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ASSESSMENT
A. General Data
• Name: Ms. X
• Sex: Female
• Address: Bacoor Cavite
• Civil Status: Married
• Age: 45
• No. of Days in this Hospital: ER
• Date of Admission: Aug 9, 2010
B. Chief Complaints
• The client experience chest pain which she described as
radiating from her sternum area towards her xyphoid process
lasting approximately for about 10-15 minutes which
provoked her to go to the hospital.
F. Physical Assessment
Date: August 9, 2010 Clinical Area: St. Dominic Medical Center
Initial vital signs:
T = 36˚C
CR = 120bpm
RR = 20cpm
BP = 130/90 mmHg
• General Appearance
The patient is conscious, coherent and is not in distress.
She looks according to age and is calm and engaging. One can
see that she is well nourished and practices good hygiene.
A. Drug Study
III.Concept Map
1.Decreased
Cardiovascular
Cardiac 4.Acute Pain
Disease
Output
2.Ineffective 3.Impaired
Tissue Gas Exchange
Perfusion