Assignment task:
Patient Scenario:
Patient: AB, male, 45 years old, Caucasian
Admitting medical diagnosis: s/p MVA with a fractured pelvis and multiple contusions
Weight 165 pounds, height 5 ft 7 in,
BP 144/88 mm Hg, HR= 90bpm, RR 22bpm, Temp 99.0°F
Reason for admission: "I was in a car accident"
No known allergies
No current meds
Medical/Surgical History: Appendectomy at age 8 years
Neuro/Orientation: Alert/oriented to person, time, and place
Cardiovascular: denies dyspnea, nonsmoker, breath sounds clear to auscultation bilaterally; no cough; apical pulse 90 bpm and regular, peripheral pulses equal, regular, and strong bilaterally; skin warm, pink, and dry; capillary refill less than 2 seconds.
Nutritional/fluid: denies difficulty chewing or swallowing food, normal appetite; no nausea or vomiting; skin is elastic with instant recoil; nothing by mouth (NPO ordered)
Elimination: foley catheter to gravity with clear, light yellow urine; reports regular bowel movement daily but no BM for 4 days; abdominal bowel sounds are hypoactive in all four quadrants.
Rest and sleep: Sleeps at 10 pm until 5 am
Answer these questions:
Q1. What is another term for subjective data?
Q2. What is another term for objective data?
Q3. What are the steps in the assessment process?