Nursing Health Assessment - Case Study Example

Basically, the diagnosis and potential nursing intervention in this patient would be achieved through the nursing process that involves a systematic process of deduction based on knowledge. The information and findings in this patient thus would need to be collected, analysed, and validated through this process to reach a nursing diagnosis that sets the basement of the management of the patient (Jarvis, 1999, 23-75). The objective of such assessment process is to collect information regarding the client's health status in order to identify deviations from normal in order to pinpoint actual problem and the risk it poses to the patient's future health (Bickley & Szilagyi, 2003, 31-46).

History: The health history is the subjective database for the assessment. Health history also serves to set up the nurse-patient relationship. I started taking the history from the patient. Since the patient is a relative, I needed no introduction. The purpose had to kept in mind while doing this, since this process not only provides information regarding actual and potential health problems, but it is also a tool to recognize the patient's supports and strengths, a medium to identify the needs and necessity for collaborative care (Fuller & Schaller-Ayers, 2000, 53-81).

Elements in History: The patient's identification demograp. As much as information in relation to the patient's life style and activities of daily living were attempted to be extracted. The target was to explore in depth the health profile of the person in question (Jarvis, 1999, 79-102). It began from the past history of this patient, starting right from the childhood. This patient had no major childhood illness as far as he remembers. He had no surgeries. Of late, he is having trouble with similar problems of exacerbated cough, fever, respiratory distress, and for this reason he had been hospitalized for several times.

He has no other medical problems known to him or does not recollect any other diagnosis for his ailments that had been told by his primary care physician. He has no known allergies to medications, and he has a list of medications that as far as he remembers are azithromycin and aerosol salbutamol inhalers for regular use. He has not been traveling recently, and he was never in the military service. His family history is not suggestive of any congenital diseases or diseases of familial origin.

In the section of social history, he admits that he is smoker for quite a few years. His few attempts as quitting smoking have failed, and he has no plans to quit in the near future. His drinking habit is also from his teens, and he rates himself as a moderate drinker. He thinks there are no adverse effects from his drinking habit, and he finds no reason to think about abstaining from it. The patient has a supportive family, and he finds strength in the family. At present he seeks care due to his exacerbation of symptoms of chronic cough with difficulty breathing.

Of late, he is observing that the frequency of such events is increasing. This history