Professional Communication in Nursing Health Assessment Clinical Note

This document is a clinical note for a nursing health assessment. It includes the patient's background, assessment observations, eating habits, alcohol and cigarette consumption, daily activities, and recommendations for managing and improving health.

401205 Professional Communication in Nursing
Health Assessment Clinical Note
Student Number: Student Name:
Tutor’s Name: _______________________________________________________________________________
URL for Health Assessment Video: _________________________________________________
Clinical Note
Student (Community – Registered Nurse): Use professional written communication to document the
findings from the nursing health assessment during the interview with the patient
Introduction
Date: / /2019
Patient’s Name: Chester Abioye Date of birth: 14th January 2000
Address: 97 Leafy Avenue, Broadfields, 2173
Situation
Reasons for assessment, allergies, and relevant personal details: Patient does not have any allergy; he wants
to improve his health as well as change his lifestyle.
Background
(1 mark)
Health history, general health and psychosocial status: Patient has been suffering from depression in the past .
Living arrangements and family relationships: He lived alone in Australia and is working in the storeroom at Aldi.
He used to work overtime to save money so that he could send back to his family in Zambia ( Romeo, 2017). He has a
girlfriend with whom he enjoys talking and mailing on the computer.
Assessment
(1 mark)
Observations, height, weight (shape): Age 19, Height 187 cm: Weight 73 kg (BMI = 20.9). BP = 118/70, HR 86,
RR 22, temperature 37.0 C, SaO2 99% on room air.

Eating habits (nutrition/diet): The patient is not good in the kitchen, so he used to eat rice, bread, and meat and rarely
eat vegetables in a meal (Panahi, Ghanei, Hajhashemi & Sahebkar, 2016). (1 mark)

Assessment (cont’d...)
Alcohol (frequency, amount): Chester often drinks 6 to 10 standard once in a month .
(0.5Mark)
Cigarettes (frequency, duration): Chester used to smoke 30 cigarettes daily .
(0.5Mark)
Daily activities / exercise / amount of physical activity (type, frequency, time): Abioye mainly spent his time in
watching television whenever he is at home and rarely do exercises.
Describe: Community - Social / cultural / spiritual (or religious): He does not like to follow any religion and
never wear a hat or sunblock while going outside.
Recommendation
(1 mark)
Confirm health assessment information and implications for well-being, recommend changes to manage
and improve health and suggest timeframes for any plans: Recommend to wear a hat or apply sunscreen
while moving outside, eat more and more vegetables daily, and drink three standard drink. Chester is advised to do
exercise for 1 hour daily for being active in his activities, avoid watching too much television instead spent time in
doing physical work. Recommended to follow religion by visiting the temple once a week
Patient Progress Notes Date:
(1 mark)
Time:
Nursing Chester Abioye came to General Practitioner’s Office for health assessment. He has a concern that he is not
very active and feel stress and want to improve his health (Castaldo et al., 2015). He was suffering from depression in the
past. The patient lives without his family in Australia. The family of the patient lives in Zambia, and his girlfriend lives in
Melbourne. Patient catches up with his two friends once in a month and drinks up to 6-10 standard drink (Grossi, Perski,
Osika & Savic, 2015). Works at Aldi and often work overtime for saving money. He discontinued the course of commerce
after doing one year as he felt boring. Chester Abioye regularly eats rice, bread as well as meat and rarely buys vegetables
for the meal. The patient sometimes does exercise and regularly watching television when he stays at home ( Birks, Davis,
Smithson & Cant, 2016). Height 187 cm; weight 73 kg (BMI = 20.9). BP 118/70, HR 86, RR 22, temperature 37.0 C, SaO2
99% on room air (Southwick, Cranley & Hallisy, 2015). Patient regularly smokes 30 cigarettes daily. He does not wear a hat
or uses sunblock while going outside. He enjoys emailing as well as talking to his family and girlfriend on the computer
(Haagsma et al., 2015). It is recommended to Chester Abioye to eat healthier diets daily, exercises regularly for half or one
hour, wears the hat while moving outside, follow any religion by visiting a nearby temple and spent time to relax. Advise
smoking less as much as he can and enjoy visiting to park or clubs. He should also play outdoor and indoor games with his

friends to get relief from stress (Luan, Wang, Hou, Chen & Lou, 2017).
Signature: Name: Student Registered Nurse
(4 marks)
(Add to Rubric Mark - Task Performance Criteria Documentation) Subtotal Mark: /10
Marker’s Name: Signature: Date: