Utica College Geriatric Health History & General Information Discussion

I’m working on a nursing multi-part question and need an explanation to help me study.

Tips for the Health History

• Find a geriatric (?65) volunteer to be a “patient”. See the sample history in the student resources module.
• Use the correct form based on your patient’s age. They are slightly different. The forms Word documents located in the dropbox. Type directly in to the form.
• Use concise, but complete sentences in ALL areas.
• Address ALL items. State what the “patient reports…”, what the “patient denies…”, or what the patient is “unable to recall” or is “unknown”.
• Explore anything the patient reports as appropriate. In other words, provide details about anything abnormal or unusual.
• Document only SUBJECTIVE information…what the patient tells you.

Identifying and General Information

• This is straightforward information.
• State who is giving the information. In most cases, it is the patient and he/she would be considered reliable unless there are deficits/limitations noted. For example; if you choose a geriatric patient with early dementia, you may get some of the information from a family member who is also present.
• You have 2 options here depending on what your patient tells you
  • The patient does NOT have a chief concern – In this case, make a statement about why the patient is here, a statement about his/her general health, and leave OLDCARTS items blank. For example; The client is here for an annual exam and reports excellent health.

  • The patient HAS a chief concern – In this case, state the concern and explore the details using OLDCARTS as appropriate. If any OLDCART item is not applicable, then state that.
    • Chief concern – document in the “patient’s” own words using quotations. For examples, “My throat hurts” or “I’ve been so depressed lately”.
    • Onset = state when the problem started
    • Location = state location of the problem if applicable. For example, for a sore throat, the location would be throat. But for depression, location would be inapplicable.
    • Duration = document frequency and how long it lasts; constant or intermittent?
    • Character/quality = state descriptors
    • Aggravating/associated factors = state what makes the problem worse and any other associated symptoms (e.g., loss of appetite, nausea, etc.)
    • Relieving factors = state what was tried to bring relief and effectiveness
    • Temporal factors = change over time. For example; has it gotten better, worse, or unchanged since onset?
    • Severity = Problems like pain, can be rated on a numeric scale. Other problems are measured based on limitations the problem has causes (e.g., cannot walk far without getting SOB, cannot drive, had to call in sick for the past week from work, etc.).
• Address all items – Patient reports…??? or Patient denies…??? and state what is unknown…???
• Provide details for any items the patient reports (e.g. year, treatment, complications, etc.)
• Address all items – Patient reports…??? or Patient denies…??? and state what is unknown…???
• Provide details for any items the patient reports (e.g. year, treatment, complications, etc.)
• Address all items – Patient reports…??? or Patient denies…??? and state what is unknown…???
• Provide details for any items the patient reports (e.g. year, treatment, complications, etc.)
• Document only SUBJECTIVE information…what the patient tells you – this is a history. Do NOT document your observations – this is not a physical exam.

Chief Concern and History of Present Illness

Past Medical History

Personal and Social History

Review of Systems

Priority Systems

• Based on the patient information, identify at least 2 systems you would pay special attention to if you were to do a physical exam.
• For example, if the patient reported any cardiac problems, then examining the cardiac system would be a priority. If the patient has a family history of diabetes, then the endocrine system would be a priority. If the patient wears glasses and has not had an eye exam in decades, then the eyes would be a priority.
• Give an explanation of your choice based on the information in the history. For example: The cardiac system would be a priority based on the family history of cardiovascular illnesses and the patient’s personal history of diabetes, complaints of occasional palpitations, high fat diet, and high job stress.
• You do NOT need to cite/reference professional sources. This is not a paper.

Health Promotion Recommendations and/or Referrals

• Based on the patient information, identify at least 2 recommendations/referrals. These may or may not be based on the priority systems.
• For example, the diabetic patient may need diet education and followup. Any patient who reports a poor diet or has personal/family history of cardiac problems may need diet and physical activity education or visit a cardiac specialist. A patient with oral pain and lesions may need encouraged to visit a dentist
• Give an explanation of your choice based on the information in the history. For example: Diet and physical activity education and follow-up is recommended based on the family history of cardiovascular illnesses and the patient’s personal history complaints of occasional palpitations, high fat diet, and high job stress.