Nursing Interview

Name of Students: Jayson, Joyce D.

Ehurango, Rhea

Section/Year: BSN - 1E

Subject: Health Assessment

BIOGRAPHICAL INFORMATION:

Name: J.B.T
Age: 23 Years old
Gender: Male
Occupation: E- commerce
(Costumer Service)
Marital Status: Single
Religion: Roman Catholic
Family: 3 siblings and Auntie

History of Present health concern: The patient complains having difficulty to move due to the chest pain
radiates down to his feet 2-3 hours ago. The patient denies any recent trauma or injury to the area.

Physical Symptoms:

 Difficulty of walking, bending, or sitting comfortably

 Stiffness of joints, stiffness of neck
 Nail (pale white)
 Body weakness
 Inability to perform BADLs (basic activities of daily living)

Personal health history:

 None

Family history:

 None
NCP:

Assessment Nursing Diagnosis Planning Implementation Evaluation

SUBJECTIVE: Decrease activity SHORT-TERM INDEPENDENT: After 8 hours of nursing
tolerance related GOAL: – Encouraged intervention, the
– The patient to impaired the patient to patient understood the
stated, physical mobility After 8 hours of eat more health diet modification,
“Sumasakit ang as manifested by: nursing foods or well performed passive
dibdib ko pati intervention, the balance diet. range of motions,
daliri at paa pero —Difficulty of patient will importance of
ngayon okay na walking, bending, understand the – Encouraged increasing potassium.
ako kaso hindi or sitting diet modification, the patient to
lang makakilos ng comfortably perform passive increase fluid
maayos.” —Stiffness of range of motions intake.
joints, stiffness of and importance of
– The patient neck increasing – Encouraged
stated, “Low po — Low potassium potassium. the patient to
sa potassium.” level take a rest in
(hypokalemia) a proper and
– The patient – Nail is pale comfortable
stated, “May white position using
pangangalay at – Body weakness pillows for
sakit sa katawan support.
kasi nakahiga
buong araw.” – Teached the
patient on slow
– The patient movements and
stated, practice
“Nagsimula itong standing, sitting
sakit ko noong on the edge or
2022, parati na side of the bed.
kong
nagpapahospital – Provided
or check up support during
monthly pero nito movements to
lang mga minimize the
nakaraang weeks patient’s
mas grabe at discomfort and
lumala pa.” pain.

– The patient – Monitored vital

stated, signs such as
”Wala naman blood pressure,
akong heart rate,
naging sugat or temperature, and
trauma sa kahit respiratory rate,
ano.” to assess for
changes indicating
OBJECTIVE: worsening of pain
and report any
 – Difficulty of
walking, bending, significant
or sitting findings to the
comfortably healthcare
professional right
– The patient is away for further
lying on the bed. evaluation.

– Stiffness of
joints, stiffness of
neck DEPENDENT:
– Administered
– Nail is pale prescribed
white medication such
as muscle
— Body relaxants or pain
weakness medications, as
ordered to
— Inability to manage acute
perform BADLs pain effectively
(Basic activities of and improve the
daily living) patient’s comfort.

— Collaborated
with physical
Vital Signs:
therapists to
Blood Pressure: develop a plan
100/70 mmHg focusing on
PR: 20bpm strengthening
RR: 20Bpm exercises and
Temperature: 37 functional training
Ozsa+: 99 to improve mobility
and alleviate pain.