not recall last clinical breast exam or mammogram.” Gastrointestinal: Client does not appear to have any abdominal distention. Shape is consistent with age and symmetric. States that their “appetite has changed” and they “don’t eat as often” as he used to. Will experience occasional heartburn. States bowels as up to 3x a day. Client does not have a history of gastroesophageal reflux disease. Denied pain, nausea/vomiting, vomiting blood, jaundice, changes in bowel habits, diarrhea, constipation, or flatus. Had a colonoscopy performed “about 4 years ago” and the results were negative. Genitourinary: No bladder tenderness or distention. Client denies any pain or burning while voiding. Claims frequency and urgency to be moderate. Reports clear, yellow urine. Does not experience any issues regarding urgency, incontinence, or hesitancy. Urine flow has

progressively increased but states that its “probably due increased fluid intake.” Client denies flank pain, nocturia, and blood in urine. Female/male reproductive: Appears to be no swelling or discomfort. Described as free of rashes, lesions, and lumps. Stated good hygienic care. Denied any recent discharge, pain or infertility problems. Reported having “slight change in sex drive.” Client has never had an STD and is aware of STD prevention and safe sex practices. He mentioned mild pain during intercourse. Client is involved in a heterosexual relationship and has been with this person for over 25 years. He does not use birth control. Client was diagnosed with prostate cancer in 2009. Was treated with radiation for 3mo., currently “cancer free.” He reported he had a checkup last year. Denies scrotal problems and impotence. Stated that he is relatively satisfied with his sexual performance. He occasionally performs a testicular self-examination and does so by examining both testicles for lumps and swelling. Musculoskeletal: Clients body structure provides him a good base for support. No noticeable issues with stride. Does not need any assistive devices to get around. Client believes they are in “good shape” for their age group. ROM is good aside from lateral curvature associated with lower lumbar pain. He does believe this puts some limitations on his mobility. Has experienced muscle and joint pain recently. Treated swelling with ice pack. Denies any fractures, weakness, stiffness, or loss of height. Client states that he does not recall bone density scan. Neurological: Client’s cognitive function appears to be up to par. He is oriented to reality. Good attention during interview. Was able to recall many situations from the past, reflecting long-term memory abilities. Denies any pain, fainting, or seizures. Noted minor, age-related changes in cognition but appears to still reason well. Reported changes in memory and sensory deficits including his hearing ability. Does not have any issues with gait, balance, or coordination. Denies tremors or spasms.

Psychosocial Profile Health practices and beliefs/self-care activities: Client routinely takes part in resistance training with the use of weights and other strenuous equipment. He prefers “being up and staying active,” and understands how diminished activity can affect the aging body. He is a firm believer in assessing his own body and takes part in inspections regularly. Client reports he brushes his teeth 2x a day but does experience “oral issues.” He also noted that he flosses every once in a while. Client states he has to check his BP at home on a regular basis and monitor it closely. Other than this, he reports he does not get any other screening done very often.

Nutritional patterns: Client reported 24-hour recall as: Liquids - 2 cups of coffee - 1 Blue Gatorade - 12 oz beer (bud light) x2 - Water Snacking - Yogurt - Crackers and sharp cheddar cheese - Mini chocolate bar - Blackberries (1 cup) Dinner - Pork roast (pork, potatoes, carrots) Client reported this to be relatively normal for him. States his appetite has “declined over the last two years.”

Functional Ability: Client confirms he is able to independently participate in all self-care activities at this time. He is able to dress, go to the restroom, eat, walk around, shop, cook, and participate in housekeeping by himself. He even reports to move the lawn and work around his house on a daily basis. Sleep/rest patterns: Client feels that he gets an adequate amount of sleep each night. He goes to bed between 10 and 11 pm and gets up around 9 am. He reported to get at least 8 hours of sleep per night and does not take naps often. Client does not use sleep aids. Personal habits (tobacco, alcohol, caffeine, and drugs): Client is a nonsmoker. He confirmed alcohol consumption, 2-4 12 oz beers a day. He does not drink hard liquor. Reported to drinking 2 cups of coffee (basic blend) each morning. Client states that he does not use drugs. Environmental history: The client’s environment was described as rural. He reports to take extreme measures regarding home safety and has cameras, alarms, and smoke detectors in place. He lives in a home on a canal with a decent amount of privacy between. His home contains heating and plumbing and it “more than satisfies the needs of myself and my family.” He noted that the neighborhood he lives in is very family-oriented.

Socioeconomic status: Client does have health insurance (Medicare). He appears to be financially stable and in good terms. Family/social relationships: Client reports to have been married to his significant other for 30 years. She is his “support system.” Client lives at home with wife and daughter. He “is the sole provider for the family.” Client also considers his daughter to be very supportive. Outside of the home, client states having a few “close buddies” that he goes out with from time to time. Him and his wife occasionally spend time with their adjacent neighbors. Client is not involved with any community agencies. Cultural/religious influences: Client states he “doesn’t really have any cultural or religious beliefs on health” but does “believe in the system and that it works.” Mental Health: Client claims to recently experiencing symptoms of depression. Reported to have just lost both of his parents and family dog. These stressful events have led him to “feelings of sadness and frequent mood swings.” He confirmed feelings of irritability and believes his coping strategies “could use some work.” Client denies any recent anxiety.

Individual Health History Reflection I was somewhat uncomfortable when taking this individual's health history because I know him relatively well. It felt humorous in the beginning; however, these are things I will need to practice to be successful as a nurse. I believe practicing scenarios has a lot of merit. I overcame the challenge by remembering it is in my best interest to conduct this assessment as it were an actual patient in a healthcare setting. Doing so allowed me to stay focused and not feel as uncomfortable with the interviewing process. I also reminded myself of the likelihood that this individual may alter his answers or not reveal reliable information. I am sure if the circumstances were different, he would have included more related symptoms and feedback. One interviewing technique I used was active listening. I think listening actively and being attentive helped me obtain a decent amount of information. With that said, it also made his contributions feel essential. In addition to active listening, I provided instructions at the beginning and let the interviewee know what I expected of him. I think this offered him some ease. One technique I found difficult was sitting back and remaining silent in order for him to process what I had asked. It seemed that he refrained from answering questions that were uncomfortable for both of us, such as satisfaction with sexual performance. Remaining silent made it even more cringeworthy, and I felt I needed to add justification to the question at hand. I am confident this will get easier with practice. I think one of this individuals' strengths is that he still possesses a positive outlook on life regardless of his aging. He still has passion and drive and seems extremely enthusiastic overall. I believe this benefitted me personally. One of his weaknesses that appeared to me is how he progressively lets his appetite diminish. He currently does not seem to be consuming an adequate amount of the essential nutrients. It is so imperative that the older adult population continues to

nourish their bodies to prevent illness or disease. Their immune system is weakening and does not have as much strength to combat adverse health effects. My client identified one of his physical strengths as his ability to maintain fit. I agree with this and believe he does a great job retaining his physique. In addition, he identified a psychosocial/cognitive strength as his ability to grasp and retain information, even now. He is proud of his lack of cognitive diminishment thus far. This will benefit him as the neural impulses within his brain continue to myelinate the tissues. It also will have a positive impact on his memory. On the other hand, one psychosocial/cognitive weakness he identified is his frequent changes in mood and behavior. I agree with this statement partially because I know this individual and know how it affects his relationships. I think he could improve this by improving his coping skills....