University:
American Career College
Course:
NURS-113 | Beginning Medical/Surgical Nursing
Academic year:

2020
Views:

325

Pages:

7
Author:

Prince Sampson

RM 1608 HOLISTIC NURSING ASSESSMENT ASSIGNMENT Directions: Complete the following holistic assessment on ONE long term care client/resident, include subjective data, objective data and history as appropriate. At the conclusion of this assessment, you will see the written assignment which accompanies the assessment All blanks should be addressed. If not applicable to your individual resident/client, please mark n/a where appropriate. This assignment should be turned in via a pocket folder to your clinical faculty member. The assessment may be handwritten (neatly), but the "Risk Factor Assignment (see bottom of assignment) should be typed as directed 1. CLIENT/RESIDENT/RESIDENT PROFILE 110 A Personal Characteristic 51 Married Source of Information Age Sex Fugle Adin Date M.L Reliability (1-4) 3 Etonic Orientation White/CaucasianLanguage English B. Current Health Orientation Admiting De left side paresis due to MCA, short term MemoRY JOBS Medical MCA Syscagn, HTN, Bicuspid Aastic Stenocis II. PHYSICAL ASSESSMENT 1. Respiratory System lungs clear to auscultatio Resp 10 NUClubbing Capillary refill <3 secs, stin blancheavie Respiratory Diagnostic Testa: (Chest X-ray, ABG's PFT's HGB HCT) List on back 2 Cardiovascular System; bicuspid CORTIC SHENESIS; whooshing present uporn ausentation, murmur AP: 89 up No edema present Cardiovascular Diagnostic Tests (CBC, Electrolytes. EKG, Angiograms, etc.) list on back 3 Gastrointestinal System; Bowel sounds positive and Normoactive in all 4 quadrants. Pt.stated "I have an Abdominal Aortic Anerysm" Urinated 9-tex a day urive color pt states" edepend Pl.states he has a BM every morning 4. Genitourinary System urinated 5-6x aday on now much I drink, urive color pt. States" depends much I drink, sometimes it's pale yellow and other tirnes its its gold 5. Neurological Syatem. PERRLA, AHOX3, Not agitated very welcoming, 6 Musculoskeletal System: Grip strength 5+ in extremety Right arm. Lower Right 7. Integumentary System: SKIN warm and dry. No ederma Noted. SKIN turgor elastic & No fenting Capillary refill 23 Braden scale