Nursing Assessment

J.P, a 40-year-old male, came to the outpatient clinic with complaints of (C/O), mild shortness of breath (SOB) and some mild intermittent chest pain (CP). He described himself as a high stress, type A personality who owns his own business and works long hours. He has smoked one pack of cigarettes per day for the past 25 years. He has tried to quit several times and has been successful for as long as 6 months at a time but when things become stressful, he starts smoking again. He stated that he is trying to lose the extra thirty pounds he is carrying, but it is very difficult to exercise due to the long hours of work. The cardiac workup is negative for cardiac disease.

Introduction

Throughout this complete health assessment, I will approach my patient, 40 years old, male, very stressed patient, and perform a head to toe examination. Starting with the gathering of information, I will start with biographic data, reason for seeking care, present illness, past health history, family history, functional assessment, perception of health, head to toe examination, and baseline measurements. The subjective data will be collected first, where the patient will provide necessary information about every organ system for further examination while the objective data will be amassed in every system based on my findings. This assignment serves as an opportunity to establish a nurse-client interpersonal relationship that will help identify the patient's individual needs and concerns to build a nursing diagnosis, care plan, interventions, and then evaluate results to treatment implementations.

When assessing a patient who is complaining of chest pain and shortness of breath, it can be a rather stressful and scary situation because as a nurse, one knows that minutes count and that it can be a life or death situation. The key elements when a patient presents in this manner is to remain calm and to stay focused. The first question one should ask is "Does this pain have other signs and symptoms?" such as shortness of breath, nausea, or diaphoresis? If the patient does, the nurse will want to alleviate the patient by applying 2 liters of oxygen via a nasal cannula. Next, the nurse should ask questions that are related specifically to the pain itself. "Does it radiate down the arm, back or up the neck?" "What does the pain feel like?" "Is it a crushing pain or burning pain?"