Comprehensive Assessments : Comprehensive Assessment

1308 WordsSep 27, 20146 Pages
Comprehensive Assessment Comprehensive assessments are crucial in high acuity nursing as it allows nurses to establish a baseline for the patient, determine oxygen supply and demand, provide individualized patient care, and make clinical decisions (House-Kokan, 2012). The components of a comprehensive assessment, including a physical assessment, corroborative diagnostic data, and the patient’s story will be assessed (House-Kokan, 2012). Physical Assessment Safety. Mr. Fedora is a 38 year-old man with insulin dependent diabetes mellitus (IDDM) who was arrived to the hospital with a blood glucose level (BGL) of 41 mmol/L. He is currently a hallway patient (pt.) admitted to the medical unit. He is currently in pain and nauseous. Neurological system. Upon inspection, Mr. Fedora has a high level of consciousness, as he was awake, and alert. He has a strong cough that is producing yellow sputum. His gag reflex is present and reports feeling nauseous. The pt. has been dry heaving, but not actively vomiting. Mr. Fedora’s motor function is adequate. Pt. reports pain to his chest and abdomen. Cardiovascular system. Mr. Fedora’s heart rate (HR) is 145 beats per minute (bpm). His temperature is 38.8˚C when measured both in the axilla and orally. His blood pressure was 80/55. Upon inspection, his skin appeared to be moist. Respiratory system. Upon inspection, Mr. Fedora’s airway is patent and clear and he is able to maintain it himself. His SpO2 is 90% on room air. He is
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