Individual Health History and Examination

Health Assessment

Perform a health history on an older adult.

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John is 74 years old. He runs his own business with his wife Pam. They have three children i.e. Susan, Debbie and Henry. In the last thirty years, John has been dealing with major health issues to include: colitis, having his gallbladder removed and two separate liver transplants. When John was in his 40s, he was sent to the hospital with an infection related to colitis. Two years after he was released, John’s skinned turned yellow and he experienced jaundice. The doctors determined that his bile was backing up into his gallbladder. They removed it and created ducts which go directly to the liver. Ten years later, John began to experience jaundice again and was informed that he had sclerosis of the liver. He was placed on the organ transplant list and received a new liver two years later. However, after the surgery he was still experiencing complications and had his new liver failed within five years. John spent the next two years going back and forth onto the transplant list and waiting for a new liver. Nearly, 10 years after receiving his first liver, he was given a second transplant. Since this time, John’s health improved and he is now following the most appropriate lifestyle and dietary choices. (Juall, 2006)

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.

John was able to survive many near death situations because of his strong individual health history. He follows a daily regimen that is focused on having a balanced diet, exercise and following the prescribe therapy protocol. For anyone who has an organ transplant, they will have to take drugs to suppress their immune system. This means that they are easily susceptible to diseases such as the common cold. The routine practices he follows are designed to maintain physical conditioning through running, walking, biking, lifting weights, practicing martial arts and playing golf. This takes place for a minimum of 30 minutes every day over the course of four days each week. His diet consists of a mixture of fruits, vegetables, nuts and limited amounts of fat. John follows the Mayo Clinic’s Pyramid Triangle. He has no other conditions and is classified to be excellent health. His second transplant is a success and he made a full recovery. He takes a positive attitude about himself and his family. This is something he has utilized to go from being a TV repairman to owning his own electronics store with nothing more than a high school education. John has the appearance of someone who is confident and in control. He believes his transplants are something which gave him more perspective about his life and the direction he wants it to go. These areas help John to effectively channel his stress. Over the course of time, this has enabled him to deal with critical challenges and make adjustments to his lifestyle choices. (Juall, 2006)

Document findings of complete physical examination in Situation-Background-Assessment-Recommendation (SBAR) format.

Situation: John is following a strict exercise regimen to ensure he maintains healthy lifestyle choices. In this case, the site was the Mayo Clinic in Rochester, Minnesota. This is where John will go to receive annual checkups. We interviewed him when he went to this location, at the beginning of October 2014. The main problem he was facing is, can he moderate his diet to include a certain amount of sweets. This is because he was feeling much better and had been following the same routine for 15 years. John wanted some kind of change in his life to make everything more exciting. He felt that his diet is one place where this can add variety. (Juall, 2006)

Background: John started to develop health issues when he was in his early 40s from colitis. . Two years after he was released, John’s skinned turned yellow and he experienced jaundice. The doctors determined that his bile was backing up into his gallbladder. They removed it and created ducts which go directly to the liver. Ten years later, John began to experience jaundice again and was informed that he had sclerosis of the liver. He was placed on the organ transplant list and received a new liver two years later. However, after the surgery he was still experiencing complications and had his new liver failed within five years. John spent the next two years going back and forth on the transplant list and waiting for a new liver. Nearly, 10 years after receiving his first liver, he was given a second transplant. (Juall, 2006)

Assessment: The situation with John is showing how the lifestyle choices and levels of health will have a dramatic impact on him. In this case, he was able to recover from two transplants and has been able to reverse his condition for the better. However, he wants to change his diet and eat foods that he often avoided. The challenge is finding a balance which enables him to maintain these objectives and instill a sense of balance. (Juall, 2006)

Recommendation: The best recommendation is for the PHN to encourage John to slightly alter his lifestyle choices. This is because he has made tremendous amount of progress. However, in the process, he is becoming somewhat bored with his routine and wants to modify it. This is how he is able to follow the most basic treatment protocol for his condition. In this case, he can alter his diet and activities as long as he maintains the same levels of health. Once this occurs, is when John can live a lifestyle that is more reflective of his personality and builds off the successes of the past. (Juall, 2006)


Nutrition and Healthy Eating. (2014). Mayo Clinic. Retrieved from: pyramid/art-20045416

Juall, L. (2006). Handbook of Nursing Diagnosis. Philadelphia, PA: Lippencott.

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