Health Assessment Skills – Script

Case: Hypertension
Nurse – Bianca Sandoval
Patient – Gloria Navalta

A. Initiation
Nurse: Good afternoon po, this is Bianca Sandoval po, I will be your student nurse for today.
What may I call you po Ma’am?

Patient: Good afternoon also. You may call me Ma’am Glo. And oh, a student, from which
college?

Nurse: Yes Ma’am, I am from Far Eastern University po.

Patient: Oh, a pretty good university. Okay, let’s carry on.

Nurse: Alright Ma’am Glo, I have been told po that I will be the one to attend to you regarding
your health, and this may take for about 10 minutes po, is that okay with you Ma’am?

Patient: Okay, it is fine.

Nurse: Okay Ma’am. I will be asking some questions po to get some basic information, about
your daily activities and whereabouts, and also what kind of medications are you taking. So, I am
expecting for your deepest cooperation po.

Patient: Oh yes of course, I will do cooperate.

Nurse: Thank you so much po, Ma’am Glo. I appreciate it. Oh, and also, I would just like to
inform you po that I will be jotting down some notes during our conversation later in order for us
to know the focal points po that we need to know for it will be necessary because it will be of
help po for the next step to be taken. And lastly, don’t you worry po Ma’am Glo, everything
would be strictly confidential, and it will only be shared with others who has the legal right to
know. Is everything unclear po Ma’am or are we good po?

Patient: Everything is loud and clear. Thank you so much for explaining everything.
Nurse: Always my pleasure po Ma’am. And if there is anything you don’t want to talk about,
don’t hesitate to say it. Now, shall we proceed po?

Patient: Yes, we shall.

B. Body

Nurse: How old are you Ma’am Glo?

Patient: I am already 78 years old.

Nurse: Okay, when is your birthdate po?

Patient: It’s April 4, 1942.

Nurse: Alright, for the gender, Female... What is your marital status po, Ma’am Glo?

Patient: I am widowed.

Nurse: Okay po Ma’am. So, what brings you here po Ma’am Glo?

Patient: My urgent health concern is about my headache; I tend to experience hypertension these
past few days.

Nurse: Hmm, do you always experience this po?

Patient: Quite often.

Nurse: Is it at morning or at night?

Patient: Around afternoon to night.

Nurse: Noted, Ma’am. So, before po, have you experienced this kind of bothering headache that
led you to hypertension?

Patient: Not really, it’s just this time, I cannot handle it and I had to come here because I am
worried for my health.

Nurse: Well, I am glad you came here Ma’am and I will serve you the best I can po. So, moving
on, does anyone in your family, like your late mother or father, do they also experience
hypertension po? Because hypertension tends to run in families po.
Patient: Unfortunately, my mother passed away early but as far as I can remember, my father
does also experience hypertension.

Nurse: I see… Beside from hypertension po, do you have any current health problems you have
encountered?

Patient: I guess that would be all, hypertension is really my main health problem, I presume.

Nurse: Noted po, Ma’am Glo. Regarding to your lifestyle, what is your sleeping hour po Ma’am?

Patient: I sleep around 9-10pm. Then, I would wake up early the next day.

Nurse: Hmm. How about a nap? Do you usually take a nap po, like in the afternoon?

Patient: I don’t prefer taking a nap in the afternoon because I can’t sleep in the evening.

Nurse: Ohh, we are the same Ma’am! Hmm, when waking up po, what do you feel?

Patient: Do you mean like specific feeling when I wake up?

Nurse: Yes po, Ma’am Glo. Do you feel fresh, or does your head ache or do you feel drowsy?

Patient: I feel drowsy sometimes.

Nurse: Oh, okay po Ma’am. Furthermore, are you using any medication po for sleeping?

Patient: No, I don’t use any.

Nurse: Alright, we’re almost there. Do you have any exercise or walking at night po, Ma’am
Glo?

Patient: I don’t usually do exercise because I can’t properly do it anymore and no, I don’t walk at
night.

Nurse: Okay Ma’am, thank you so much po for all the information. I really appreciate your
cooperation po. Well, those are all the questions I have for now.

Patient: No worries. So, what do you think?

Nurse: Well, clearly po, hypertension is not just hypertension. It can lead po to severe health
problems and it can also increase the risk of heart disease, and stroke. Most of the time, people
who have high blood pressure do not have any symptoms. In some cases po, people may
experience a pounding feeling in their head or chest, a feeling of dizziness po, and such other
signs. However, if your blood pressure is extremely high, you need to look out for certain
symptoms po like severe headaches, nose bleeding, vision problems, chest pain, difficulty in
breathing, and such. So, you need to be really aware po on what happens in your body.

Patient: Okay, I will. Could you tell me the causes of hypertension so I would be aware?

Nurse: The most common causes of hypertension include obesity po, lack of physical activity, a
deficiency in vitamin D, stress, aging, and sleeping pattern po. That’s what you need to improve
on po, Ma’am Glo.

Patient: I see… Is there any way to manage and treat it?

Nurse: Well, yes po Ma’am Glo. First po, you need to reduce your stress or merely just avoid
stress po. Continue with your medications po, the one in your maintenance Ma’am. Of course,
eating more fruits and vegetables po would be of help too. And you should reduce your salt
intake po Ma’am.

Patient: Thank you so much for making be educated about these things.

Nurse: My utmost pleasure to help you po, Ma’am Glo. Uh, do you have any questions in mind
po, Ma’am? Are there any left unclear?

Patient: Nothing more. Thank you so much.

Nurse: Alright po. For a brief summary, let us review what we have just covered in this
interview. Well, you tend to experience hypertension po Ma’am. You often experience it at
afternoon to night, is this right Ma’am?

Patient: Yes, right.

Patient: Yes, that is all.

Nurse: Well, that’s all I need to know from now po, Ma’am Glo. Next week, we would like to
meet you again po, I think February 22 would be the date then. Let us see how you are managing
your health po. And I would be gladly passing this on to the person in charge to look after you
po. Are there any questions Ma’am?

Patient: Alright, thank you. I have nothing more to ask then.

Nurse: Thank you so much for your time and cooperation, Ma’am. You have answered all of our
questions, and it will be definitely of help in planning your nursing care.

Patient: Thank you so much also for everything you have told me.

Nurse: No worries po, Ma’am Glo. I hope everything goes well for you, Ma’am.

Patient: Thank you, I will be going on my way now. Thank you so much again for your help, I
appreciate it.

Nurse: You are welcome po Ma’am. Take care po!