Objective Data for Patient EA, Case Study Example

Objective Symptoms:

Vital Signs

Inspection – There is clear unevenness in the abdominal area that causes a rift into the abdominal wall. Repeated pushing on stomach leads to heavy increase in pain for patient. Vital signs do not indicate a clear blockage in arterial blood flow. Pulse rate is normal. Respiration rate is normal. Blood pressure is slightly elevated. Patient maintains high blood pressure with low BMI. Resting pulse rate is normal. Heartbeat is regular with no signs of palpitation or murmur. Lung contraction is normal. Patient complains of pain in chest when taking deep breaths.

Auscultation – A bruit was produced indicating possible alteration of arterial blood flow in the abdomen area. Further tests are required to ascertain potential damage to the area as well as potential decrease in blood flow throughout the body. High blood pressure exists with patient E.A. despite low BMI and excellent resting pulse rate.

Palpation – Abdominal tenderness exists towards the upper abdominal wall. There appears slight swelling just underneath the upper abdomen on the right side noticeable only to the touch. Upon touch, patient E.A. does not show difficulty breathing but does complain of pain.

Percussion – All signs appear normal.

References

Weber, J. & Kelly, J. (2010). Health assessment in nursing (4^th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.