Name: Caday Sherish Millen S.

Knowledge Check Activity # 1

Activities of the Assessment Process (Collecting Data)
A. Case Analysis
Case no. 1
                Maria Cruz brings her 2-year-old daughter, Lauren, to the emergency room (ER)
with a fever of 39.40C. Ms. Cruz states that Lauren has had a cough and runny nose for the
past 2 days and is not sleeping or eating well. Lauren is irritable, tugs at her ear, and says “
my ear hurts”. Lauren’s old record show that she has been treated three times over the
past year for otitis media. From the data given, identify the following:
1. Primary Data Source: 2-year-old, Lauren
2. Secondary Data Source:

 Maria Cruz, mother

 medical history record, otitis media

3. Subjective Data:

 “my ear hurts”

 Not sleeping well
 Not appetite
 Had a cough for two days

4. Objective Data:

 Runny nose
 The patient is irritable
 Keeps tugging at her ear.

 
Case no. 2
                Rose Vee, age 78, comes to the ER with chest pain. Subjective and Objective data
include: Patient states, “My chest is killing me; it feels like a heavy chest pressure.” Pain
severity 10/10; difficulty of breathing; blood pressure (BP) 170/110 mmHg; pulse 118
beats/min and regular; respiration 32/min; temperature 99.8 0F; pulse oximetry 90% on
room air; patient is diaphoretic, pale, and clammy; cardiac monitor shows sinus
tachycardia with occasional premature ventricular contractions; ECG, chest X-ray and
cardiac enzymes done; oxygen via nasal cannula at 3L/min. Intravenous nitroglycerin
started, and chest pain decreased to 8/10 within ½ hour after starting nitroglycerin; BP
160/100mmHg; pulse 110 beats/min; respirations 28 breaths/min; pulse oximetry 93% on
3L of oxygen. Old records show history of hypertension (HPN). From the data given,
identify:
5. Primary Data Source: Rose Vee, 78-years-old
6. Secondary Data Source: patient’s old record that shows history of hypertension (HPN)
7. Subjective Data:

 “My chest is killing me; it feels like a heavy chest pressure.”

 Pain severity 10/10
 After the intravenous nitroglycerin, the chest pain scale is 8/10 (decreased)

8. Objective Data:

 difficulty of breathing
 blood pressure (BP) 170/110 mmHg
 pulse 118 beats/min and regular
 respiration 32/min
 temperature 99.8 0F
 pulse oximetry 90% on room air
 patient is diaphoretic, pale, and clammy
After ½ hour of IV nitroglycerin
 BP 160/100mmHg
 pulse 110 beats/min
 respirations 28 breaths/min
 pulse oximetry 93% on 3L of oxygen

Identify the following data as subjective or objective.

1.       Nausea subjective
2.       Cyanosis objective
3.       Jaundice objective
4.       Edema objective
5.       Numbness subjective
6.       Diaphoresis objective
7.       Pallor objective
8.       Ptosis objective
9.       Dizziness subjective
10.   Stridor objective
11.   Palpitations subjective
12.   Irregular pulse objective
13.   Shortness of breath subjective
14.   Chest pain subjective
15.   Blurring of vision subjective