Nursing Assessment of Mr. William: Case Study and Nursing Problems

Running Head: Nursing Assessment, Case Study of Mr. William
1
Nursing Assessment, Case Study of Mr. William
Student Name
Institution
Date

Nursing Assessment, Case Study of Mr. William 2
GENERAL APPEARANCE
Mr. Williams is a 48- year- old man. He was admitted following a fall from a
height of approximately 2 meters at his workplace. As a result of the fall, he
sustained some injuries such as fractured ribs on his right side, significant bruising
on his upper thigh and a dislocation on his right shoulder. Additionally, he also
sustained some damage on his protective headwear although no loss of
consciousness was reported. Williams’s rate of ambulation has been minimal with
a bit of morphine to help manage the pain.
DATA/ CUES / Signs and Symptoms. Indicate Normal
(N) or Abnormal (A)
Neurological CNS Subjective: conscious (N), able to make movements (N), hearing well
(N), no coordination of movement (A).
Objective: Pain 4/10 (A), 3 fractured ribs (A)
CVS Subjective: conscious (N), no reports of cardiac output (N)
Objective: HR irregular (A), HR- 105 (A), BP- 150/80 (A)
Respiratory Subjective: No history of cardiac diseases (N), oxygen saturation 94%
(N), No visible airway obstruction (N)
Objective:RR-25bpm (A)

Nursing Assessment, Case Study of Mr. William 3
Genitourinary
Renal
Subjective: Has been passing urine normally (N)
Objective:
Musculoskeletal
Subjective: Normal movement of muscles (N)
Objective:
Gastrointestinal
GIT
Subjective:
Objective:
Integument
Subjective:
Objective:
Endocrine/
Metabolic
Subjective:
Objective:
Psychosocial/other
Subjective: Talks in a friendly manner (N)
Objective:

Nursing Assessment, Case Study of Mr. William 4
Assessments
SYSTEM ABNORMAL NORMAL
Neurological and sensory  3 fractured ribs  conscious
System difficulty to move  Able to make movements
 Pain (4/10 level)  No symptoms of seizures
slightly high  Hearing well
 No coordination of  Able to adjust herself in bed
Movement  Doesn’t have slurred speech
 Limited ambulation
Mental health  Restlessness  Appears to be conscious
Cardiovascular system  HR- irregular  Conscious and does not report
 HR-105 Any breathlessness or low
Cardiac output
 BP-150/80
Respiratory system  RR-25bpm  No history of cardiac diseases
 Oxygen saturation 94%
 No visible airway obstruction
Renal/bladder  Has been passing urine normally
Skin, hair, nails  Pale Dry skin and  Greying hair
Temp-37.8
Musculoskeletal  Full body movement
 Correct posture
Psychosocial  Friendly to talk