Comprehensive Health, Assessment Example

Health History of the Patient

The Nurse should obtain health history of the patient before commencing physical assessment. It is done by interviewing the patient leading to the collection of crucial information relating to his or her health history. The data gathered helps in focusing on specific areas of concern when conducting the physical examination (Capezuti et al., 2011).

Interviewing the patient

The Nurse should speak clearly as well as to minimize distractions to enhance rapport and promote the exchangeof information. The patient should be put at ease by explaining to him or her importance of the interview, and giving a brief outline of the whole process. The patient should be asked to give reasons for seeking health care. It is important to establish when the symptoms of the illness began. The Nurse should ask the patient about his or her past illnesses, which needed medical attention, other procedures, as well as hospitalization. Determine if the patient has a a history of respiratory, cardiovascular, neurologic, or renal disorders; cancer, diabetes mellitus, falls, or injuries. Ensure that all prescription and non-prescription medications for the patient are properly documented. For example, the patient’s name, dosage, and frequency should be documented.

Integumentary System

Most integumentary changes related to aging are easy to observe. For example, wrinkled skin, and graying hair are easy to spot in a patient. However, the changes are not always solely associated with aging. Some changes may be as a result of environmental and lifestyle factors.

Assessing the Skin

Wrinkled skin is caused by loss of turgor and elasticity. Aging causes the skin to thin gradually as well as lose density; hence exposing it to tears and bruising. The skin should be inspected for moles and lesions. The Nurse should check for irregular shapes when examining moles. The patient should be asked if he has witnessed any mole grow bigger or change color. Any positive findings should lead to further evaluation. Check for the pressure ulcers. The pressure ulcers rates range between 10% and 18%, according to the NPUAP. Pressure ulcers are commonly found in heels, sacrum, and trochanters  (Capezuti et al., 2011).

Assessing the Hair

Aging results in decrease of melanin in the body. Therefore, the color of the hair becomes less vibrant. It starts graying. Older adults lose hair altogether. The dermal vascular beds start to diminish as aging sets in.

Assessing the Nails

Nail surfaces are always slightly curved or flat regardless of the age of the patient. The nurse should note their length, color, and cleanliness. Check for any abnormalities in the nails. For example, clubbing of nails may indicate pulmonary or cardiac disorder. Transverse and pitting groves may indicate peripheral vascular disease, diabetes, or arterial insufficiency. Decreased vascular supply may cause brittleness.

Face, Head, and Neck

The nurse should note the general shape and size of a patient’s head. He should determine whether or not the head is appropriate to the body size. The head rests on the neck flexible vertebrae. It is the neck that hives maximum mobility to the head. The limited range of the motion may cause pain and discomfort in older adults. The nurse should stay alert as he evaluates neck ROM so that he gathers reports of dizziness or pain, which may act as clues to the health problems  (Capezuti et al., 2011).

Assessing Face

Note whether or not the eyes, mouth, and nose are symmetrical and centered. Asymmetrical features indicate signs of stroke. Encourage adults to get an annual examination of their eyes.

Next Steps

Use the findings from the assessment to develop an effective and comprehensive plan of care, which focuses on geriatric-appropriate support services and interventions. The nurse should conduct continuous monitoring by means of follow-ups. This gives the nurse a chance to modify the plan of care as needed. If the assessment findings of the patient are abnormal, consider consulting geriatrician or geriatric nurse practitioner (Capezuti et al., 2011).

Reference

Capezuti, E., wicker, D., Mezey, M., & Fulmer, T (2011). Evidence-based Geriatric Nursing    Protocols for Best Practices: Fourth Edition (Springer Series on Geriatric Nursing). New York, NY: Springer Publishing Company.