Health Assessment: Signs, Symptoms, Nursing Problems, and Frameworks

HEALTH ASSESSMENT 1
Health assessment
Student Name
Institution
Date

HEALTH ASSESSMENT 2
Health assessment
Part A
Signs and symptoms
Neurological CNS Severe to moderate pain
Cardiovascular CVS Regular heart and rhythm rate, Blood
pressure 150/20, temperature 37.8 degrees
Celsius heart rate 105
Respiratory Oxygen saturation 94%, respiratory rate 25,
history of smoking at least 20 cigarettes in a
day
Genitourinary No data available
Musculoskeletal Right arm supported in sling, fractured rib,
dislocated shoulder, bruising on the right
upper thigh, very little movement
Gastrointestinal No known drug allergies
Integument A lot of sweat
Endocrine or metabolic Sweating and appears pale
Psychosocial Possible withdrawal symptoms due to lack
of smoking cigarettes

HEALTH ASSESSMENT 3
Part B
Nursing problem Rationale
Pain Administration of analgesics like morphine,
injectable drugs like Toradol (ketorolac) or
muscle relaxants help to relieve bone pain
and have a longer action.
Fluid and electrolyte imbalance An imbalance in the fluid and electrolyte
causes excessive sweating. This imbalance
may delay bone growth and the rate of
healing
Anxiety and stress Encouraging the patient to discuss problems
that relate to the fall, may help to reduce
anxiety. Reliving the accident experience
helps the patient to cope and come to terms
with the reality
Withdrawal symptoms Most hospitals do not allow smoking. The
patient may be facing withdrawal symptoms
from the lack of tobacco intake. This is
visible through the sweating, paleness and
muscle spasms
Movement of bone fragments Any movement to the dislocated shoulder or
broken ribs increases the risk of more
physical injury. It also slows down the
healing process.
Nursing problem Assessment plan Rationale evaluation criteria
or assessment
findings
Pain Three open-ended
questions
- Using a scale
of 1 to 10,
which
number best
describes
your pain,
with 1 being
moderate and
10 being
- Using the
scale it is
possible to
self-report in
order to
administer
the correct
medicine
- This
The patient reported
a pain level of 4/10
Morphine had been
effective in reducing
the pain
The patient-reported
no other underlying

HEALTH ASSESSMENT 4
acute?
- is the
morphine
effective?
- How are you
feeling
today?
Further assessment:
- Observe the
nonverbal
cues such as
aggravation,
change in
emotions,
crying and
the need for
consolation
establishes
the
effectiveness
of morphine
- It helps to
identify other
underlying
symptoms
Nonverbal cues can
also help in an
objective analysis of
the pain level
symptoms
Nonverbal Cues
showed that the
patient is in
moderate pain
Electrolyte and fluid
imbalance
Three open-ended
questions
- how do you
feel?
- are there any
new
symptoms
since the last
check up?
- do you feel
dizzy?
Further assessment
- blood sugar
levels and
blood
pressure
should be
analysed
This helps to analyse
the extent of the
electrolyte and fluid
imbalance in the
body
Analysis of the
blood sugar and
blood pressure
shows the levels of
the imbalance
The patient reported
sweating
Blood pressure was
normal; however, the
heart rate appeared
to be high.
Stress and anxiety Three open-ended
questions
- How did the
accident
make you
feel?
- what are
some of your
- this helps the
patient to
analyse some
of the
difficult
emotions.
The patient is able to
talk about the
accident
focusing on the
positive helps to
reduce the anxiety