Example document containing objective and subjective date along with

Question Example document containing objective and subjective date along withactual or potential risk factors for the client based on the assessment findings with description or reason for selection of them.Client is Mr. Green, a 52 year old native Alaskan man who is currently living in a long term care facility. Past Medical History- hypertension, smoking, and history of stroke 2 years ago (still has lasting neurological side-effects from this, left sided weakness)Allergies- aspirin HPI-Patient currently has a headache. He describes as sever (10/10), pounding/throbbing headache that had been present for “a few hours”. He also has blurry vision. OLDCARTS about vision and headaches. Vital signs : Oral temp 36.8 C, HR 88 BPM, RR 22, and BP 168/92 mm Hg.Inspection: Alert but confused: oriented to person and place only. Speech is slight slurred. CN II impaired on Snellen test. CN VII impaired, left lower facial droop present. All other CN is intact. Palpation: Muscle strength 2/5 left arm-3/5 left leg. All other neurons assessments should be documented as intact/expected/normal. Health Science Science Nursing NURSING NUR2180 Share QuestionEmailCopy link Comments (0)

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