Subjective Data

Subjective Data

William Smaile is a 65-year-old man who presents to his general practitioner’s office with complaint of right forearm swelling, redness, and pain. He was recently discharged from the hospital where he had been receiving intravenous antibiotics for a respiratory infection.

Subjective Data

Pain level is a 5/10 location = right forearm, aching
Retired foreman at a local industrial plant
Objective Data

Vital signs: BP 150/68, T 37 degrees Centigrade, P 80, R 16
Swelling and reddened right forearm, warm to touch
+ pulses, brachial and radial (R)
+2 capillary refill fingers right hand
What other assessments should be included for this patient?
From your readings, what is the most probable cause of the swelling?
What is your nursing diagnosis?
What would be included in the nursing care plan?
What interventions might be included in the plan of care for this patient?
APA FORMAT
REFERENCE:
Jarvis, C. (2016). Physical examination & health assessment (7th ed.). Philadelphia, PA: Saunders.

Chapter 12: Skin, Hair, and Nails
pp. 199-225 (Structure, Function, Subjective and Objective Data, Documentation and Critical Thinking)
p. 250 (Summary Checklist)
Chapter 13: Head, Face, and Neck, including Regional Lymphatics
pp.251–270 (Structure, Function, Subjective and Objective Data, Documentation and Critical Thinking)
Chapter 14: Eyes
pp. 281–311 (Structure, Function, Subjective and Objective Data, Documentation and Critical Thinking)
Chapter 15: Ears
pp. 325–341 (Structure, Function, Subjective and Objective Data, Documentation and Critical Thinking)
Chapter 16: Nose, Mouth, and Throat
pp. 353–374 (Structure, Function, Subjective and Objective Data, Documentation and Critical Thinking)