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

In this assignment, you will be completing a health assessment on an older adult. To complete this assignment, do the following:

  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 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 athttps://www.ihs.gov/nnlc/includes/themes/newihstheme/display_objects/documents/resources/SBARTEMPLATE.pdfas a guide.
  4. Document the findings of the physical examination in the assessment worksheet.
  5. Using the “Individual 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 writingis expected.
This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.
Rubric
Benchmark Assignment – Individual Client Health History and Examination (A Direct Care Experience)

1
Unsatisfactory
0.00%
2
Less than Satisfactory
75.00%
3
Satisfactory
79.00%
4
Good
89.00%
5
Excellent
100.00%
80.0 %Content
40.0 %Uses SBAR Format to Include All Components of the Health History (Biographical, Past Heath, Family, Symptoms) Using Appropriate Medical Acronyms and AbbreviationsWith or without SBAR format, provides incomplete medical history with or without use of appropriate medical acronyms and abbreviations.Uses SBAR format to provide all components of the health history based upon the information collected in the health history. Appropriate medical acronyms and abbreviations are absent or inconsistent.Uses SBAR format to provide all components of the health history (biographical, past health, family, symptoms) using appropriate medical acronyms and abbreviations.Uses SBAR format to provide all components of the health history (biographical, past health, family, symptoms) using appropriate medical acronyms and abbreviations, and relates information to the diagnoses.Uses SBAR format to provide all components of the health history (biographical, past health, family, symptoms) using appropriate medical acronyms and abbreviations, and relates information to the diagnoses and integrates into treatment plan.
40.0 %Benchmark D5: Holistic Patient Care Competency 5.1: Understand the human experience across the health-illness continuumHealth screening and diagnosis do not demonstrate understand of the human experience across the health-illness continuum.Health screening and diagnosis suggest minimal understanding of the human experience across the health-illness continuum.Health screening and diagnosis demonstrate understanding of the human experience across the health-illness continuum.Health screening and diagnosis are integrated in an understanding of the human experience across the health-illness continuum.Health screening and diagnosis are integrated in an understanding of the human experience across the health-illness continuum and provide specific suggestions for treatment across this continuum.
10.0 %Organization and Effectiveness
10.0 %Mechanics of Writing (Includes spelling, punctuation, grammar, and language use)Surface errors pervasive enough that they impede communication of meaning. Inappropriate word choice and/or sentence construction used.Frequent and repetitive mechanical errors distract the reader. Inconsistencies in language choice (register), sentence structure, and/or word choice are present.Some mechanical errors/typos are present, but are not overly distracting to the reader. Correct sentence structure and audience-appropriate language are used.Prose is largely free of mechanical errors, although a few may be present. A variety of sentence structures and effective figures of speech are used.Writer is clearly in command of standard, written, academic English.
10.0 %Format
10.0 %Research Citations (In-text citations for paraphrasing and direct quotes, and reference page listing and formatting, as appropriate to assignment)No reference page is included. No citations are used.Reference page is present. Citations are inconsistently used.Reference page is included and lists sources used in the paper. Sources are appropriately documented, although some errors may be present.Reference page is present and fully inclusive of all cited sources. Documentation is appropriate and style is usually correct.In-text citations and a reference page are complete. The documentation of cited sources is free of error.

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