Chapter 6: Knowledge Integration
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