Question

The nurse is caring for a 74-year old gentleman who was admitted 2 days ago with chest pain.  His past medical history includes coronary artery disease, CHF, hypercholesterolemia, obesity, GERD, and COPD.  His 0800 vitals are:  BP 142/88, HR 86, Sp02 92% on 2L humidified 02 via nasal cannula, RR 22, temp 98.4.  

1. Describe the abnormal assessment findings you might expect to see in this client’s head-to-toe assessment.  

Answer 1

Abnormal assessment findings:

• Vital Signs:

BP 142/88, slightly elevated blood pressure. This is not an emergency condition, but it should be noted that the patient came with a chief complaint of chest pain and he has a history of CHF.

SpO2 92% on 2L humidified oxygen via nasal cannula. This indicates COPD since this comes in the COPD SpO2 range of (normal to COPD) 88% to 92%, but this is the value on 2L humidified oxygen via nasal cannula.