20 year old female arrives for routine checkup. On initial assessment patient appears short of breath
with a minor cough. Denies history of cardiac or respiratory disease. Denies symptoms of syncope,
Assessing Pain: subjective data
PQRST: System to follow when patients C.C is pain
Precipitating/Palliative/Provocative: What caused or started it? Make it better or worse?
Quality/Quantity: What does it feel like?
Patient is a 20 year old female, visiting for her annual check-up. Patient has been having annual
check-ups to monitor for symptoms of macular degeneration, claims her grandmother has
Assessing Respiratory System
o Upper respiratory tract: oronasopharynx, pharynx, larynx, upper part
o Lower respiratory tract: lower trachea, mainstem bronchi, segmental
bronchi, subsegmental bronchioles, terminal
21 year-old male, college pre-med student. Claims that mobility and sensation the same as always for
the past year. No swelling, loss of sensation, pain, or difficulty with movement. Gait
o Heart: Cone shaped muscle with 4 chambers.
o Atria: pumps blood to the ventricles
o Ventricles: right pumps blood to pulmonary circulation; left pumps
blood to systemic circulation.
o Valves: AV valves (tricuspid
Department of Nursing
351 West Univ. Blvd.
Cedar City UT 84720
Introduction to Health
Diagnosis and treatment of human responses
to actual or potential health problems.
Systematic problem-solving method using 5
2. Nursing Diagnosis