I would knock on the door enter the room, and greed while introducing myself to the patient and the family. I would wash my hands and provide a privacy. Then I would ask Daniel for his first and last name, and date of birth. I would ask Daniel if he is allergic to anything and if he doesn’t seem to be fully awake to answer the questions, then I would ask the family.
I would let Daniel and his family know that I have looked at Daniel’s blood pressure and temperature and would like to recheck his full vital sign to see if it has changed because Daniel’s blood pressure was low and he had a fever that I would like to see if it getting better
Objectives:
Temperature: 99.5 Pulse: 64 Blood Pressure: 79/49 URA Respiration: 14
Oxygen: 80
Since Daniel’s oxygen is low; I have to focus on that first and then circulations. I have to make sure his oxygen is above 90, so I start Daniel on two liter of nasal oxygen, and ask Daniel to breathe in through his nose and exhale through his mouth (smell the rose and blow out the candle) until his oxygen is …show more content…
I would check the gag reflex and it’s present. I would then inspect the ear and nothing abnormal skin is intact and he is able to hear on both ears to low sounds, the I would inspect the nasal, skin is intact no drainage and sensory is present, and able to smell the mint. Then I would inspect the eyes using the PERRLA, the eyes are nice and round, and equal and they reacted to the light while they accommodate to the movement of my pec light. I would inspect the neck for the swallow, and he says that no pain is present as swallowing the water I provided. The carotid artery is normal and so is the jugular