His diet includes organic food from animals, fruits and vegetables present in his farm. He is also a frequent alcoholic beverage drinker, with two to three bottles of beer every evening. No history of cigarette smoking had been mentioned. Mr. "S" has a family history of heart attack, breast cancer and hypertension. Occasionally he complains of shortness of breath which is relieved by rest. He thinks that he is in good health considering the time he spends outdoors.
A thorough health history must be established in order to provide a comprehensive nursing assessment. This may be done through interview or reviewing past medical records. Components of a nursing health history include biographic data, such as age, gender, occupation and usual source of medical care, chief complaint or the reason for visit, history of present illness, past history and family history. Lifestyle, social data like economic status, ethnic affiliation and neighborhood conditions, and psychological data are also considered. When assessing the history of the present condition, the onset of the symptoms, characteristic of the complaint, activity in which the patient was involved when the problem occurred and any aggravating or alleviating factors are noted.
Proper physical examination using effective tools are vital to come up with a diagnosis and to establish nursing care. A common method to identify problems is the review of systems. In this process, each body system is assessed for specific signs and symptoms that may be attributed to a deviation in the normal functioning of that organ system. In the case of Mr. "S", vital signs would have to be taken to acquire baseline data. Blood pressure is obtained using a sphygmomanometer and a stethoscope, heart rate and respiratory rate through a stethoscope, and temperature reading through the use of a thermometer. Baseline height and weight should also be measured using a tape measure and a weighing scale. Mr. "S" complained of shortness of breath relieved by rest and has a history of cardiovascular disease; therefore, data regarding cardiovascular and respiratory system must be reviewed. Aside from the heart rate, rhythm and heart sounds are also assessed, again through auscultation using a stethoscope. These are some of the parameters used in evaluating cardiovascular function. Assess for presence of edema, which is evident in Mr. "S". Perfusion can also be obtained by noting if he is warm, dry, or diaphoretic. Respiratory system review consists of observing the breathing pattern and breath sounds, presence of secretions and cough. Shortness of breath may suggest, but is not limited to, a pulmonary problem. Since Mr. "S" is having edema, pain will also have to be assessed. If pain is present, he could use a pain rating scale to be able to determine its severity. Genitourinary system must also be evaluated. His intake and output must be monitored. Ask when he last voided. Assess also for signs and symptoms of anuria, hematuria, dysuria or incontinence. This could reflect whether his edema and weight gain are brought about by a genitourinary problem. Skin assessment is done by noting presence of warts, moles, unusual discoloration, jaundice, scars and skin color. Jaundice may reflect hepatic dysfunction, in which edema may also be attributed. His lifestyle, involving drinking two to three beers every night, makes him at high risk for renal and hepatic diseases.