What physical assessment data are collected during shift assessment? Assess and document the patient’s pain assessment. Identify the differences between comprehensive assessment and shift assessment.
M.R., a 51-year-old man, was rushed to the emergency department after a motor vehicle accident 3 days ago. M.R. is now in the intensive care unit (ICU).
Subjective Data
Lost consciousness at the scene
Pain 6/10 in left leg and right arm
Family at bedside
Objective Data
Fractured left femur, repaired with casting, same day as accident, casting clean, dry, and intact, positive distal pulses, positive cap refill toes.
Fractured left wrist, repaired with external fixator, same day as accident, four pins, clean dry intact with two fixator rods lateral surfaces, no drainage, cleaned ever shift, positive pulses, positive cap refill in nail beds.
IV 20 gauge, site right forearm, placed 1 day ago, patent, no edema
Vital signs: T 36.7 BP 108/62 HR 72 Resp 18
Height: 5 feet, 9 inches
Weight: 190 lb
Medications: 1 mg morphine IV per 2-4 hours as needed for severe pain, Percocet 5/325 mg PO two every 4 to 6 hours as needed for moderate or breakthrough pain, ibuprofen 300 mg PO every 6 hours as needed for fever, Ancef 1 gm IV every 12 hours prophylactically after surgery for external fixation of fracture.
Questions
What physical assessment data are collected during shift assessment?
Assess and document the patient’s pain assessment.
Identify the differences between comprehensive assessment and shift assessment.
How will the nurse adapt the assessment of the skin to the hospitalized patient?
How will the nurse adapt the assessment of the musculoskeletal system for this patient?
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How will the nurse apply the information from the musculoskeletal system?
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