HEALTH ASSESSMENT – RLE

(Simulation)

Mary Jean S. Silvino, RN, MAN

Anngeo D. Labog, RN, MAN
Czar Cyrill Neo J. Jacobe, RN
• Cardo Dalisay is a 62-year-old married father
of 6 who was in relatively good health until 3 weeks
ago. At that time, he visited the Emergency
Department (ED) with a complaint of “nausea,
vomiting and dizziness.” His Blood Pressure (BP) upon
admission was 182/118 mmHg, so he was admitted to
the Coronary Care Unit (CCU) with the diagnosis of
hypertension (uncontrolled). His BP was controlled
with medications, and he was discharged several days
later. He is now being seen for follow-up care and
management of hypertension. Because Mr. Dalisay is
newly diagnosed with hypertension, you will need to
complete a history and thorough ____________
assessment.
Situation 2
Situation 3
• Samuel is a 32-year-old male with no significant past medical
history presents to the emergency department with abdominal
pain. He states the pain began a few days ago in the right lower
quadrant of his abdomen, and now feels as though it is
spreading to his mid-abdomen. He describes the pain as coming
on suddenly and sharp in nature. Since onset, his pain started
to improve until the morning of presentation to the emergency
department when it acutely worsened. He says that the pain is
much worse with movement. How will you continue your
thorough assessment to patient Samuel?
 • Emilio, a 67-year-old male patient
came to the clinic for a follow up
checkup. He was diagnosed with
pulmonary tuberculosis 4 years ago.
During his `visit, he reports that he has

Situation 4 fever, dyspnea and hemoptysis for 2

days. He also mentioned that he
experiences chest pain when he takes a
deep breath or coughs. How will you
provide your best approach in
continuing your thorough assessment?
Situation 5
 • Nicole, a 31-year-old female patient,
is concerned with breast lumps and
tenderness that occur each month
before her menses. She comes to the
Situation 6 clinic for her annual physical
examination. How will you provide
your best approach in continuing your
thorough assessment?
 • A 57-year-old male patient was admitted
in the Emergency Department due to productive
cough for 20 days and difficulty of breathing.
Situation 7 During interview, he describes his sputum to be
greenish in color. Considering the patient’s
manifestations, how are you going to perform a
thorough physical examination?
 JM Santos, a 48-year-old male patient came to the
Emergency Department with a chief complaint of abdominal
discomfort and pain. Upon interview, he stated that he was
not able to defecate for 6 days with episodes of nausea and
Situation 8 vomiting. He has a family history of colon cancer. As a nurse
assigned to JM, a complete assessment of his _________
system requires you to take a detailed health history and
perform a thorough physical examination.
THANK YOU ☺