Subjective Information

A 71 year old female is admitted at midnight with a diagnosis of Chest Pain. You are the RN on the tele floor. She complains of a squeezing type pain across her chest and into her left jaw area. Vital signs are: Blood Pressure-200/***; Pulse-*** beats per minute; Respirations-*** per minute; Temperature-***; Saturation of Oxygen-**% on room air; pain level */10. During your initial assessment she is rubbing her mid-chest, grimacing and is diaphoretic. The pain has been occurring intermittently throughout the evening and night. Her color is pale except around her lips which are bluish. Cardiac auscultation reveals

Sample Paper

Student ABC

Rasmussen University

COURSE#: NUR2180 Physical Assessment

Instructor: Caitlyn Schumaker

April XX, 2021

Title of Paper

Subjective Information

Patient states “…” this is the area where you put all of the subjective information the patient tells you, or that you gather – use your textbook “subjective” section to find the appropriate questions you would ask your patient about their symptoms related to the body system for this module.

Subjective data includes basic biographic data on the patient (name, age, race/ethnicity, gender assigned at birth)

· Did I mention if the patient is taking any daily medications? Did I mention if the patient has any allergies?

· HPI: Did I included all aspects of PQRST/OLDCARTS?

· P- Did I mention makes their symptoms better & what makes them worse

· Q- Did I mention the quality, characteristics, or descriptive factors of the symptoms?

· R- Did I mention the region affected? Is any radiation present?

· S- Did I mention the severity on a scale of 0-10?

· T- Did I mention when their symptoms first started and the duration of their presence?

Objective Information

This is where you would document your assessment findings – remember to include all of the assessment pieces for the body system- use your textbook for examples of what needs to be included. For most body systems you will need to include: Inspection, Palpation, Auscultation – but it depends on the body system. Do not document “normal” or “Okay” – you need to describe the assessment findings that lead you to believe it was normal or okay. For example, do not document “ears normal” document – “On inspection ears are symmetrical and free from redness and drainage.” Your Jarvis textbook “documentation” section in each chapter will provide you with a complete outline of what would be included in a full physical assessment for each body system- so please double check your textbook to make sure you have included all aspects of the exam.

Risk Factors

This is where you will think about your assessment findings and identify assessment items that put your patient at risk for something – for example if my patient has a wound on his foot he may be at risk for falls, or if my patient has been vomiting for three days she may be at risk for dehydration or electrolyte imbalance. Keep your risks nursing focused if possible – things that, as a nurse, you can help your patient with (nutrition, mobility, safety) – if you need help thinking of a risk use the resources found in the nursing library page- Reference Books – the Care Plans tab. https://guides.rasmussen.edu/nursing/referenceebooks

For risk factors, make sure you have the following:

At least 2 actual or potential risk factors are listed for this patient- to get full points make sure you can answer the following:

· Do these risk factors clearly pertain to the patient issue?

· Did I use assessment data and information to back up WHY I think this patient is at risk for this?

· Did I cite my information with in-text citations?

References

**** APA formatted references are included at the end of the assignment****

· APA guidelines can be found at https://guides.rasmussen.edu/apa