Initial Assessment Data

• Biographical data: Adolescent client (age 14)
• Reason for seeking care: Post-op surgery
• History of health/illness: Healthy
• Past history: No medications, no illnesses
• Client had abdominal surgery and was transferred from the recovery room to the surgical floor. Lethargic and oriented x 3. Awakens when name is called and responds to questions appropriately. Client rates pain 2/10. The healthcare provider assesses client’s vital signs every 30 minutes x 2 hours.

Vital Sign Record