the
401205 Professional Communication in Nursing
Health Assessment Clinical Note
Student Number: 20564096
Student Name: Sajni Kaspal
Tutor’s Name: Helana Brundell
URL for Health Assessment Video:
https://youtu.be/_6eXfTqXrGY
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:
30/05
/2021
Patient’s Name: George Pham
Date of birth: 17/01/ 1946
Address: 52 Homebush street, Central 2001
Situation
Reasons for assessment, allergies, and relevant personal details:
Mr George Pham requested a general
health assessment. He lives a stressful and busy lifestyle and looks after his grandchildren. He is active, has
no allergies and would like to change his diet and lifestyle to improve his health. He has some minor health
problems. He is concerned about the cough which is not getting off after five weeks.
(3 marks)
Background
Health history, general health and psychosocial status: He came to Australia as a boat person in 1979 with
his daughter and wife, who passed away five years later from ovarian cancer. He works as a baker and looks
after grandchildren until his daughter finishes work.
Living arrangements and family relationships He lives alone just next to his daughter in a two-bedroom rented
flat near the city centre.
(3 marks)
Assessment
Observations, height, weight (shape):
George’s Blood Pressure is 164/92. His heart rate is 74, and
respiratory rate is 20. His BMI is 24.6 and weight is 71kg. His height is 170cm. His temperature is 37C and
SPO2 IS 98% in room air. His Blood Pressure is elevated.
Eating habits (nutrition/diet): Mr Pham said that he tries to cook food at home. However, due to his busy life,
he buys take away foods from local Asian cafes and always make sure that he gets the fried noodles and rice
to take that in the work. On weekend he goes out with his friends to local Vietnamese club and had lunch.
(3 marks)
Assessment (cont’d...)
Alcohol (frequency, amount): George says that he drinks alcohol on outings with friends and socially as well.
He also drinks alcohol about 3-5 standard beers regularly with his evening meal.
(1.5Mark)
Cigarettes (frequency, duration. He used to consume 20 cigarettes a day for 42 years and gave up smoking
recently.
(1.5Mark)
Daily activities / exercise / amount of physical activity (type, frequency, time): George says he never do any
exercise. But he says that he often takes his grandchildren to the park and to the beach on Sunday in summer.
Describe: Community - Social / cultural / spiritual (or religious): George follows Buddhism, and he has a small
shrine at his house for worship and prayers.
(3 marks)
Recommendation
Confirm health assessment information and implications for well-being, recommend changes to manage
and improve health and suggest timeframes for any plans: In terms of the patient’s drinking habit, it is
recommended to have natural fruit juice/water or light drinks. The meal plan was explained and encouraged
to include more fruits and vegetables and salad. Quitline number is provided with regards to smoking and
for protection of skin, it is recommended to put on sunscreen, full sleeve clothes and hat before going out
and Cancer Council Australia brochure is provided, 30 minutes of physical exercise is added too. Mr Pham
is advised to see the doctor as soon as possible for his high blood pressure and cough.
(3 marks)
Patient Progress Notes
Date: 30/05/2021
Time: 1500hrs
Nursing Mr. George Pham, 73 years old presented for health assessment this morning. He has no allergies. He was
concerned for his cough. All-vital signs are normal except his elevated blood pressure. George came to Australia with
his wife and daughter. His wife passed away 5 years ago from Ovarian cancer. George lives in a two-bedroom flat next
to his daughter and three grandchildren. He is Buddhist. He used to have 20 cigarettes a day for 42 years. He drinks 3
to 5 standard drinks daily with evening meal, sometimes socially and with friends. He has take-away food. He does not
use sunscreen or hat while going out nor does any exercise. It is advised to visit doctor for his cough and increased
blood pressure. In terms of drinking, it is recommended to drink light drink and natural fruit juice/water. For smoking
Quitline number is provided to help him to stay quit. In terms of diet, it is recommended to have fruits and vegetables
instead of take away food and also recommended thirty minutes of daily physical exercise. Sunscreen and hat, full
sleeves clothes are recommended before going out and Cancer Council Australia brochure is provided. The patient
agreed to come for follow up in two weeks.
Signature: Sajni
Name: Sajni Kaspal
Student Registered Nurse
(12 marks)
(Add to Rubric Mark - Task Performance Criteria Documentation)
Marker’s Name:
Signature:
Subtotal Mark:
Date:
/30