Initial Assessment Data
- Biographical data: Adolescent client (age 17)
- 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. Awakes 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
Think about the client data documented on the vital sign record and try to answer the following questions. Write your answers on a piece of paper.
- Review the vital sign record and identify the trends that you see.
- What should the healthcare provider’s next action be?