Nurse * Patient “
Health History
1. Self Introduction;
* Goodmorning po, I will be your attending nurse for today, my
name is Vince De Torres, a student nurse from Batangas State
University.
2. Explained the purpose of the interview;
* This interview will consist of me taking down your health
history and will take approximately 10 minutes to conclude is
that okay with you?
* I have also ensured that we are in a private and quiet room,
everything you say is in confidentiality and will not be leaked
to anyone.
3. Worked at the same level as your client;
* I’ll also talk to you in the distance that won’t invade your
private space.
4. Open and Close Ended Questions;
4.1. Biographical Data
* Firstly I would like to know our patient’s name po, birthdate
and age.
4.2. Chief Complaint
* Next, what is your main purpose of coming for a checkup?
4.3. Present Health Concern or Illness
* I see, so how frequent are the nosebleeds you experience? And
please tell me from which part of your head are the headaches
coming from.
“ This past week I have been having one or two nosebleeds and I
don’t think that is normal.”
“Every morning I wake up and the back of my head hurts so much,
last sunday I even got a nosebleed after waking up.”
4.4. Past Health History
* So when did the nosebleeds and headaches start?
“ Uhmm, about last last week, I forgot which day it was but it
was nearing the weekend.”
“ I haven’t been able to focus on my classes because of this, and
I’m scared knowing my nose could bleed anytime in class.”
4.5. Family History
* Has anyone in your family these past few weeks inhibited your
same symptoms?
“ No not really, it’s just me.”
4.6. Review of System
* Presently, how are you feeling right now? Ma’am?
“ I’m kind of lightheaded but it’s manageable.”
4.7. Patient Profile
* Since you attend classes I can infer you are a student, may I
know if you drink frequently and sleep on time?
“ Yes I am a student of Batangas State University, I don’t drink
that much water and I only get 5 hours of sleep daily.”
5. Made eye contact and listened carefully to the person’s
responses to my questions;
* Thank you for answering my questions truthfully ma’am.
6. Take a look at your patient’s nonverbal behavior;
* I have noticed you looking a little pale, as well as touching
your temples repeatedly. I think you should drink a bit of water.
7. Consider client’s cultural background;
* So for the last question, may I inquire about how your family
thinks about your current condition?
“ They just told me to take a checkup and buy medicine, nothing
else.”
8. Provide closure for interview;
* Once again, thank you for answering everything and I have noted
down everything. Once I submit this report to the doctor I will
come back and inform you when they will come.
9. Ended with a positive statement;
* Please don’t worry ma’am I’m sure that this illness will be
dealt with soon, by fixing your sleep schedule and drinking more
water as well as the treatment the doctor suggests.
Hypertension
A chronic condition where the force of the blood against the
artery walls is consistently too high. Over time, this increased
pressure can damage the arteries and lead to serious health
complications like heart disease and stroke.
Causes and Triggers
Hypertension is often categorized into two types:
Primary (Essential): Develops gradually over many years with no
identifiable cause, often linked to genetics, aging, and lifestyle.
Secondary: Triggered by underlying conditions such as kidney
disease, thyroid problems, obstructive sleep apnea, or certain
medications.
Symptoms
Hypertension is famously known as the "silent killer" because it typically
has no visible symptoms until significant damage has occurred. In rare,
severe cases (hypertensive crisis), symptoms may include:
Severe headaches
Shortness of breath
Nosebleeds
Chest pain or visual changes
Pathophysiology and Impact
When blood pressure is high, the heart must work harder to pump blood. This
stress causes the artery walls to lose their elasticity and become scarred or
narrowed. This process, known as atherosclerosis, restricts blood flow to
vital organs. If left unmanaged, the constant pressure can lead to a
weakened heart muscle (heart failure) or the bursting/plugging of vessels in
the brain (stroke).
Treatment and Management
Lifestyle Modifications: Reducing sodium (salt) intake, increasing
physical activity, and maintaining a healthy weight.
Pharmacology: Use of ACE inhibitors, diuretics, or beta-blockers to
relax blood vessels or reduce fluid volume.
Monitoring: Regular blood pressure checks to ensure readings stay
within the target range (typically below 120/80 mmHg).