Jennessee S.

Miague BSN 1-D

MODULE 1: Introduction to Health Assessment

Case Study

CASE STUDY I

From the data given, identify:

Subjective Data.

● Estrella says “my hear hurts”

● Mr. Dela Cruz states that Estrella has had cough and runny nose for the
past 2 days and is not sleeping or eating well.
● old records show that she has been treated three times over the past year
for otitis media.

Objective Data.

● 39oc temperature
● irritable
● tugs at her ear

CASE STUDY II

From the data given, identify:

Primary Data Source.

● PATIENT - Rose Montefalco, age 78

Secondary Data Source.

● Old records showing health history

Email: cn@usa.edu.ph | Tel. No.: 0999-997-1485 | Fax No.: (033) 337-4403

Subjective Data.

● Patient states, “My chest is killing me; it feels like I’m in a vice.”
● Old records show a history of hypertension.

Objective Data.

● Pain severity 10/10

● difficulty breathing
● blood pressure (BP) 170/110 mmHg
● pulse 118 beats/min and regular
● respirations 32/min
● temperature of 37.6oC
● pulse oximetry 90% on room air
● patient diaphoretic, pale and clammy
● sinus tachycardia with occasional premature ventricular contractions,
electrocardiogram (ECG)
● oxygen via nasal cannula at 3L/min

After starting nitroglycerin:

● chest pain decreased to 8/10 within ½ hour

● BP 160/100 mmHg
● pulse 110 beats/min
● respirations 28/min
● pulse oximetry 93% on 3L of oxygen

Email: cn@usa.edu.ph | Tel. No.: 0999-997-1485 | Fax No.: (033) 337-4403