Comprehensive Health Assessment: Clinical Note on Patient Interaction

This assignment presents a clinical note documenting a health assessment conducted by a student nurse on a patient named Raymond Nguyen. The assessment covers various aspects of Raymond's health, including his reasons for seeking the assessment, health history, psychosocial status, observations (height, weight, BMI, blood pressure, oxygen saturation), eating habits, alcohol and cigarette consumption, daily activities, and social/cultural/spiritual background. The note highlights concerns such as high blood pressure, unhealthy eating habits, smoking, and alcohol consumption. Recommendations are made to improve Raymond's lifestyle through dietary changes, smoking cessation, increased physical activity, and counseling. Patient progress notes indicate that Raymond presented to the general practice office for a continuous health assessment, showing an understanding of the need for lifestyle changes.

Health Assessment Clinical Note
Student Number: Student Name:
Tutor’s Name: _______________________________________________________________________________
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: 3 /06 /2018
Patient’s Name: Raymond Nguyen Date of birth: 17/01/1955
Address: 52 Homebush st, central post box 2001
Situation
Reasons for assessment, allergies, and relevant personal details: Mr. Raymond Nguyen made a request
to have a health assessment. The patient has no allergies. He works in a local news agency thus living a very
busy life. During his free time, he spends it together with his grandchildren who live next door. Furthermore,
he aspires to live a better and healthy life by improving his diet, better lifestyles as well as physical exercise.
Background
(1 mark)
Health history, general health and psychosocial status: Presently, Mr. Raymond is not feeling well. He lost
his wife two years ago to lung cancer but is lucky to have his daughter living next door. He is permanently
employed in a news agency firm and during his free time takes his grandchildren to the beach.
Living arrangements and family relationships. In his case, he lives in a one bedroom flat with his daughter
and grandchildren living next door.
Assessment (1 mark)
Observations, height, weight (shape): Mr. Raymond’s height is 172cm, a weight of 74kg, and a BMI of 25.
His blood pressure was 180/85 which is very high while the oxygen saturation was normal at 98%.
Eating habits (nutrition/diet): Mr. Raymond skips breakfast almost every morning and eat at lunch and
supper. Cooking for him is troublesome and when he does cook it is not a balanced diet. Thus, the eating
habit was risky for his health as his intake was mostly snacks, carbohydrates and very little intake of fruits
and vegetables. (1 mark)

Assessment (cont’d...)
Alcohol (frequency, amount): Mr. Raymond takes 6-10 standards drinks every evening as he eats his food
at night.
(0.5Mark)
Cigarettes (frequency, duration): Mr. Raymond has smoked cigarettes for 42 years where in day he
consumes 20 cigarettes.
(0.5Mark)
Daily activities / exercise / amount of physical activity (type, frequency, time): Mr. Raymond says that it
only on Sundays that he takes his grandchildren out to the beach to relax.
Describe: Community - Social / cultural / spiritual (or religious): Mr. Raymond was born in Vietnam but later
moved to Australia as a boat person. He is a Buddhist but around where he lives there is no temple.
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: Mr. Raymond was recommended to change
most of the practices in his lifestyle. He has high consumption on carbohydrates from the alcohol and rice
together with a fat diet. The importance of making such changes has being discussed. This includes
increasing his intake of fruits and vegetables. His willingness to meet up with the dietician as well as a
counselor shows the importance of the recommendation made. Furthermore, the patient understands the
side effects of smoking where he has tried stopping the addiction. Physical exercise is maintained to also be
contribute to a healthy living. The walk would take around 15-30 minutes at most. Thus the patient is
recommended to walk severally to take precaution of the risky diseases (Mansen & Gabiola, 2015 ).

Patient Progress Notes Date: 3/06/2018
Nursing: Mr. Raymond Ngeyun, aged 63, presented to the general practice office for a
continuous health assessment. He has no already identified allergies. His experiences chest
pain but does minimum amount of physical exercise which was vital for him increase on for
health safety measures (Kane, Ouslander, Abrass & Resnick, 2017). His blood pressure is
high above the normal rate but his height, weight and BIM are in the normal ranges. Mr.
Raymond lost his wife two years ago but has a daughter who lives next door with her children
who gives him company. He takes 20 cigarettes in a day together with 6-10 standards of
alcohol after work. Due to his busy schedule at work he rarely takes breakfast. During the day
the patient consumes take away foods as well as junk food. He rarely finds time to cook
because he is always very busy looking after his grandchildren.
Signature: Name:

Reference
Kane, R. L., Ouslander, J. G., Abrass, I. B., & Resnick, B. (2017). Essentials of clinical
geriatrics. McGraw-Hill Medical Publishing Division.
Mansen, T. J., & Gabiola, J. (2015). Patient-focused assessment: The art and science of
clinical data gathering. Pearson Education.