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Patient Information Name: Florence Nightingale Age: 55 Gender: Female Allergies No known allergies Vital Signs Blood Pressure: 135/85 Pulse: 78 Weight: 203 lbs Temperature: 98.3 F Breaths/Minute: 30 Reason for Admission Lives alone and has had several episodes of recent falls within the past several months. Chest hurts. Wheezing is present when she takes slow deep breaths through her mouth. Observation Patient is currently lying in bed and appears to be having difficulty breathing. Her appearance is unkept: hair uncombed, shirt untucked, and various stains on their clothes. Patient is lying in bed not in alignment, sort of half on the bed. Legs and feet dangling off the side of bed. There is oxygen tubing by the side of the bed, but it is not on the patient. Patient has an intravenous (IV) access in place with fluid infusing via an infusion pump. The call bell and phone are not within the patient's reach. The call bell has fallen underneath the bed and the cell phone is on the window sill. Her eye glasses are also on the window sill across the room. Answer the following questions: What can you interpret from the vital signs? What can you interpret based on the summary of information in the intake form? Identify and label 1 example of objective and subjective information in the intake form. (Provide one example for each type) Based on the patient's unkept appearance, what assumptions can you make from this information? What can you do next to confirm your assumption?
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