Health Assessment Case Study

This is the case study I submitted for Health Assessment unit, I no longer have the task information. I received a Distinction for this assignment.

Please note my writings are published for educational purposes only, all of my works have been submitted to Turnitin so please do not copy and paste or you will be flagged for plagiarism. My reference list is included at the bottom.

There are four types of health assessments that are used in nursing. A comprehensive assessment encompasses a complete health history and physical assessment and is generally undertaken upon first visit to a health care facility (Taylor, Lynn & Bartlett, 2019). A focused assessment is used to address a specific short term issue such as determining the cause of abdominal pain (Taylor et al., 2019). An emergency health assessment is used in life threatening or unstable situations to primarily assess airways, breathing and circulation (Taylor et al., 2019). An ongoing partial assessment follows up on health problems previously identified and is undertaken at scheduled intervals to assess positive and negative changes in health conditions, and to monitor the outcomes of prescribed interventions for effectiveness (Taylor et al., 2019). Based on these definitions, the assessment chosen as most appropriate for Lee is an ongoing partial assessment. The information available for Lee’s medical history suggests a comprehensive health assessment has already taken place and medical interventions have been prescribed. Abnormally high readings for blood glucose levels and blood pressure indicate Lee is not managing his health issues as well as he needs to despite being on medication for them, therefore he needs ongoing regular monitoring and assessment as well as education on lifestyle changes to increase the effectiveness of his medications and improve his health.

Vital signs / Assessment findings
John Hopkins Medicine (2019), classifies normal parameters for a healthy adult for temperature as 36.5°C – 37.2°C, pulse rate 60 – 100 beats per minute and respiration 12 – 16 breaths per minute. Lee’s results of 36.7°C for temperature, 89 beats per minute pulse and 16 breaths per minute respiration fall within the normal parameters. Normal blood glucose levels should be kept within a narrow range of 3.5 to 5.5 mmol/L, levels may temporarily range either side of these values, for example after eating, but should fall back within this range quickly (Güemes, Rahman, & Hussain, 2016). Lee’s blood glucose level of 15.7mmol/L is well above the recommended range. It is essential to diagnose diabetes to effectively manage the condition, interventions can include medications as well as lifestyle changes such as weight loss and exercise (Chamberlain, Rhinehart, Shaefer, & Neuman, 2016). The National Heart Foundation of Australia (NHFoA) classifies 120/80mmHg as an optimal blood pressure measurement, further classifying Lee’s blood pressure reading of 160/90mmHg as moderately high for systolic and severely high for diastolic (NHFoA, 2016). Clients who are diagnosed with both diabetes and hypertension are highly recommended to keep their blood pressure under 140/90mmHg (Chamberlain et al., 2016). The Australian Department Government of Health (AGDoH) (AGDoH, 2019) places Lee’s weight of 125kg and height of 170cm well within the obese category with a Body Mass Index (BMI) over 30. The healthy weight range for someone of Lee’s height is between 55 and 75kg (AGDoH, 2019). Diabetes, hypertension and obesity are three of the highest risk factors for metabolic syndrome and the global leading cause of death is cardiovascular disease (Mohamed, 2014).

Metformin Hydrochloride is an oral medication prescribed for patients with Type 2 Diabetes Mellitus (Health Direct, 2019). The Schedule 4 (S4) drug is of particular use to overweight patients whose diet and exercise is not helping to lower their blood glucose levels (NPC Medicinewise, 2019). People diagnosed with Type 2 Diabetes are either not able to make enough insulin or effectively utilise the insulin that is produced, causing glucose to build up in the blood leading to serious medical issues (NPC Medicinewise, 2019). Metformin works by aiding the patient’s body to more effectively use the insulin made by the pancreas to lower glucose levels in the blood (NPC Medicinewise, 2019). Things to consider when educating patients about metformin usage are potential side effects, conditions under which the medication should not be taken, how and when to take the drug, things you must not do while taking the medication and reactions to watch out for while taking metformin (NPC Medicinewise, 2019).

Lifestyle / predisposing factors
Lee’s lifestyle is not an active one, his work in IT would mainly consist of desk time and he does not currently exercise outside of work. Additionally, mealtimes are primarily takeaway foods and may not be fulfilling his nutritional needs. Lee’s age, weight, and medical/family history all indicate a significant need to overhaul his lifestyle to be healthier. The health risks associated with a sedentary lifestyle include obesity, type 2 diabetes, vitamin deficiencies, elevated cholesterol levels, muscular/skin changes and cardiovascular disease (Inyang & Stella, 2015). Understanding the health complications linked to a sedentary lifestyle is critical to reducing the rates of mortality and morbidity and so people should be encouraged to introduce light to moderate exercise into their lives (Inyang & Stella, 2015). Four primary health behaviours to be encouraged are physical activity, ceasing smoking, limiting alcohol consumption and healthy eating (Inyang & Stella, 2015). It is recommended to aim for at least 30 minutes of physical activity per day (AGDoH, 2019), this can be achieved by allowing time for movement and recreation in the work place (Inyang & Stella, 2015) to decrease how much time is spent sitting for long periods. Some ways to increase daily activity include taking the stairs instead of the lift, parking further away from work and walking, and taking short walks during meal breaks (AGDoH, 2019). It may also be beneficial to wear an activity tracker to monitor exercise and increase awareness of activity level and remind wearers to move more often (Dontje, de Groot, Lengton, van der Schans & Krijnen, 2015). Maintaining a regular schedule of physical activity has many health benefits and healthy adults should aim to complete 10,000 steps per day to increase or manage their health (Dontje et al., 2015). Lee’s father experiencing a heart attack at a similar age to Lee, his own history of hypertension, diabetes and being overweight are all risk factors that increase his likelihood of developing heart disease (Masethe & Masethe, 2014). Early intervention and comprehensive changes to lifestyle to manage the risk factors include adequate control of blood pressure and glucose, appropriately prescribed medication and correctly maintaining those medications (Piepoli et al., 2014). Such interventions are critical to the curtailing of cardiac disease progression and prevention of cardiac episodes in the future (Piepoli et al., 2014).

Australian Government Department of Health. (2019). Australia’s Physical Activity and Sedentary Behaviour Guidelines: Tips and Ideas for Adults (18 – 64 years). Retrieved from
Australian Government Department of Health. (2019). Body mass index (BMI). Retrieved from
Chamberlain, J., Rhinehart, A., Shaefer, C., & Neuman, A. (2016). Diagnosis and Management of Diabetes: Synopsis of the 2016 American Diabetes Association Standards of Medical Care in Diabetes. Annals of Internal Medicine., 164, 542-552.
Dontje, M., de Groot, M., Lengton, R., van der Schans, C., & Krijnen, W. (2015). Measuring steps with the Fitbit activity tracker: an inter-device reliability study. Journal of Medical Engineering & Technology., 39, 286-290.
Güemes, M., Rahman, S. A., & Hussain, K. (2016). What is a normal blood glucose?. Archives of disease in childhood, 101, 569-574.
Health Direct. (2019). Brand name: Metformin Hydrochloride (AN) TM. Retrieved from,662341000168101/metformin-hydrochloride-an
Inyang, M., & Stella, O. (2015). Sedentary lifestyle: health implications. J Nursing Health Sci, 4, 20-5. Retrieved from
John Hopkins Medicine. (2019). Vital Signs (Body Temperature, Pulse Rate, Respiration Rate, Blood Pressure). Retrieved from
Masethe, H. D., & Masethe, M. A. (2014). Prediction of heart disease using classification algorithms. In Proceedings of the world Congress on Engineering and computer Science, 2, 22-24. Retrieved from
Mohamed, S. (2014). Functional foods against metabolic syndrome (obesity, diabetes, hypertension and dyslipidemia) and cardiovasular disease. Trends in Food Science & Technology, 35, 114-128.
National Heart Foundation of Australia. (2016). Guideline for the diagnosis and management of hypertension in adults. Retrieved from
NPS Medicinewise. (2019). Consumer medicine information APO-Metformin Metformin hydrochloride. Retrieved from
Piepoli, M., Corrà, U., Adamopoulos, S., Benzer, W., Bjarnason-Wehrens, B., Cupples, M., … Giannuzzi, P. (2014). Secondary prevention in the clinical management of patients with cardiovascular diseases. Core components, standards and outcome measures for referral and delivery. European Journal of Preventive Cardiology., 21, 664–681.
Taylor, C., Lynn, P., & Bartlett, J. (2019). Fundamentals of Nursing: The Art and Science of Person-Centered Care (9th ed.). Philadelphia, PA: Wolters Kluwer.

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