Post on 24-Oct-2014
CENTRAL LUZON DOCTORS’ HOSPITALEDUCATIONAL INSTITUTION
San Pablo, Tarlac City
CASE STUDY FORMAT
I. IntroductionII. Objectives
Nurse centeredIII. Nursing Process
A. Data Basea. Nursing health history A
1. Demographic data2. Chief complaint3. History of present illness4. Past medical history5. Family history6. Social and personal history7. Review of system
b. Nursing health history B1. General Description Of Client2. Health Perception-Health Management Pattern3. Nutritional-Metabolic Pattern4. Elimination Pattern 5. Activity-Exercise Pattern6. Sleep-Rest Pattern7. Cognitive-Perceptual Pattern8. Self-Perception – Self-Concept Pattern9. Role-Relationship Pattern10.Sexuality-Reproductive Pattern11.Coping-Stress Tolerance Pattern12.Value-Belief Pattern
c. Physical examinationd. Laboratory Findingse. Review of anatomy and physiologyf. Pathophysiology (highlight patient manifestation)
B. NCPC. Drug StudyD. Medical and Nursing ManagementE. METHOD
IV. Evaluationa. Narrative evaluation of the objectivesb. Patient condition upon discharge
V. RecommendationVI. References/Bibliography
CENTRAL LUZON DOCTORS’ HOSPITALEDUCATIONAL INSTITUTION
San Pablo, tarlac city
CASE STUDY FORMATI. Introduction
a. Introduction about patient/background
Age
Gender
Address
b. Significance/relevance to the concept
c. Background knowledge
Definition
Causative agent
Clinical manifestation
Mode of transmission
d. Current/target population
e. Risk factors/contributing factors
f. Prognosis and complications
II. Nurse centered
a. Objectives
NURSING HEALTH HISTORY A
Demographic data
Patient:Date: Ward: Bed:Age: Sex: C/S: Religion:Examiner:Informant:
I. Chief complaint
II. History of present illness
III. Past medical history (include dates and complications, if any)A. Pediatric and Adult Illness
Mumps Pertussis HPNMeasles Rheumatic Heart DiseaseChicken Pox Pneumonia HepatitisRubella Tuberculosis Others
B. Immunizations/Tests
BCG HEP B For PneumoniaDPT Measles OthersOPV For Flu
C. Hospitalizations
D. Injuries
E. Transfusions
F. Obstetrics/gynecologic History
G. Medications
H. Allergies
IV. Family history
AGE List:Parents, Spouse, Children
Health Status or Cause of
Death
Diseases Present in the FamilyL D
L = Living TB = Tuberculosis HPN = Hypertension OB = ObesityD = Deceased DM = Diabetes Mellitus CA = Cancer J = Jaundice
HD = Heart Disease MI = Mental Illness KD = Kidney Disease O = Others
V. Social And Personal History
Birthplace: Birthday:Education: Ethnic Background:
Age and Sexes of Children (if any):
Client’s position in the family:
ResidenceHome Environment:
OccupationNature of present occupation: (stresses, hazards, etc.)
Financial Support System:
Habits (tobacco/alcohol use, others):
Diet (meal distribution, others)
Physical Activity/Exercise, if any:
Brief Description of Average Day:
VI. Review of system
General Description:Weight Loss: __________ Fatigue: ____________ Anorexia: ____________
Night Sweats: ____________ Weakness: __________
Skin:Itch: _________________________ Bruising: ________________________Rash: ________________________ Bleeding: ________________________Lesions: ______________________ Color Change: ____________________
Eyes:Pain Itch Vision LossDiplopia Blurring Excessive TearingGlasses/Contact Lenses
Ears:Earaches Discharge Tinnitus Hearing Loss
Nose: Obstruction Epistaxis Discharges
Throat and Mouth:Sore Throats Bleeding Gums Tooth Aches Decay
Neck:Swelling Dysphagia Hoarseness
Chest:Cough Sputum: (Amount & Character) HemoptysisWheeze Pain on Respiration Dyspnea: Rest/ExertionBreast: Lumps Pain Bleeding Discharge
CVS:Chest pain Palpitation Dyspnea on exertion EdemaPND Orthopnea Others: _________________________
GIT:Food tolerance Heartburn Nausea JaundiceVomiting Pain Bloating Excessive GasConstipation Change in BM Melena
GU:Dysuria Nocturia Retention Polyuria DribblingHematuria Flank painMale: Penile Discharge Lesion Testicular pains others:Female: Menarche: (age) LMP: (date) Cycle: _____ others:
Extremities:Joint pains varicose veins ClaudicationEdema Stiffness Deformities
Neuro:Headaches Dizziness Memory Loss FaintingNumbnessTingling Paralysis: ____________ Paresis: _________Seizures Others: ______________________________
Mental Health Status:Anxiety Depression InsomniaSexual Problems Fears
NURSING HEALTH HISTORY B
a. General Description Of Client
b. Health Perception-Health Management Pattern
c. Nutritional-Metabolic Pattern
d. Elimination Pattern
e. Activity-Exercise Pattern
f. Sleep-Rest Pattern
g. Cognitive-Perceptual Pattern
h. Self-Perception – Self-Concept Pattern
i. Role-Relationship Pattern
j. Sexuality-Reproductive Pattern
k. Coping-Stress Tolerance Pattern
l. Value-Belief Pattern
PHYSICAL EXAMINATION
GENERAL SURVEY:
Height: ______ Weight: ______ Body Makeup: ______ Communication Pattern: ______
Skin: Color: __________ Turgor: ___________ Bruises: __________
State of Hydration: _____________
Eyes: Sclera: _____________________ Pupils: ______________________
Respiratory: Easy Breathing in Distress No Distress
VITAL SIGNS:
HR ___________ / min Temperature: ____________
BP Supine R/L arm ___________ mmHg Capillary Refill: ____________
Sitting R/L arm ___________ mmHg RR: _____________________
Standing R/L arm ___________ mmHg
Others: ______________________________
BODY POSITION/ALIGNMENT:
Supine: _______ Fowlers: ________Semi-Fowlers: _______ others: _________________
Alignment: Appropriate Inappropriate
MENTAL ACUITY:
Oriented coherent appropriately responsive others: ___________
Disoriented incoherent inappropriately responsive
SENSORY/MOTOR RESTRICTIONS:
Amputation deformity paresis paralysis fracture
Gait hearing disorder speech others: ______________________
EMOTIONAL STATUS:
Euphoric Depressed Apprehensive
Angry/Hostile Others: ___________________________
MEDICALLY IMPOSED RESTRICTIONS:
CBR w/out BRP_____ BR w/ BRP_____ OOB – Chair_____ Restricted Ambulation _____
OTHER HEALTH RELATED PATTERNS:
Fatigue Restlessness Weakness Insomnia Coughing
Dyspnea Dizziness Pain Others: ______________________
ENVIRONMENT:
Room Temperature: Adequate Inadequate
Lighting: Adequate Inadequate
SAFETY:
Violations of medical asepsis: ________________________________________________
Violations of safety measures: ________________________________________________
ACTIVITIES OF DAILY LIVING:
Can/Cannot perform
Feeding Brushing teeth Bathing Transferring
Dressing Combing Others: __________________________________
PHYSICAL EXAMINATION FINDINGS
HEAD/SKULL:
EYES/VISION:
EARS/HEARING:
NOSE, MOUTH AND THROAT:
NECK AND LYMPH NODES:
THORAX (CHEST AND LUNGS):Anterior:
Posterior:
HEART AND CARDIOVASCULAR SYSTEM:
ABDOMEN:
NEUROLOGICAL:
MUSCULOSKELETAL:
GENITALIA:
EXTREMETIES:
(Follow IPPA format when documenting Physical Examination findings)
LIST OF IDENTIFIED NURSING PROBLEMS
PRIORITIZATION OF NURSING PROBLEM
1. Oxygenation2. Nutrition3. Elimination4. Activity and Exercise5. Comfort and Safety6. Sexual- Reproductive7. Psychological8. Psychosocial
LABORATORY FINDINGS
Review of anatomy and physiology
Pathophysiology (highlight patient manifestation)
NCP
ASSESSMENT INTERVENTIONEVALUATION
CUES NURSINGDIAGNOSIS
SCIENTIFICEXPLANATION
PROBLEM STATEMENT
(GOAL)
NURSINGINTERVENTION RATIONALE
Drug Study
DRUG NAME/
GENERIC
CLASSI-FICATION
DOSAGE/STOCKDOSE
ACTION INDICATION CONTRAINDICATION
SIDEEFFECTS
ARVERSEREACTION
NURSING RESPONSIBILITIES
Medical Management (
Nursing Management
Discharge Planning
METHOD (Example)
M (Medications):Lasix (Furosemide). Decreases swelling and blood pressure by increasing the amount of urine. Expect increased frequency and volume of urine. Report irregular heartbeat, changes in muscle strength, tremor, and muscle cramps, change in mental status, fullness, ringing/roaring in ears. Eat foods high in potassium such as whole grains (cereals), legumes, meat, bananas, apricots, orange juice, potatoes, and raisins. Avoid sun/sunlamps. Take with breakfast to avoid GI upset.Digoxin (Lanoxin). Used to treat CHF. Taking too much can result in GI disturbances, changes in mental status and vision. Report the following signs/ symptoms to your doctor: Nausea, vomiting, lack of appetite, fatigue, headache, depression, weakness, drowsiness, confusion, nightmares, facial pain, personality changes, sensitivity to light, light flashes, halos around bright objects, yellow or green color perception. Take pulse rate for one minute before dose and call doctor if pulse is below 60 before taking medication. Don’t increase or skip doses. Don’t take over the counter medications without talking to MD. Report for follow-up visits with your doctor to monitor lab values.
E (Exercise/Environment):Your eldest daughter will provide help with activities of daily living in the home. She will transport you to followup appointments. It is important to take steps to prevent falls: use of a 3-point cane for stability with ambulation; removing objects like throw rugs, cords that may cause fall; pausing before standing and again before walking to prevent drop in blood pressure. The “life line” allow you to access 911 for emergency help. You may resume activities as tolerated and you have a follow-up appointment with the doctor in 1 week.
T (Treatments):Apply A & D ointment to reddened coccyx and heels three times a day. Keep pressure off of these areas by keeping off of back and elevating heels off of bed. Keep skin clean and dry. Report any changes in skin condition to doctor. (i.e. open areas, drainage, elevated temp.)
H (Health knowledge of disease):Lasix can cause a loss of potassium. It is important to eat foods high in potassium and to have regular blood levels drawn to make sure potassium level stays normal. Monitoring the pulse rate before taking digoxin is important because this medicine can cause the pulse to drop. Call the doctor if pulse rate is below 60 beats per minute. New signs and symptoms should be reported to the physician, because they may indicate electrolyte imbalance &/or digoxin toxicity. Sodium causes water retention so it is important to limit sodium intake by eating a no added salt diet. Be careful to check labels for hidden salt content.
O (Outpatient/inpatient referrals): (include resources such as websites and organizations): American Heart Association www.americanheart.org Visiting Nurses’ Association for F/U skin assessment. Referral made to outpatient dietician for diet planning. Meals on Wheels.
D: (Diet):Do not add salt to your diet. Eat foods high in potassium such as bananas. We will arrange for you to meet with the dietician.
Evaluationa. Narrative evaluation of the objectivesb. Patient status after discharge
Recommendation
References/Bibliography