Activity 1

Health Assessment

Assessment

John visits his general physician on Monday because he was feeling sick over the
weekend. When he is called back from the waiting room, the nurse on staff takes his
temperature, heart rate, and blood pressure. She then asks John a series of questions about
how he's been feeling lately. The nurse notes his responses when he says he's been having
difficulty breathing and has been feeling very tired. She also sees on John's medical
history that he has had previous problems with his cholesterol levels and blood pressure.
John also has a blood sample taken during his doctor's visit.

Diagnosis

The nurse looks over John's symptoms and notes that his heart-rate is higher than average
and his blood pressure is elevated. She also considers that he has experienced fatigue and
shortness of breath before when his cholesterol levels were very high. The nurse
determines that John is experiencing Hyperlipidemia, also known as having high levels of
fat within the blood. John's blood tests confirm this hypothesis. The nurse is also
concerned that John is at risk for heart disease.

Planning

John returns on Tuesday for a follow-up visit. The nurse sits down with him in a closed
room and explains his cholesterol levels and high blood pressure. She suggests that John
be put on medication to help lower these numbers and recommends he exercise at least
twice a week. The nurse also tells John he should stay away from salty foods and eat less
red meat. John agrees with the nurse, and they setup a follow-up appointment two weeks
later. The nurse reminds John to call if there are any changes in his condition, or if he
starts to feel worse.

Implementation

John is prescribed the medication and takes it as recommended. One week later, he has a
day where he feels especially sick and calls the doctor's office. The nurse explains that the
medication could cause nausea as a side-effect and advises John to drink Ginger-Ale and
avoid any foods that generally upset his stomach. John continues taking the medication
and goes to the gym four times during the two-week period. Once the two weeks has
passed, he returns to the doctor's office for his follow-up appointment Evaluation When
John returns, the nurse asks him a series of questions about how he's been feeling. John
replies that he has been having an easier time breathing and feels significantly less tired
since exercising and taking the medication. The nurse marks "Patient's Condition
Improved" on his official medical records and congratulates John on his well being. She
then advises him to remain on the medication for one more month and to continue his
exercise. Although there are calculated steps behind the nurse's approach, her methods are
extremely friendly and warming and care is taken to treat the patient like a human being.
As you can see, the nursing process will feel like second nature when put into real-world
practice.