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.
Student (Community – Registered Nurse): Use professional written communication to document the findings from the nursing health assessment during the interview with the patient
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.
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
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).
Alcohol (frequency, amount): He drinks six to ten glasses of alcohol occasionally while partying with his friends
Cigarettes (frequency, duration): He smokes almost a full packet consisting of thirty cigarettes per day.
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.
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.
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)
(Add to Rubric Mark - Task Performance Criteria Documentation) Subtotal Mark: /10
Marker’s Name: Signature: Date:
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.