Nurse-Patient Interaction: Health Assessment Clinical Note

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)