Given the case scenario List subjective & objective data that can be identified from Mrs. Perez before initiating a plan of care

Phlebotomy Essentials
6th Edition
ISBN:9781451194524
Author:Ruth McCall, Cathee M. Tankersley MT(ASCP)
Publisher:Ruth McCall, Cathee M. Tankersley MT(ASCP)
Chapter1: Phlebotomy: Past And Present And The Healthcare Setting
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Given the case scenario

List subjective & objective data that can be identified from Mrs. Perez before initiating a plan of care

Case Scenario:
I Mrs. Perez, 48 years old, is admitted to the nursing unit 2 hours after undergoing a right
surgical removal of her breast (mastectomy). The floor nurse receives a report from the post anesthesia care unit
(PACU) nurse that includes the patient's admitting diagnosis of breast cancer, latest vital signs, focused
assessment, medication & intravenous (IV) orders, pain level & the time she was last medicated for pain & status
of the surgical dressing. Initially, Mrs. Perez appears to be comfortable, dozing occasionally between short
conversations with her husband, who is at her side. When she was fully awake 3 hours after, she complains of
sharp, constant pain on the right side of her chest. She rates her pain at 8/ 10 on the pain scale. She is grimacing
and appears tense. The RN took her vital signs - T = 36.5 "C; BP = 130/100 mmHg; RR = 20 bpm; PR = 80
beats/min. She inspected the surgical wound, at the right breast and reveals that the dressing is slightly soaked
with blood and intact, no pus & slightly swelling noted.
Transcribed Image Text:Case Scenario: I Mrs. Perez, 48 years old, is admitted to the nursing unit 2 hours after undergoing a right surgical removal of her breast (mastectomy). The floor nurse receives a report from the post anesthesia care unit (PACU) nurse that includes the patient's admitting diagnosis of breast cancer, latest vital signs, focused assessment, medication & intravenous (IV) orders, pain level & the time she was last medicated for pain & status of the surgical dressing. Initially, Mrs. Perez appears to be comfortable, dozing occasionally between short conversations with her husband, who is at her side. When she was fully awake 3 hours after, she complains of sharp, constant pain on the right side of her chest. She rates her pain at 8/ 10 on the pain scale. She is grimacing and appears tense. The RN took her vital signs - T = 36.5 "C; BP = 130/100 mmHg; RR = 20 bpm; PR = 80 beats/min. She inspected the surgical wound, at the right breast and reveals that the dressing is slightly soaked with blood and intact, no pus & slightly swelling noted.
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