History for Nurse & Patient Interaction- Bruce O’Grady- Nursing Case Study Assignment

Internal Code: 4ABH

Nursing Case Study Assignment:

Task: Patient 3: History for Nurse and Patient Interaction – Health Assessment Student (Community – Registered Nurse): Use professional nursing communication with the patient to conduct a 10 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 well-being, recommend changes to manage and improve health and suggest timeframes for any plans. Assessor (Patient – Bruce O’Grady): 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. STUDENT (General Practitioner’s Office – REGISTERED NURSE) Scenario 3: Patient- Bruce O’Grady Bruce O’Grady has come to see a Registered Nurse at his General Practitioner’s Office for a health assessment. Bruce is not very active and has a stressful lifestyle with work and helping caring for son’s children. He has some minor health problems and wants to improve his health through regular exercise, eating well and by making positive changes to his lifestyle. Bruce O’Grady: Male, height 180 cm; weight 105kg (BMI = 32.4). BP 184/ 70, HR 100, RR 24, temperature 37.9 C, SaO2 94% on room air. Bruce recently separated from his wife but is still married. He helps care for his son’s two children since his daughter-in-law passed away. Biodata • Bruce is a 65 year old man (DOB- 14th May 1953) and lives at 47 Leafy Avenue, Broadfields, 2173 in a two bedroom flat by himself close to the main street. His son and grandchildren live 2 kms away. He is allergic to surgical tape. • Bruce separated from his wife, Lorraine, two years ago and she moved to the North Coast. • Bruce developed a deep chesty cough in the last few weeks. He regularly smokes about a packet (30 cigarettes per day) and sometimes has more when he goes to a local pub. • Bruce often drinks 6 to 10 standard drinks (beer, wine and spirits) of an evening. He sometimes drinks socially or on outings with his friends from the pub. • Bruce was born in Australia to his Aboriginal single mother and identifies as an Aboriginal Australian. He has never met his father who was white. He mother’s family came from the Wiraduri people and live near Wagga Wagga. • Bruce recently retired from his job as a manager at a local supermarket but still has a busy life. Of an afternoon he cares for his grandchildren, Lily aged 12 and Ben aged 5, after school to help out his son, Mark, whose wife died twelve months ago from breast cancer at the age of 37 years. Mark works at a local hotel three nights a week on top of his day job as a mechanic. • Bruce often goes for afternoon walks with his Lily and Ben to a local park and playground. He also enjoys swimming laps at his local pool in summer. • Bruce says he is no good in the kitchen so he buys most of his meals. He often skips breakfast, frequently has pizza for lunch, and usually buys McDonald’s or KFC take away meals of an evening. • During the summer Bruce takes his grandchildren fishing but often gets sunburned. He doesn’t like wearing a hat or using sun block. • Bruce loves going back to Wagga Wagga to visit his extended family and misses them terribly when he comes home. He looks forward to visiting again with Mark, Lily, and Ben next January. • Bruce went to a Baptist school but left high school at 14 years of age. He sometimes goes to a local Baptist church and takes Lily and Ben to the local Aboriginal youth program on a Sunday.