Health Assessment

Table of Contents


Vital signs / Assessment findings.


Lifestyle / predisposing factors.

Universal precautions.



In order to get an allover understanding about the condition of the patient, a comprehensive health assessment will be conducted. It may provide the nurse with the understanding of the physical status of the patient. This will include a record of medical history, a general survey and an entire physical assessment. As mentioned by Toney-Butler & Unison-Pace (2019), a number of techniques will be required to be applied in the current case which includes inspection, Auscultation, Palpation and percussion. A thorough assessment of Skin, Ears, eyes, nose and throat, Cardiac-pulmonary system, Abdomen, Muscles and joints, limbs, shoulders, hips, ankles and feet will be considered.

The rationale for choosing this assessment procedure is, the patient is visiting the clinic and preparing for the consultation with the doctor. This assessment is required to be conducted so that the abnormal condition of the patient can be easily determined against the normal condition (Jarvis, 2018). The comprehensive health assessment will clearly indicate if the patient requires any medical care or diagnostic testing. Additionally, the comprehensive health assessment will allow considering all the factors associated with the health of the patient so that even minor symptoms do not get overlooked.

Vital Signs / Assessment Findings

There are some vital signs that the current patient is demonstrating. This include the status of the Blood Pressure which is 160/90 mmHg in the case of Brian. An ideal blood pressure is considered to b between 90/60mmHg and 120/80mmHg. Apart from that, the respiration rate has been found to be 18 breaths per minute. The normal respiratory rate is between 12 and 16 breaths per minute which is not the case in the current scenario (Flenady, Dwyer & Applegarth, 2017). Additionally, the pulse or heart rate of the patient was102 beats per minute whereas the normal parameter for heart rate among adults ranges from 60 to 100 beats per minute. Therefore, the normal parameter has been considered to identify if there is any abnormality in the physical functioning of the patient. However, the body temperature of the current patient has been found to be normal as normal temperature may range from 97°F (36.1°C) to 99°F (37.2°C), where Mr. Brian did not show any abnormality in body temperature.

The pain assessment results have indicated that there is a presence of general body aches but nothing to major which can be considered as associated with the sedentary lifestyle of the patient (Vancampfort et al., 2018). The normal blood sugar level of a person do not exceed 7.8 mmol/L, whereas, in the case of Brian it is 15.7 mmol/lt which is an indicator of high level of glucose in the blood. The assessment results also show that the height of the patient is 170 cm according to which, his weight is higher than normal range. The normal weight for 170 cm male ranges from 58-72 kg which is not the case in current situation.

The measurement has been considered within the normal parameters so that the abnormalities can be easily found to be intervened. As there is the presence of some vital signs of breathing and pulse abnormalities along with mild body aches and with other symptoms, there is an indication of tachycardia.


Captopril is a medication that Brian is currently taking which can be considered as a general drug (Yang et al., 2019). Brian is likely to take the medication mentioned above for treating high blood pressure. This medication also helps in the case of heart failure, heart related problems, diabetic kidney disease and others. This can effectively manage the symptoms of heart failure and other related disease and this is relevant may be due to increased heartbeat which is an indicator of underlying complications.

One of the major nursing consideration for the medication is to administer the medication 1 hour before meals. The patient chart is required to be alerted with an indication that Captopril is being taken by the patient. The nursing intervention can be effectively categorized into several procedures through which the medication can be appropriately administered. The nurse is required to consider the appropriate dosage as prescribed by the physician. Along with this the following procedure may be followed. Initial dose can be given of 0.01-0.05 mg/kg every 12 hours. After administration of the drug, some possible adverse reactions may occur including Proteinuria (Thompson et al., 2019). In order to help the client with this condition, patient can be referred to assessments of kidney functioning. Rash and angioedema may also take place which are required to be intervened by the nurse by placing a wet and cool cloth on the affected area. The blood pressure is required to be checked frequently. The Blood Urea Nitrogen is also required to be monitored by the nurse. The adverse reactions can be monitored closely by the nurse so that any requirement for medical treatment may be referred to if the patient needed. The dosage is required to be reduced if any renal function impairment is detected.

The patient will be provided education such as being careful about the blood pressure, taking medications one hour before meals, avoiding over the counter medications, about the side effects including cough, cold, allergy and others and mouth sores are to be reported. The rights of medication include right patient which is considered as important as medicated prescribed to one person may be harmful to others if not required. The appropriate medication (right medication) is required to be used so that intended health issues may be treated. Right time is also required to be maintained to ensure proper impact of the medication (Kandzari et al., 2018). Right documentation is also required to be considered noting on chart the time, route and other specific information. The appropriateness of the medication can be ensured by gathering right response from the patient.

Lifestyle / Predisposing Factors

It has been identified from the case study that the patient’s weight is 125 kg though is height is 170 cm only. Therefore, it can be stated that the patient is suffering from obesity. This can be considered as one of the main predisposing factors behind the condition of the current patient, Brian. Another predisposing factor that is working behind the current health condition of the patient includes his sedentary life style. It has been identified from the existing literature that sedentary lifestyle is associated with different diseases including type 2 diabetes and heart diseases as well. Even after being involved into a regular exercise or activities, it is likely for the people to develop heart diseases like tachycardia if they follow sedentary lifestyle (de Oliveira et al., 2019). Therefore, the intervention strategy in this context will be educating the patient about the importance of activities for maintaining health; the possible barriers will be identified in achieving optimal active phase. The patient is required to be supported at every stage of activity implementation. Along with this, the patient can be suggested to associate himself with a social group for making the activities enjoyable.

Nursing intervention for obesity will include carrying out daily food diary such as types and amount of food and eating habits. An eating plan is required to be formulated with the patient to show respect towards the food habit of the patient and personal preferences of the patient can be respected (Jager et al., 2019). The nurse is required to regularly monitor the proportion of height and weight of the patient so that based on this information; the dietitian can be alerted for choosing specific food for the patient. The result of the administered diet plan is required to be measured and monitored regularly. Emphasis should be given upon avoiding protein diet. Realistic incremental weekly goals may be set with the client so that the patient can be kept on a track towards reaching to the optimum level of weight.

Universal Precautions

Coronavirus disease (Covid-19) can be considered an infectious respiratory disease that is caused by Coronavirus (World Health Organisation, 2020). People that are affected with covid-19 are likely to face respiratory illness and may not require any special treatment to recover from the condition. It can be dangerous for the people with underlying disorders such as diabetes, cardiovascular disease and other respiratory diseases. This disease can spread through droplets of saliva primarily when an infected person coughs or sneezes.

It can be stated that preventive measure or precautions that can be taken under consideration by the nurses include being informed about the causes and the processes through which it can spread. The patient might protect his or her body from getting into the contact of others. The patient will also be suggested to maintain respiratory etiquette.

Infections can be prevented through spreading awareness about its cause and effects. Apart from that good hygiene maintenance such as bathing, hand washing, wearing washed cloths and so on are required to be considered (Campbell et al., 2018). Proper food safety techniques are required to be taken under consideration while cooking, before eating and after eating meals. Proper vaccinations are required to be provided to protect. Proper contraceptive measures are required to be taken for avoiding infections.

References for Sedentary Behavior and Anxiety

Campbell, S. J., Biritwum, N. K., Woods, G., Velleman, Y., Fleming, F., & Stothard, J. R. (2018). Tailoring water, sanitation, and hygiene (WASH) targets for soil-transmitted helminthiasis and schistosomiasis control. Trends in parasitology34(1), 53-63.

de Oliveira, L. D. S. S. C. B., Souza, E. C., Rodrigues, R. A. S., Fett, C. A., & Piva, A. B. (2019). The effects of physical activity on anxiety, depression, and quality of life in elderly people living in the community. Trends in psychiatry and psychotherapy41(1), 36-42.

Flenady, T., Dwyer, T., & Applegarth, J. (2017). Accurate respiratory rates count: So should you!. Australasian Emergency Nursing Journal20(1), 45-47.

Jager, M., de Zeeuw, J., Tullius, J., Papa, R., Giammarchi, C., Whittal, A., & de Winter, A. F. (2019). Patient Perspectives to Inform a Health Literacy Educational Program: A Systematic Review and Thematic Synthesis of Qualitative Studies. International journal of environmental research and public health16(21), 4300.

Jarvis, C. (2018). Physical Examination and Health Assessment-Canadian E-Book. Elsevier Health Sciences.

Kandzari, D. E., Böhm, M., Mahfoud, F., Townsend, R. R., Weber, M. A., Pocock, S., ... & Brar, S. (2018). Effect of renal denervation on blood pressure in the presence of antihypertensive drugs: 6-month efficacy and safety results from the SPYRAL HTN-ON MED proof-of-concept randomised trial. The Lancet391(10137), 2346-2355.

Thompson, A., Carroll, K., Inker, L. A., Floege, J., Perkovic, V., Boyer-Suavet, S., ... & Gillespie, B. S. (2019). Proteinuria reduction as a surrogate end point in trials of IgA nephropathy. Clinical Journal of the American Society of Nephrology14(3), 469-481.

Toney-Butler, T. J., & Unison-Pace, W. J. (2019). Nursing Admission Assessment and Examination.

Vancampfort, D., Stubbs, B., Herring, M. P., Hallgren, M., & Koyanagi, A. (2018). Sedentary behavior and anxiety: association and influential factors among 42,469 community-dwelling adults in six low-and middle-income countries. General hospital psychiatry50, 26-32.

World Health Organisation, (2020), Coronavirus. Retrieved on 13 September 2020 from:

Yang, T., Aquino, V., Lobaton, G. O., Li, H., Colon‐Perez, L., Goel, R., ... & Pepine, C. J. (2019). Sustained captopril‐induced reduction in blood pressure is associated with alterations in gut‐brain axis in the spontaneously hypertensive rat. Journal of the American Heart Association8(4), e010721.

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