HA-RLE Worksheet # 5

ASSESSING GENERAL STATUS AND VITAL SIGNS

Case Study:

Read the following case study. Then work through the steps of analysing the case study data.

1. First identify abnormal data and strengths in subjective and objective findings;
2. Assemble cue clusters;
3. Draw inferences;
4. Make possible nursing diagnoses;
5. Identify defining characteristics;
6. Confirm or rule out the diagnoses; and
7. Document your conclusions.

Case Study:
Steve Marin is a 36-year-old white man, who comes to the employee health center for
advice. He says he has been under a lot of stress lately. He believes he is drinking too much
coffee (12 cups daily) and smoking more than usual (2 packs daily). He is neatly and
appropriately dressed in a business suit. His posture is erect, and his gait is smooth. His hands
are trembling. He has excess subcutaneous fat, distributed primarily around the waist. Mr. Marin
appears tired, anxious, and hurried. He is cooperative, maintains good eye contact, and
answers questions quickly. His speech is clear but fast paced.
Vital Signs
Oral temperature: 37.04 degrees centigrade
Radial pulse: 92 beats/minute, shallow and somewhat labored
Respirations: 23 breaths/minute
Blood pressure: sitting, right arm 180/112mm Hg; left arm 172/108 mm Hg; standing, 155/100
mm Hg (standing Bp taken in either arm due to similarity of sitting Bps). Denies any pain and
discomfort.
Note: Please secure consent before starting the interview to actual client….
NURSING INTERVIEW GUIDE TO COLLECT SUBJECTIVE DATA
QUESTIONS FINDINGS
Present History
1. Can you tell me your height? 63.7 inches

2. I also need to know your weight? 75.74 kg

3. Do you have any fever? Afebrile

4. Describe the sign or symptoms, where did He’s been under a lot of stress. His hands are
it begin? Does it occur anywhere else? trembling. Comes and goes each day, last for
How long does it last? What makes it several hours. He also believes that it became
better or worse? What other symptoms worse when he’s drinking 12cups of coffee daily.
occur with it? How does it affect you? He appears tired, anxious, and hurried. He said
that it bothers him when his hands are trembling.
5. Do you have any allergies? None

6. Present Health Concerns Subjective: He has been under a lot of stress.

Objective: He appears tired, anxious and hurried.

Past History
1. Weight gains or losses? He has excess subcutaneous fat, distributed
primarily around the waist.

2. Previous high fevers, cause, and NA

treatment?

3. History of abnormal pulse? Past record: 82 beats/minute, normal

Current record: 92 beats/minute, shallow and
somewhat labored
4. History of abnormal respiratory rate or Past record: 16 breaths/minute, normal
character? Current record: 23 breaths/minute, abnormal
5. Usual blood pressure, who check it last, Past record: sitting right arm, 110/75 mmHg,
and when? sitting left arm, 120/80 mmHg - standing left arm,
112/80 mmHg, standing right arm, 115/80 mmHg.
Current record: sitting, right arm 180/112mm Hg;
left arm 172/108 mm Hg; standing, 155/100 mm
Hg (standing Bp taken in either arm due to
similarity of sitting Bps). Denies any pain and
discomfort.

6. History of pain and treatment? NA

Family History
1. Hypertension? He has a family history of hypertension and
diabetes through his father.
His mother has a history of breast cancer at the
age of 65.

2. Metabolic /growth problems? NA

Lifestyle and Health Practices

1. Religious affiliation NA

PHYSICAL ASSESSMENT GUIDE TO COLLECT OBJECTIVE DATA

Questions Findings
Overall Impression of the client
1. Observe physical development (appears Has excess subcutaneous fat distributed primarily
to be chronologic age) and sexual around the waist that can be seen in obesity as a
development (appropriate for gender and result for abnormal findings number 1. A 36 year-
age). old white man. The patient appears to be his
stated chronologic age which is normal.

2. Observe skin (generalized color, color Color of the skin is even without obvious lesions
variation, and condition which relates to normal findings.

3. Observe dress (occasion and weather He appropriately dressed in a business suit.

appropriate).

4. Observe hygiene (cleanliness, odor, He is neatly dressed.

grooming).

5. Observe posture (erect and comfortable) His posture is erect, and his gait is smooth.
and gait (rhythmic and coordinated)

6. Observe body build (muscle mass and fat He has excess subcutaneous fat around the
distribution). waist.

7. Observe consciousness level (alertness, He is trembling, he appears tired, anxious, and

orientation, hurried. He is cooperative and maintains good eye
appropriateness). contact, answers questions quickly. His speech is
clear but fast paced.
8. Observe comfort level The patient assumes relatively relaxed posture
without excessive position shifting.

9. Observe behavior (body His speech is clear but fast paced

movements, affect, cooperativeness,
purposefulness,
and appropriateness).

10. Observe facial expression (culture- Appears to be tired, anxious and hurried.
appropriate eye contact and facial Maintains good eye contact.
expression).

11. Observe speech (pattern and style) His speech is clear but fast paced.

Vital signs
1. Gather equipment (thermometer, Identify the equipment needed to measure vital
sphygmomanometer, stethoscope, and signs and the proper use of piece of equipment.
watch)

2. Measure temperature (oral, axillary, Oral temperature is normal with a range of 37.04
rectal, tympanic). degrees centigrade.

3. Measure radial pulse (rate, rhythm, Radial pulse is shallow and somewhat labored
amplitude and contour, and elasticity). with a result of 92 beats/minute which results to
abnormal rate.

4. Monitor respirations (rate, rhythm, and Respiration had a result of 23 breaths/minute that
depth). alters abnormal breathing.

5. Measure blood pressure The patient’s blood pressure in the right arm while
in sitting position 180/112 mmHg which indicates
hypertension stage 3. His left arm has a blood
pressure of 172/108 mmHg. Standing position is
155/100 mmHg. The patient has abnormal blood
pressure.
Analysis of Data
1. Formulate nursing diagnoses (wellness,  Risk for metabolic imbalance syndrome
risk, actual). susceptible to a toxic cluster of biochemical
and physiological factors that develop
cardiovascular disease arising obesity and
type 2 diabetes, which may compromise
health, with relation to stress overload, and
has a family history of hypertension. (NANDA
00263)
 Hypertension related to too much stress that
causes tiredness, anxious and hurried.
Wellness - readiness for enhanced health
management related to hypertension in order to
learn more about health promotion and manage
high blood pressure.
Risk - risk for fluid build up in the lungs
- risk for vision loss
- risk for kidney damage
- risk for erectile dysfunction
- risk for memory loss
- risk for too much stress
Actual - Impaired verbal communication related to
barrier related to the patient’s fast paced speech.
- Impaired verbal communication related to
inability to clearly express self or understand
others.
- Increased stress level due to unhealthy
lifestyle and a family history of hypertension.
2. Formulate collaborative problems RC: Risk for metabolic imbalance syndrome
RC: Hypertension
RC: Unhealthy lifestyle

3. Make necessary referrals. If not properly treated, hypertension can lead to

serious issues, including heart attack or stroke.
Changing your lifestyle can help control and
manage high blood pressure. Eating a heart-
healthy diet with less salt and getting regular
physical activity are least of the best ways to
prevent high blood pressure. (Mayo Clinic, 2020)