Scribd
Upload
107 views1 page

Health Assessment and Vital Signs Summary

The document provides a nursing interview guide and findings from assessing a client's general health status and vital signs. It includes questions about the client's present history, including their height, weight, presence of fever or pain, allergies, and health concerns. It also covers the client's past medical history, family history, and lifestyle practices. Key findings are that the client reports back pain for 2 weeks that is exacerbated by activity, as well as recent weight loss and a fever last month treated with biogesic. The client's usual blood pressure was checked last year.

Uploaded by

Cyril Joy N. Fernando
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
107 views1 page

Health Assessment and Vital Signs Summary

The document provides a nursing interview guide and findings from assessing a client's general health status and vital signs. It includes questions about the client's present history, including their height, weight, presence of fever or pain, allergies, and health concerns. It also covers the client's past medical history, family history, and lifestyle practices. Key findings are that the client reports back pain for 2 weeks that is exacerbated by activity, as well as recent weight loss and a fever last month treated with biogesic. The client's usual blood pressure was checked last year.

Uploaded by

Cyril Joy N. Fernando
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd

Assessing General Health Status and Vital Signs

Student: Cyril Joy N. Fernando BSN 2C

Nursing Interview Guide to Collect


Subjective Data From the Client
Questions Findings
Present History
5'5"
1. Height?
101.4 pounds
2. Weight?
None.
3. Fever?
C - Appearing uneasy and tense, facial frown and
4. Pain? (COLDSPA) groaning
O - It begins last two weeks.
L - It occurs at her back when she do strenuous
activities in their home.
D - Usually it occur within 10 - 15 minutes and it
reoccur when she again do any activities that
include more physical effort.
S - It affect her body movement which limit her
ability to do work.
P - It's getting worse when she continually do an
activity that makes her feel the pain. It gets
better when she got enough rest and apply
ointments where the pain occur.
A - Pain through the feeling of aching which
makes her stop what she's doing and not being
motivated to the task.
None.
5. Allergies?
Stress
6. Present health concerns?
Past History
The client losses weight for almost 3 or 4 kg.
1. Weight gains or losses?
It was last month when she was got wet by the
2. Previous high fevers, cause, and rain. The client take biogesic for her high fever.
treatment?
None.
3. History of abnormal pulse?
None.
4. History of abnormal respiratory rate
or character?
Usual blood pressure is 90/60 mmHg last year,
5. Usual blood pressure, who checked it month of May at ASMGH by the medical staff.
last, and when?
6. History of pain and treatment?
Family History
None.
1. Hypertension?
None.
2. Metabolic/growth problems?
Lifestyle and Health Practices
Christianity which is Roman Catholic.
1. Religious affiliation?

You might also like