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Examples Of Objective Assessment

Decent Essays

Objective Assessment Ms. R. is a 73 year-old divorced female, who has history of hypertension (HTN), coronary artery disease (CAD), hypercholesterolemia, and osteoporosis. She is on Ecotrn, Fosamax, Citracal, Crestor, Zestril. Ms. R. has been retired for more than 7 years as a factory worker. She lives with her daughter and a dog, named Abbey. Ms. R. lives an active lifestyle, e.g., she walks Abbey three times a day, walks to church for three miles on Sundays, and does work around the house. Every afternoon, she works in her garden where she grows some herbs and seasonal flowers. The vital signs taken at the time of the interview: Temperature = 98.8°F; Pulse = 78; Respiration = 12; and Blood Pressure = 110/80.
Subjective Assessment The …show more content…

Activities of Daily Living: The score demonstrated that Ms. R. is highly independent in the performance of all activities of daily living; with no need for supervision, direction, or personal assistance.
3. Oral Health: The condition of the oral cavity, teeth, gums, and mucus membrane, all indicate that Ms. R. is well hydrated. Although, there is a need for a dental care follow-up on her broken tooth.
4. Fulmer SPICES Assessment: The result confirmed the data on the two assessment tools on sleep and fall risk. Ms. R. identified these two areas, where she had evidence of a problem. She indicated having a disordered sleeping pattern and a history of a fall.
5. Nutrition: Ms. R.’s score of thirteen (13) on the assessment tool, showed that she has normal nutritional status and has a body mass index (BMI) of 21.9 that falls within the normal range for her weight and height.
6. Pain: Ms. R. at the time of the interview, declared that she did not have pain. However, she stated that on some occasions, she experiences mild to moderate pain on her lower back.
7. Hearing: The Hearing Handicap Inventory indicated that Ms. R has a mild-moderate hearing impairment.
8. Fall Risk: Results showed a score of zero (0), which indicated that Ms. R does not have any risk for

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