History for Nurse and Patient Interaction

Assessment 3: Health Assessment
Professional Communication in Nursing 2018: History for Nurse and Patient Interaction – HealthAssessment
Scenario 2
Patient 2: History for Nurse and Patient Interaction – Health Assessment
Student (Community – Registered Nurse): Use professional nursing communication
with the patient to conduct a 15-minute health assessment interview taking into account
the 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 and
values, and cultural/spiritual/religious practices
• Recommendation – confirm health assessment information and implications for wellbeing,
recommend changes to manage and improve health and suggest timeframes
for any plans
Note: You will have a maximum of 5 minutes at the completion of your nurse and
patient interaction to finalise the written documentation from the interview findings
and your progress notes for the patient in the health assessment nursing record.
Assessor (Patient – Eileen Murphy): You are cooperative, alert and orientated. You are
willing to provide all requested information. You like to ask general questions of the nurse
related to the health assessment and like to know your observations and if they are within
normal limits. You are open to discuss ways to improve your health through possible
changes to your diet, exercise, daily habits, and lifestyle choices

.
Assessment 3: Health Assessment
Professional Communication in Nursing 2018: History for Nurse and Patient Interaction – HealthAssessment
STUDENT(General Practitioner’s Office – REGISTERED NURSE)
Scenario 2: Patient- Eileen Murphy
Eileen Murphy has come to see a Registered Nurse at his General Practitioner’s Office for a
health assessment. Eileen is not very active and has a stressful lifestyle with work and other
activities. She is well but always feels tired and would like to know how to feel more
energetic through regular exercise, eating well and by making positive changes to her
lifestyle.
Eileen Murphy: female, height 162 cm; weight 52 kg (BMI = 20). BP 162/ 90, HR 96, RR
20, temperature 36.4 C, SaO2 99% on room air.

Scenario 2: Patient 2- Eileen Murphy
BIODATA:
• Eileen is a 67-year-old female (D.O.B: 24/02/1951) with no known allergies, and her
current address is 48 Villahome Drive St, Southwood, 2074
• Eileen was born in County Cork, Ireland and came to Australia in 1956 with her
parents. They initially settled in Tumut because her father worked on the Snowy
Mountains Scheme but they moved to Sydney in 1972. Eileen worked as a secretary
until 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 she
has nine grandchildren who all live nearby. Hannah still lives at home with her mother
and is studying engineering at university.
• Bob died last year from a melanoma, probably caused by working in the sun as a
builder. 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 takeaway
from the local shopping centre. She general misses breakfast, has a toasted steak
sandwich for lunch and buys Italian or Asian for dinner. Presently her only exercise is
the 10-minute walk to work every day, but she is always on the move when she is
looking after the children in her care.
• She does not drink during the week but when she visits the club on weekends she has
6 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 and
knows that too much sun exposure caused her husband’s melanoma.
• Eileen has always been very religious, and goes to mass at the Catholic Church every
Sunday morning. She insists on taking her grandchildren to mass and this sometimes
causes conflict with her son, Brett. Eileen becomes upset that her relationship with
Brett is often strained.
• Eileen and Hannah are very close but she realises that Hannah has a serious
relationship with her boyfriend, Dominic, and that she may move in with him in the
near future. Eileen worries about being alone but is glad that Megan and Sean visit
regularly with the children.
• Eileen has come for a health check and would like to know if there is anything she can
do to stop her feeling tired all the time.

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