Chapter 6: Knowledge Integration
Case Study: Adolescent Client
Initial Assessment Data
- Biographical data: Adolescent client (age 14)
- Reason for seeking care: Post-op surgery
- History of health/illness: Healthy
- Past history: No medications, no illnesses
- Client had abdominal surgery and was transferred from the recovery room to the surgical floor. Lethargic and oriented x 4 (person, place, self and time). Awakens when name is called and responds to questions appropriately. Client rates pain 2/10. The healthcare provider assesses client’s vital signs every 30 minutes x 2 hours.
Vital Sign Record
![](http://pressbooks.library.ryerson.ca/authorsguide/wp-content/uploads/sites/177/2021/01/adolescent-documentation-Updated-scaled-1.jpg)