Health Assessment

Running head: HEALTH ASSESSMENT
HEALTH ASSESSMENT
Name of the student:
Name of the university:
Author note:

HEALTH ASSESSMENT
1
Consider the patient’s condition:
The patient is 82 year old man who resides in the rural part of the country. He has been
admitted to the hospital due to chief complaints of nausea, headache, fatigue, hazy and loss of
appetite. By interviewing the patient, it is identified that the patient recently had an accident from
bike. The patient became unbalanced and fell down striking left side of his head to the ground.
The patient witnessed minor skin tear on his left forearm and minor abrasion to the left elbow.
During assessment the patient denies any pain, injury or stiffness and also does not experience
any stiffness or reduced movement to the chest, limbs or neck. The patient has a past medical
history of hypertension, but he has not been prescribed to any hypertensive drugs. The patient
does not have any past medical history of brain injury or concussion.
The chief complaints observed in the case of john (patient), is the nausea, headache,
fatigue, hazy and loss of appetite. It is observed that severe headache can cause loss of appetite
into the patient. According to Jensen, Radojicic and Yri (2016), the risk factor behind headache
in the case of john could be brain injury due to the accident he met recently or hypertension.
Apart from this, the other chief complaints of the patient such as, fatigue, hazy, lightheadness,
nausea and dizziness is due to the past medical history of the patient, which is hypertension, as
the patient stated that he does not take any anti-hypertensive medication.
Collect cues and information:
To get more clear information regarding the health condition of the patient, I will first collect
the subjective and objective data.

HEALTH ASSESSMENT
2
The subjective data includes the symptoms of the disease experienced by the patient (Jun,
Cha and Lee 2015). The subjective data that has been collected from the patient includes,
1. Nausea
2. Headache
3. Hazy
4. Dizziness
5. Mild confusion
6. Fatigue
7. Loss of appetite
After collecting the subjective data from the patient, the objective data are also collected by
after proper assessment of the patient (Briesacher et al. 2019).
1. Body temperature : 36.7 degree Celsius
2. Blood pressure: 148/84
3. Pulse rate: 81 beat per minute
4. Respiratory rate: 17 breaths per minute
5. Oxygen saturation: 97% on the room air
6. Headache: pain 4/10
The body temperature of the patient (36.7 degree Celsius), the pulse rate of the patient (81
beat per minute), oxygen saturation (97% on the room air) and the respiratory rate (17 breaths
per minute) of the patient is normal. However, the blood pressure of the patient is 148/84, which
is high than that of the normal blood pressure (120/80) (Ochiai et al., 2015). The pain score of