Donna Turner, is a 73 year-old African American female, admittedfrom the ER during the night with the diagnosis of syncopal attack.Past medical history of HTN, CAD, and DJD. Admitted to Telemetryfor monitoring and workup. CT head negative and labs within normallimits. Saline lock in left hand. Medications: Lisinopril,Cardizem, HCTZ daily and Tylenol prn for pain. Scheduled fordiagnostic test in AM. Vital Signs B/P 150/85, Pulse 87Respirations 20 and Temperature 97.5, Oxygen saturation 96% on 2Liters via Nasal Cannula.

1. Initial Focused Assessment

After reviewing the client’s background and nursing report, youare ready to assess. Under each category, identify how you wouldtarget your assessment for a complete health history and head totoe assessment. Are there any questions you need to ask the patientor family to obtain additional relevant data? Fill in theinformation below:

General Appearance
Neuro
HEENT
Integumentary
Respiratory
Cardiovascular
Breasts
Musculoskeletal
Reproductive

Developmental

(Ericksons)

Family Support

2. Nursing Diagnoses-Identify three priority nursing diagnosesfor Donna Turner.

Assessment Data Nursing Diagnosis Nursing Intervention Patient Outcome Criteria

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