Nurse-Patient Interaction: Health Assessment Clinical Note

This document is a clinical note that documents the findings from a nursing health assessment during an interview with a patient named Raymond Nguyen. It includes information about the patient's background, assessment observations, and recommendations for managing and improving health.

Running head: HEALTH ASSESSMENT 1
Nurse-Patient Interaction: Health Assessment Clinical Note

Running head: HEALTH ASSESSMENT 2
Contents
Introduction......................................................................................................................................3
Situation...........................................................................................................................................3
Background......................................................................................................................................4
Assessment.......................................................................................................................................4
Assessment (cont’d...)......................................................................................................................5
Recommendation.............................................................................................................................6
References:.......................................................................................................................................8

Running head: HEALTH ASSESSMENT 3
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: / /2018
Patient’s Name: Raymond Nguyen Date of birth: 17/01/1955
Address: 52 Homebush St, Central, 2001
Situation
Reasons for assessment, allergies, and relevant personal details: This assessment is all
about Raymond Nguyen who is 63 years old male. He is basically from Vietnam but now he
lives in Australia. Around two years ago his beloved wife died from suffering with cancer. He
now has one daughter and has two grand children who lived in his neighbourhood in Australia.
He is quiet tall around 172 cm. His current weight is 74 kg. His current blood pressure is 180/85.
This is much higher than normal. His usual body temperature is 37.90 c. His usual heart rate is
104, which is quite high. His respiratory rate is 20 which is bit higher than normal. His saturation
rat of pulse oximetry is 98 percent, with which we can assume that he might have some kind of
respiratory disease inside his body.
(1 mark)

Running head: HEALTH ASSESSMENT 4
Background
Health history, general health and psychosocial status: Normally Mr. Raymond is quiet fit
and strong person. But after his wife’s death it seems like he become alone and mentally
unstable. This condition leads him towards drinking. He consumes almost 10 bottles of bear
every evening. He was a chain smoker once. At the age of 42 he smoked around more than 20
cigarettes in a day. He quitted smoking since a month ago. He had severe cough and chest issues
for smoking. As he feels lonely he often pend times at bars and local clubs at night.
Living Arrangements And family relationships: He stays alone at 52 Homebush st, central,
2001. It is a small rented flat. It has two small bedrooms as well. But his daughter who is 35
years old stays at his next door along with his three grand children. They are 14, 10 and 6 years
old. Thus apparently we cannot consider him lonely as he every day spent rest of his quality time
with his only daughter and grand children.
(1 mark)
Assessment
Observations, height, weight (shape): He is 172 cm tall. In order to this he is not over weight.
His weight is 74 kg which is normal according to his height. His BMI is also quite normal. His
BMI value is 25. But his blood pressure is much higher. This might be the result of the stress and

Running head: HEALTH ASSESSMENT 5
anxiety issues which he i suffering with. As we can see after his wife’s death he is bit alone
though he stays next to his daughter still he cannot overcome the grief of his loss. He consumes
high amount of alcohol everyday to forget his pain, loss and grief. This high alcohol
consumption is the actual reason behind the high blood pressure.
Eating habits (nutrition/diet): He is still working at the age of 63. He works as a local
newsagent at morning. Then he looks after his grand children after they came back home from
school as his daughter is busy with her work too. As he works as a newsagent in the morning
most of the time he doesnot manage the time for his breakfast. Then at lunch most of the time he
will have noodles and fried rice as he cannot have time to cook his own meal. We can see he
consumes high calorie food every day by taking noodles and fried rice at daily basis. High
calorie food at this age is not health for him. This is also the reason behind of his high blood
pressure or hypertension problem.
(1 mark)
[Type text] [Type text] [Type text]
Assessment (cont’d...)
Alcohol (frequency, amount): He drinks regularly. He consumes high amount of alcohol every
day. He consumes almost 10 bottles of beer every day. Sometimes he took wine as well. Alcohol
consumption at this age is not good for his health. Sometimes he spent time with his friend at the
local bars and night clubs as well. That time the consumption level gets higher.
(0.5 Mark)
Cigarettes (frequency, duration): He was a chain smoker at his early age. He took almost 20
cigarettes in a day untill his 42. Then he tried to shorten the amount and finally few weeks back

Running head: HEALTH ASSESSMENT 6
he quit his smoking habit. As he was suffering with some bad cough and also suffering with
some chest issues. Still he cannot get over his smoking habits. He still have craving for
cigarettes.
(0.5 Mark)
Daily activities / exercise / amount of physical activity (type, frequency, time): He did not
get much time for exercise as he is working as a newsagent in morning. Then he is looking after
of his grandchildren as his only daughter is out for her work. But in weekend he often goes to
children’s park along with his grandchildren. Sometimes in summer days he goes to the beach
too with his grandchildren. In the weekend time he spent his quality hours with his Vietnamese
fellows and friends to some specific club which are belongs to their Vietnam community in his
town.
Describe: community – social/ cultural/ spiritual( or religious):He follows Buddhism. But
there are not a single Buddhist temple is there in his locality. In that case he missed every festival
and sometime prayers also. Thus he made a small temple himself inside his rented flat.
(1 mark)
Recommendation
Confirm health assessment information and implications for well-being, recommend
changes to manage and improve health and suggest timeframes for any plans:

Running head: HEALTH ASSESSMENT 7
He did not have any kind of critical health issues but he have some hypertension problem and
his heart rate is much higher than normal this may leads to the stroke or cardiac arrest. thus he
needs to quit his drinking habits. In case of his daily meals he must intake a heavy breakfast
everyday. As heavy breakfast is the primary requirement for the body which gives them energy
to work. He should avoid junk and high calorie foods as well.
(1 mark)
Patient Progress Notes Date: Time:
Nursing: In this health care unit staffs and nurses must encourage him to exercise daily. They
need to make a proper diet chart for him. He at his 60’s thus his body needs proper rest daily. As
he becomes lonely after his wife’s death he need to stay with his daughter not alone. In this
health care centre nurses need to be very kind and empathic to help him throughput his condition
(Forbes & Watt, 2015).
Signature: Name: Student Registered Nurse

Running head: HEALTH ASSESSMENT 8
(Add to Rubric Mark - Task Performance Criteria Documentation) Subtotal Mark:
/10
Marker’s Name: Signature: Date:
[Type text] [Type text] [Type text]
References:
Forbes, H., & Watt, E. (2015). Jarvis's physical examination and health assessment. Elsevier
Health Sciences.