Mr. Gordon, a 52 year-old client who was admitted to the hospital following an MVC (motor vehicle crash). He suffered rib fractures and has a laceration along his right thigh. Mr. Gordon states that his pain is 9 on a 0 – 10 scale (0 being no pain, 10 being the worst). In addition his vital signs are: BP 150/88, HR 105, RR 22, SpO2 95% on RA (room air), T 98.6 degrees Fahrenheit taken orally.
Introduction
This case study discusses the presentation and assessment of a 52-year-old patient named Mr. Gordon, who was admitted to the hospital following a motor vehicle crash (MVC). Mr. Gordon has sustained rib fractures and a laceration on his right thigh. This paper will analyze Mr. Gordon’s reported pain level and vital signs, including blood pressure (BP), heart rate (HR), respiratory rate (RR), oxygen saturation (SpO2), and body temperature (T).
Pain Assessment
Mr. Gordon reports his pain level to be 9 on a scale of 0 to 10, with 0 indicating no pain and 10 representing the worst possible pain. Pain assessment is crucial in the management of patients, as it helps determine the severity and intensity of pain and guides appropriate interventions (McCaffery & Pasero, 1999). Mr. Gordon’s self-reported pain level indicates that he is experiencing severe pain.
Vital Signs Assessment
Blood pressure (BP) is essential in determining a patient’s cardiovascular status. Mr. Gordon’s BP reading is 150/88 mmHg. The systolic pressure of 150 mmHg indicates the pressure in the arteries during ventricular contraction, while the diastolic pressure of 88 mmHg represents the pressure in the arteries during ventricular relaxation. These readings suggest that Mr. Gordon may have hypertension or a stress response related to pain or trauma (Pagana & Pagana, 2018).
Heart rate (HR) refers to the number of times the heart beats per minute. Mr. Gordon’s HR is recorded at 105 beats per minute (bpm). The normal resting HR for an adult is typically between 60 and 100 bpm (Pagana & Pagana, 2018). Mr. Gordon’s elevated HR could be attributed to pain, anxiety, or a compensatory physiological response to the traumatic event (Lewis et al., 2019).
Respiratory rate (RR) represents the number of breaths a person takes per minute. Mr. Gordon’s RR is measured at 22 breaths per minute. The normal respiratory rate for adults ranges from 12 to 20 breaths per minute (Pagana & Pagana, 2018). While Mr. Gordon’s RR is within the normal range, it is slightly elevated. This may be a response to pain and anxiety, as well as a compensatory mechanism to maintain adequate oxygenation (Lewis et al., 2019).
Oxygen saturation (SpO2) measures the extent to which hemoglobin is saturated with oxygen. Mr. Gordon’s SpO2 level is 95% on room air (RA). A normal SpO2 level for healthy individuals is generally considered to be above 95% (Pagana & Pagana, 2018). Mr. Gordon’s SpO2 reading suggests that he is adequately oxygenated. However, it is important to monitor his oxygen saturation closely, as pain and chest injuries may affect ventilation and oxygenation.
Body temperature (T) provides an indication of the patient’s thermal balance. Mr. Gordon’s temperature is recorded as 98.6 degrees Fahrenheit (°F) orally. The normal body temperature range for an adult is typically between 97.7°F and 99.5°F (Pagana & Pagana, 2018). Since Mr. Gordon’s temperature falls within this range, it can be considered as normal.
Conclusion
In conclusion, Mr. Gordon, a 52-year-old patient who was hospitalized after a motor vehicle crash, presents with severe pain, rib fractures, and a laceration on his right thigh. His vital signs include a BP of 150/88 mmHg, HR of 105 bpm, RR of 22 breaths per minute, SpO2 of 95% on RA, and a T of 98.6°F. These findings suggest that Mr. Gordon is experiencing pain and physiological responses related to his injuries. It is essential to assess, monitor, and manage his pain and vital signs to ensure appropriate care and promote his recovery. Furthermore, ongoing monitoring of these parameters will be important to identify potential complications and guide further interventions if necessary.