Nursing assessment is collecting or gathering information about the patient’s

psychological, sociological, physiological and spiritual status by a nursing officer.

The importance of assessment is essential in delivery of quality care of the patient.
Assessment is the first and basic aspect of nursing process and the need for
accuracy and timely assessment is essential.
The medical assessment or interview is different with nursing assessment as
medical interview focus on disease or medical condition whereas nursing
assessment deals with human response to actual or potential health problems and
life processes. For example, a medical diagnosis of Cerebrovascular Attack (CVA or
Stroke) provides information about the patient's pathology.
Data from nursing assessments are necessary to identify problems in the order of
clinical significance at a specific time and according to the urgent need for nursing
interventions. The information may include general and specific data on the
presenting problems as defined by the patient and the caregiver, medical diagnoses,
prescribed medical treatments, status of physical and mental functions, alternate
healthcare resources, patient goals and expectations, safety risks, self-care abilities
for recovery, including the ability to perform activities of daily living, and other
information that a nurse considers clinically relevant to the case or situation.
Identifying nursing diagnoses and prioritizing these problem areas are the major
intended process outcomes.

History and Physical Examination

Patient Name: SB
Referral Source: Outpatient Department
Data Source: Patient
Chief Complaint & ID:
Mr SB is a 40 y/o Male Indian. Who has been having headache for past
2days.

History of Present Illness

This is the first presentation to outpatient department for this 40 years old man
who claims to be in good health status till 2 days prior to presentation to
hospital. At the onset headache started while doing gardening in the evening
at about dawn. Mr SB has been since increasingly bothered by headache that
is left sided, usually throbbing pain but settles with Brufen Tablet 400mg.
Typically his head ache us rated 2/10. He currently has headache on
presentation which is rated 7/10. Mr SB recently missed his work for 2 days
and avoid noise and bright light. His head ache is not associated with any
nausea and vomiting. His recent headache, which made him present to
hospital which was most severe lasted about 6 hours.
During the headache dark room help to resolve some extend of pain and gets
relieved when patient is asleep. According to patient had history of fall from
swing at age at of 5 years old and had head injury, does not rememeber any
more about it, but no problem in childhood.

Patient Perspective
Mr SB thinks headache lead to him in some other medical condition as his
elder brother died of brain tumour.

Past Medical History

Childhood Illnesses
Nil of significance.

Adult Illnesses
Never been admitted to hospital
Not a known case of any medical condition.

Psychiatric Illnesses
None
Nil family history as well.

Immunisation
Last Tetanus in 2016 after had cut in hand with knife while cutting meat.

Current Health Status

Allergies
Nil Known to any medication or food.
Medications
Not on any regular medications expectation takes Tab Brufen 400mg for
headache.
Health Screening
Had ECG done in 2016 – claims normal findings.
Lifestyle Habits
Non smoker
Non alcoholic
Never tried any illegal drugs

Psychosocial History
Lives with wife whose is a school teacher and 2 boys.
Works as a Team Leader in a hotel.
Has good sexual life and enjoys his married life.
Denies work stress or depression.
Mr SB feels safe at work and at home.

Family History
Mr SB is eldest son of 2 boys.
Mother and father lives with younger in overseas.
Son 10 years old, healthy and well.
Son 7 years old, healthy and well.

Review of Systems
HEENT
No complaints change in vision.
No complaints with nose, ear or has any sore throat.
Claims of head ache – left sided.

Cardiovascular

Gastrointestinal
No complaints of dysphagia, nausea, vomiting or change in stool pattern.