Professional Communication in Nursing: Health Assessment Clinical Note

This document presents a student's health assessment nursing record, focusing on a nurse-patient interaction. The assessment involves a 65-year-old male patient with an unhealthy lifestyle, including smoking, alcohol consumption, and a lack of regular exercise. The student nurse conducts a comprehensive assessment, gathering information on the patient's health history, eating habits, and social/cultural background. The clinical note documents the patient's situation, including allergies and personal details, and provides a detailed assessment of the patient's physical and psychosocial status, including BMI, eating habits, and lifestyle factors. The student nurse recommends lifestyle modifications, including exercise, smoking cessation, and diet changes. The document includes patient progress notes, vital signs, and a nursing plan, along with references to support the assessment and recommendations.

Task Performance Criteria (Documentation) Due 29/5/18 word count 5oo words
Written health assessment
(Nurse-Patient Interaction: Health Assessment Nursing Record) based on the Professional Communication task
performance criteria for the nurse-patient interaction OSCA.
Exceptional : documentation covering all aspects of the task as found on the Nurse-Patient Interaction: Health
Assessment Nursing Record. Demonstrates an excellent understanding of effective professional communication
in nursing. Evidence of exceptional use of written communication.
Assesses the patient by using appropriate questions to elicit health information relevant to the patient
anddocumentation.
Part 1 –Student (nurse) engages in a general status health assessment with the patient. The student (nurse):
 Asks at least four (or more) questions related to patient’s health
 Asks relevant initial assessment questions
 Responds verbally and clarifies patientinformation
 Responds topatient’s questions and paraphrases understanding
through discussion with the patient using culturalcompetence
Assesses the patient by using appropriate questions to elicit detailed health information relevant to the patient and
documentation.
Part 2 - Student (nurse) conduct a further health assessment of the patient by discussing detailed aspects related
to this health issue and patient well-being. The student (nurse):
 Asks at least four (or more) relevant questions involving detailsabout the patient’s health issue using
cultural competence
 Responds appropriately to the patient, offering somepossible explanations about the health issue / to
improve well-being.
Assesses the patient by using appropriate questions to elicit health information relevant to the patient and
documentation.
Part 3 – Student (nurse) uses the health assessment information to:
• Describe and confirm what the patient said
• Discuss with the patient your understanding of the health issueand any
implication for well-being using cultural competence
• Explore how this health issue and improvement in well-being might be
related to culture, values or personal beliefs.

• Concludes the interaction and explains that he/she is at hand for any further assistance.
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: 25 / 05 /2018
Patient’s Name: Bruce O’ Grady Date of birth: 14-May-1953
Address: 47 Leafy Avenue Broadfields 2173
Situation
Reasons for assessment, allergies, and relevant personal details: Bruce is suffering from deep chesty
cough and has come to the hospital to improve his health through regular exercise and lifestyle modification.
He is allergic to surgical tape. Bruce has a history of cigarette smoking and occasional drinking. He smokes
thirty cigarettes a day and drinks six to ten standard drinks while partying with his friends occasionally. He
has a busy life and thus he doesn’t exercise regularly, however; he often goes for swimming and occasional
afternoon walks with his grandchildren.
Background
(1 mark)
Health history, general health and psychosocial status: Bruce is leading an unhealthy lifestyle. He neither
exercises on a regular basis, but also is a chronic cigarette smoker and occasional drinker. His overall BMI is
not within normal range and thus he requires lifestyle modification. Moreover, he is recently separated from hi
wife thus emotional needs of the patient should be taken care of before making any intervention plan.
Living arrangements and family relationships He is separated from his wife and lives alone. However he
lives close to his son and his grandchildren, who require his constant support.
Assessment
(1 mark)

Observations, height, weight (shape): His BMI is approximately 34.2 and is classified under obese
category. He immediately requires lifestyle modification including weight reduction and smoking cessation to
improve his overall health and prevent cardiovascular complications.
Eating habits (nutrition/diet): His eating habits are abnormal and unhealthy. He is not good at cooking and
buys his meals and often skips his breakfast and eats fast food mostly pizza and burger at the time of lunch.
He is already obese, and thus should avoid the consumption of fast food, however; he is regularly consuming
fast food which is the prime cause of obesity (Teixeira et al., 2015).
(1 mark)
Assessment (cont’d...)
Alcohol (frequency, amount): He drinks six to ten glasses of alcohol occasionally while partying with his
friends
(0.5Mark)
Cigarettes (frequency, duration): He smokes almost a full packet consisting of thirty cigarettes per day.
(0.5Mark)
Daily activities / exercise / amount of physical activity (type, frequency, time): He does not exercise on a
regular basis, however, he often goes for afternoon walk with his grandchildren and also goes for swimming
sometimes.
Describe: Community - Social / cultural / spiritual (or religious): Bruce describes himself as an aboriginal
Australian. His mother was an aboriginal and his father was Caucasian. He often goes to Baptist church
along with his grandchildren and also visits Aboriginal youth programs. He often visits his native place once
in a while and misses his relatives after returning from his visit to his naïve place.
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: Bruce requires lifestyle modification in order to
improve his health and wellbeing. He should be involved in regular exercise and should be educated
regarding smoking cessation and reducing his drinking habits. His BMI is 34.2, which is classified under
obese category (Skinner et al., 2015) and thus a diet modification must be also included to manage and
improve his health.
Patient Progress Notes Date: 25/05/18
(1 mark)
Time: 11:30 am
Nursing: Bruce is a 65 years old male who arrived at the physician office for regular health assessment. He
does not a have healthy lifestyle. He has to take care of his grandchildren as his daughter in law died

earlier and his son has to work in day and even night shifts to manage finances for his children. He himself
is separated from his wife and has no other member who looks after his health. He has a busy schedule
and he neither exercises and nor he consumes a healthy diet. Due to all these factors his health is
deteriorating and his vitals are abnormal. His BP is slightly increased (184/70) and his BMI indicates
obesity (34.2) (Dudgeon, 2015). He is also suffering from certain health issues such as deep chesty cough
and he wants to improve his lifestyle by indulging in regular exercise and eating a health and balanced
diet. Bruce should be advised to consult a dietician who can help him to change his eating habits. Also, he
should be educated to incorporate regular exercise in his daily routine. For management of cough, the
prescribed medications (expectorants) by the physician need to be administered in a timely manner. Also,
he should be advised to quit his smoking habit as chemical irritants can further exaggerate his cough and
can even worsen his health problems (Gonzales et al., 2013).
Signature: Name: Student Registered Nurse
(4 marks)
(Add to Rubric Mark - Task Performance Criteria Documentation) Subtotal Mark: /10
Marker’s Name: Signature: Date:
References
Dudgeon, D. (2015). Dyspnea, death rattle, and cough. Care of the Imminently Dying, 7.
Gonzales, R., Anderer, T., McCulloch, C. E., Maselli, J. H., Bloom, F. J., Graf, T. R., ... & Metlay, J. P.
(2013). A cluster randomized trial of decision support strategies for reducing antibiotic use in
acute bronchitis. JAMA internal medicine, 173(4), 267-273.
Skinner, A. C., Perrin, E. M., Moss, L. A., & Skelton, J. A. (2015). Cardiometabolic risks and severity of
obesity in children and young adults. New England Journal of Medicine, 373(14), 1307-1317.
Starr, K. N. P., McDonald, S. R., & Bales, C. W. (2014). Obesity and physical frailty in older adults: a
scoping review of lifestyle intervention trials. Journal of the American Medical Directors
Association, 15(4), 240-250.
Teixeira, P. J., Carraça, E. V., Marques, M. M., Rutter, H., Oppert, J. M., De Bourdeaudhuij, I., ... &
Brug, J. (2015). Successful behavior change in obesity interventions in adults: a systematic
review of self-regulation mediators. BMC medicine, 13(1), 84.