Scribd Logo
Upload

Welcome to Scribd!

  • 456 views

    HA-RLE-WS # 5 Assessing General Status and Vital Signs

    Uploaded by

    Ashley Blaise Jore
    This document provides guidance on assessing a patient's general status and vital signs through a case study analysis. It outlines steps to 1) identify abnormal subjective/objective findings and strengths, 2) assemble cue clusters, 3) make inferences, 4) develop possible nursing diagnoses, 5) identify defining characteristics, 6) confirm or rule out diagnoses, and 7) document conclusions. The case study describes a 36-year-old man presenting with stress, excessive coffee/smoking, and elevated vital signs. Guidelines are provided to collect additional subjective data through questions and objective data through physical assessment of vital signs and overall impression.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd

    HA-RLE-WS # 5 Assessing General Status and Vital Signs

    Uploaded by

    Ashley Blaise Jore
    456 views5 pages
    This document provides guidance on assessing a patient's general status and vital signs through a case study analysis. It outlines steps to 1) identify abnormal subjective/objective findings and strengths, 2) assemble cue clusters, 3) make inferences, 4) develop possible nursing diagnoses, 5) identify defining characteristics, 6) confirm or rule out diagnoses, and 7) document conclusions. The case study describes a 36-year-old man presenting with stress, excessive coffee/smoking, and elevated vital signs. Guidelines are provided to collect additional subjective data through questions and objective data through physical assessment of vital signs and overall impression.

    Original Title

    HA-RLE-WS # 5 Assessing General Status and Vital Signs

    Copyright

    © © All Rights Reserved

    Available Formats

    DOCX, PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    This document provides guidance on assessing a patient's general status and vital signs through a case study analysis. It outlines steps to 1) identify abnormal subjective/objective findings and strengths, 2) assemble cue clusters, 3) make inferences, 4) develop possible nursing diagnoses, 5) identify defining characteristics, 6) confirm or rule out diagnoses, and 7) document conclusions. The case study describes a 36-year-old man presenting with stress, excessive coffee/smoking, and elevated vital signs. Guidelines are provided to collect additional subjective data through questions and objective data through physical assessment of vital signs and overall impression.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    456 views5 pages

    HA-RLE-WS # 5 Assessing General Status and Vital Signs

    Uploaded by

    Ashley Blaise Jore
    This document provides guidance on assessing a patient's general status and vital signs through a case study analysis. It outlines steps to 1) identify abnormal subjective/objective findings and strengths, 2) assemble cue clusters, 3) make inferences, 4) develop possible nursing diagnoses, 5) identify defining characteristics, 6) confirm or rule out diagnoses, and 7) document conclusions. The case study describes a 36-year-old man presenting with stress, excessive coffee/smoking, and elevated vital signs. Guidelines are provided to collect additional subjective data through questions and objective data through physical assessment of vital signs and overall impression.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 5

    HA-RLE Worksheet # 5

    ASSESSING GENERAL STATUS AND VITAL SIGNS

    Case Study:

    Read the following case study. Then work through the steps of analysing the case study data.

    1. First identify abnormal data and strengths in subjective and objective findings;
    2. Assemble cue clusters;
    3. Draw inferences;
    4. Make possible nursing diagnoses;
    5. Identify defining characteristics;
    6. Confirm or rule out the diagnoses; and
    7. Document your conclusions.

    Case Study:
    Steve Marin is a 36-year-old white man, who comes to the employee health center for
    advice. He says he has been under a lot of stress lately. He believes he is drinking too much
    coffee (12 cups daily) and smoking more than usual (2 packs daily). He is neatly and
    appropriately dressed in a business suit. His posture is erect, and his gait is smooth. His hands
    are trembling. He has excess subcutaneous fat, distributed primarily around the waist. Mr. Marin
    appears tired, anxious, and hurried. He is cooperative, maintains good eye contact, and
    answers questions quickly. His speech is clear but fast paced.
    Vital Signs
    Oral temperature: 37.04 degrees centigrade
    Radial pulse: 92 beats/minute, shallow and somewhat labored
    Respirations: 23 breaths/minute
    Blood pressure: sitting, right arm 180/112mm Hg; left arm 172/108 mm Hg; standing, 155/100
    mm Hg (standing Bp taken in either arm due to similarity of sitting Bps). Denies any pain and
    discomfort.
    Note: Please secure consent before starting the interview to actual client….

    NURSING INTERVIEW GUIDE TO COLLECT SUBJECTIVE DATA

    QUESTIONS FINDINGS
    Present History
    1. Height?
    2. Weight?

    3. Fever?
    4. Pain? (COLDSPA)

    5. Allergies?
    6. Present Health Concerns

    Past History
    1. Weight gains or losses?

    2. Previous high fevers, cause, and


    treatment?
    3. History of abnormal pulse?
    4. History of abnormal respiratory rate or
    character?
    5. Usual blood pressure, who check it
    last, and when?

    6. History of pain and treatment?

    Family History
    1. Hypertension?

    2. Metabolic /growth problems?

    Lifestyle and Health Practices


    1. Religious affiliation
    PHYSICAL ASSESSMENT GUIDE TO COLLECT OBJECTIVE DATA

    Questions Findings
    Overall Impression of the client
    1. Observe physical development
    (appears to be chronologic age) and
    sexual development (appropriate for
    gender and age).

    2. Observe skin (generalized color, color


    variation, and condition)

    3. Observe dress (occasion and weather


    appropriate).

    4. Observe hygiene (cleanliness, odor,


    grooming).

    5. Observe posture (erect and


    comfortable) and gait (rhythmic and
    coordinated)

    6. Observe body build (muscle mass


    and fat distribution).
    7. Observe consciousness level
    (alertness, orientation,
    appropriateness).
    8. Observe comfort level

    9. Observe behavior (body


    movements, affect, cooperativeness,
    purposefulness,
    and appropriateness).
    10. Observe facial expression (culture-
    appropriate eye contact and facial
    expression).

    11. Observe speech (pattern and style)

    Vital signs
    1. Gather equipment (thermometer,
    sphygmomanometer, stethoscope,
    and watch)

    2. Measure temperature (oral, axillary,


    rectal, tympanic).

    3. Measure radial pulse (rate, rhythm,


    amplitude and contour, and elasticity).

    4. Monitor respirations (rate, rhythm, and


    depth).
    5. Measure blood pressure

    Analysis of Data
    1. Formulate nursing diagnoses
    (wellness, risk, actual).

    2. Formulate collaborative problems

    3. Make necessary referrals.

    You might also like