History for Nurse and Patient Interaction

Assessment 3: Health AssessmentProfessional Communication in Nursing 2018: History for Nurse and Patient Interaction – HealthAssessmentScenario 2Patient 2: History for Nurse and Patient Interaction – Health AssessmentStudent (Community – Registered Nurse): Use professional nursing communicationwith the patient to conduct a 15-minute health assessment interview taking into accountthe following:
• Introduction – nurse and patient• Situation – reasons for assessment, allergies, and relevant personal details• Background – health history, general health and psychosocial status• Assessment – observations, nutrition/diet, exercise, lifestyle, health beliefs andvalues, and cultural/spiritual/religious practices• Recommendation – confirm health assessment information and implications for wellbeing,recommend changes to manage and improve health and suggest timeframesfor any plansNote: You will have a maximum of 5 minutes at the completion of your nurse andpatient interaction to finalise the written documentation from the interview findingsand your progress notes for the patient in the health assessment nursing record.Assessor (Patient – Eileen Murphy): You are cooperative, alert and orientated. You arewilling to provide all requested information. You like to ask general questions of the nurserelated to the health assessment and like to know your observations and if they are withinnormal limits. You are open to discuss ways to improve your health through possiblechanges to your diet, exercise, daily habits, and lifestyle choices
.Assessment 3: Health AssessmentProfessional Communication in Nursing 2018: History for Nurse and Patient Interaction – HealthAssessmentSTUDENT(General Practitioner’s Office – REGISTERED NURSE)Scenario 2: Patient- Eileen MurphyEileen Murphy has come to see a Registered Nurse at his General Practitioner’s Office for ahealth assessment. Eileen is not very active and has a stressful lifestyle with work and otheractivities. She is well but always feels tired and would like to know how to feel moreenergetic through regular exercise, eating well and by making positive changes to herlifestyle.Eileen Murphy: female, height 162 cm; weight 52 kg (BMI = 20). BP 162/ 90, HR 96, RR20, temperature 36.4 C, SaO2 99% on room air.
Scenario 2: Patient 2- Eileen MurphyBIODATA:• Eileen is a 67-year-old female (D.O.B: 24/02/1951) with no known allergies, and hercurrent address is 48 Villahome Drive St, Southwood, 2074• Eileen was born in County Cork, Ireland and came to Australia in 1956 with herparents. They initially settled in Tumut because her father worked on the SnowyMountains Scheme but they moved to Sydney in 1972. Eileen worked as a secretaryuntil she married Bob in 1979.• Eileen has four children (Megan-36 years, Brett-34years, Sean-28 years, and Hannah– 24 years). Eileen is very proud that her eldest three children have married and shehas nine grandchildren who all live nearby. Hannah still lives at home with her motherand is studying engineering at university.• Bob died last year from a melanoma, probably caused by working in the sun as abuilder. Eileen has now returned to work in the local before and after school day care.It is a busy job but she really enjoys spending time with the children she looks after.• Eileen currently feels well but is often too tired to cook meals and she buys takeawayfrom the local shopping centre. She general misses breakfast, has a toasted steaksandwich for lunch and buys Italian or Asian for dinner. Presently her only exercise isthe 10-minute walk to work every day, but she is always on the move when she islooking after the children in her care.• She does not drink during the week but when she visits the club on weekends she has6 to 8 glasses of wine with her friends. This is the only time Eileen smokes cigarettes,usually 10-15 cigarettes, which she says she really enjoys.• Eileen is very conscious of protecting her skin from the sun as she is very fair andknows that too much sun exposure caused her husband’s melanoma.• Eileen has always been very religious, and goes to mass at the Catholic Church everySunday morning. She insists on taking her grandchildren to mass and this sometimescauses conflict with her son, Brett. Eileen becomes upset that her relationship withBrett is often strained.• Eileen and Hannah are very close but she realises that Hannah has a seriousrelationship with her boyfriend, Dominic, and that she may move in with him in thenear future. Eileen worries about being alone but is glad that Megan and Sean visitregularly with the children.• Eileen has come for a health check and would like to know if there is anything she cando to stop her feeling tired all the time.

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