Health Assessment Report: Clinical Nursing Notes for Chester Abioye

This report presents clinical nursing notes from a health assessment of a 19-year-old patient named Chester Abioye. The assessment covers his lifestyle, including smoking habits, diet, exercise, and living situation. The report includes a detailed patient history, assessment findings, and recommendations for improving his health, such as dietary changes, exercise, and seeking help for smoking cessation. The patient's progress notes document improvements in his health after implementing the recommendations, including controlled blood glucose levels, weight loss, and a reduced smoking rate. The report highlights the importance of lifestyle interventions and patient engagement in managing health conditions.

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Running Head: Clinial Nursing Notes
CLINICAL NURSING NOTES

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Clinial Nursing Notes
Situation
Chester is 19 years old and shares his residence with four other people. He is a chain smoker,
smoking up to 30 cigarettes in a day and also indulges in heavy drinking once a month. He lives
a sedentary lifestyle, without any exercise and his diet consists of heavy carbohydrate and fat
intake. There is a lack of vegetables and thus essential nutrients in his diet and put together with
heavy fats and carbohydrate intake can cause his deficiency disorders. He works overtime to
save money for his family and prefers not to use any protection from the sun.
Background
Chester has had a history of depression and is found to soon lose interest in things. He is living
away from his family residing in Zambia to commence a degree in law. However, after 1 year of
the course, Chester lost his interest and therefore decided to discontinue. He also reported that he
finds exercising boring. Chester has a very short interest span and requires an activity to be
stimulating for him to indulge in it. The resultant benefits or outcomes of the activities do not
seem to attract Chester.
Chester is living along with 4 other people in a communal house. He occasionally enjoys talking
to his family and his girlfriend online.
Assessment
Chester was found to be overweight which can be attributed to his stationary lifestyle, lack of
exercise. He does strenuous work in the storeroom and chooses to overwork sometimes to gain
money. This does not provide enough activity for the body. On the other hand, it overworks the
body muscles that have been conditioned to live an easy life. His preferred food mostly consists
of meat, rice and bread and rarely any vegetables. This is hardly what is recommended for a
growing person. Chester drinks rarely but above the permitted amount. He drinks up to 6-10
drinks one a month. He is non-religious and is not associated with any other groups, interests or
hobbies. Other than his family and his girlfriend, he lives an unattached life.
Recommendation
Chester is required to make some decided changes in his lifestyle in order to have a positive
impact on his health and ensure his mental wellbeing. He is required to at least exercise one a
week for about 30 minutes and has a high protein, less carbohydrate containing diet. He must
immediately seek help from a counseller for curbing his smoking habit and end it gradually.

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Clinial Nursing Notes
Patient Progress Notes
Chester has showcased a great deal of change after he was admitted. He was admitted for
recurrent depression and lifestyle-induced conditions. His blood glucose level was also above the
normal range because of the high starch content in his diet. After managing his diet and drinking
habit the glucose level was controlled. Through dietary interventions and mild exercise Chester
was also able to shed extra weight and is now within the allowed range. After receiving
medication, therapy and being a part of an anti-smoking group, his smoking rate is lowered to
about 5-6 cigarettes in a day. Chester is trying to end the habit as he has accepted the hazards
caused due to smoking.