Complete Set of Edited Case Studies Jan_28_2011

CASE 1- CLINICAL CASE STUDY

CHAPTER 1 ASSESSMENT

A. Nursing Health History

Biographical Information:

Heidi, 5 years old female was born on December 5, 2001 at Imus, Cavite. Presently residing with her parents at Zobel Roxas, Malate, Manila. She is currently enrolled in a prep school somewhere in Malate. She is a Roman Catholic. These data were gathered and confirmed on July 12, 2006 at the Ospital ng Maynila.

Chief Complaint

"Ilang araw nang mataas ang lagnat nya" , as verbalized by the client's mother.

History of Present Illness

Three days prior to admission, the client experienced high grade fever with a temperature of 40C, sudden loss off appetite and body weakness. The next day (1 day prior to admission), her mother brought her to the health center. Health care provider did a torniquet test and the result was positive (+). The health care provider advised the clients mother to bring her child to the nearest hospital for more thorough work up, and, as advised, the client was brought to Ospital ng Maynila. CBC (Complete Blood Count) was done. CBC shows that her platelet count is significantly decreased. Symptoms persist and rashes (petechiae) started to develop. With the results, the client was admitted at the pediatrics ward.

Past Medical History

a. Gynecologic History

Client's mother experienced menarche when she was 12 years old; consumed 3-4 pads a day, moderately soaked, without dysmenorrhea. Subsequent menses have been regular; consuming 3-4 pads a day moderately soaked, without dysmenorrhea. OB Score Gravida 2 Parity 2 (2-0-0-2) TPAL.

b. Pre- natal history

Client is the eldest of 2 siblings. The mother never failed to visit the health center for check up during the entire period of pregnancy. The clients mother had Urinary Tract Infection during her fifth month of pregnancy, but, has been treated accordingly by an OB doctor. She was able to receive TT1 and TT2.

c. Intranatal History

Client was born at 40 weeks of gestation, cephalic presentation, via Normal Spontaneous Vaginal Delivery, by a midwife at their house, without difficulty or complications.

d. Post Natal History

The client received complete doses of BCG, DPT, OPV, Measles and Hepa B immunizations. She was breastfed up to 6 months old, solid foods were also introduced. Clusivol syrup was her daily vitamins she has not experienced mumps and other childhood illness.Client experienced no major injuries, accidents. The present admission is the client's first hospitalization. Client has no known allergies to food, drugs and other substances.

Family Health History

No heredo-familial diseases.

Social History

Client is the eldest of 2 siblings. At 6 months, she was already able to crawl and speak the words like "mama" and "papa". She is leaving with her parents at Zobel Roxas, Malate, Manila. The house is small but made of both wood and concrete cement, located beside a small creek. However according to the mother, the space is just adequate for the 4 of them. The breadwinner is the client's father, who is a cook at a canteen near UST, earning 6000 pHp a month. The client's mother is a house wife, taking care of the client. According to them, the income is just enough for their basic necessities. The client enjoys playing outside their house with her playmates.

Developmental Theories Psychosocial theory

According to Erik Erikson's psychosocial theory, at this age, the social task of the child is to develop initiative versus guilt. Initiative adds to autonomy the quality of undertaking, planning and attacking a task for the sake of being active and on the move. The child is learning to master the world around them, learning basic skills and principles of physics. Things fall down, not up. Round things roll. They learn how to zip and tie, count and speak with ease. At this stage, the child wants to begin and complete their own actions for a purpose.Analysis:

In relation to our client, the mother stated that her daughter was trying to do things on her own. One example of it was to ride the bicycle alone or cross the street alone, according to the mother.

Psychosexual Theory

In psychosexual theory, Freud describes school age as the phallic stage.. In this stage, the primary focus of the libido is on the genitals. Children also discover the differences between males and females.

Analysis:

In relation to our patient, her mother stated that their child wants to always be with her father anywhere he goes.

Cognitive theory

According to Piaget's cognitive theory, at the age of between 4 and 7 years, Children tend to become very curious and ask many questions; begin the use of primitive reasoning.[10]There is an emergence in the interest of reasoning and wanting to know why things are the way they are.[10]Piaget called it the intuitive substage because children realize they have a vast amount of knowledge but they are unaware of how they know it.Analysis:

According to the clients mother, Heidi tends to ask many questions and feels as if she always know the answers.Moral Development Theory

Kohlberg defines School age in pre-conventional level stage 2, in which child develops individualism. Child carries out action to satisfy own needs rather than society. Toddler may not obey request from other people because they do not view their authority as being the same as their parents' authority.

Analysis:

Mother states that the patient likes to buy candies on her own so they just give money.

Spiritual Development Theory

James Fowier view the school age as an intuitive-projective faith in which children at this age has no real understanding of spiritual concept. They view faith as magical, inventive, and derived primarily from significant others or parents.

Analysis:

The mother told us that they used to bring their son to the church, but still the child wasn't able to know the reason why they go to church. The only thing that the child knows is to behave inside the church.

B. Physical Examination

A. General AppearanceThe client has a small frame body built. She has an upright posture and a smooth rhythmic gait. The client is appropriately dressed and well groomed. She has no body odor. She weighs 24kg and has no obvious physical deformity. Generalized rashes were observed, dominantly on the clients lower extremities. Mosquito bites were also seen. She is weak looking. Vital signs are as follows: Temp 38.5 C, HR= 100bpm ; RR= 22 cpm; BP 100/70 mmHg

B. Mental StatusThe patient is conscious, coherent but irritable. With mood affect and oriented to place, time and person. Responds appropriately and slowly in an understandable manner. Uses simple words to communicate.C. SkinThe skin is of normal racial tone (brown). Warm to touch, dry and smooth. Elastic and mobile skin turgor. With generalized rashes and obvious mosquito bite marks.

D. Hair

With black hair at shoulder level, evenly distributed, thin silky and resilient. No infestation and dandruff seen.

E. Nails

Nail plate shape is convex. Approximately 160 in curvature. Nails are cut short; nail bed color is pink, capillary refill within 3 seconds upon administration of blanche test. The texture is smooth.

F. Head and Face

With rounds, normocephalic and symmetrical with frontal, parietal, and occipital prominence . Hair is evenly distributed. Facial features are symmetrical and so is the facial movement. The clients skin is flushed.

G. Eyes

Thin eyebrows and eyelashes are evenly distributed and symmetrical. Skin surrounding the eyes is intact without any discoloration, lids close symmetrically with 15-20 blinks/min. The sclera is white, palpebral conjunctiva is shiny, smooth and pinkish while bulbar conjunctiva is clear. No edema or tenderness on the lacrimal glands. The pupils are equally round (2-3mm) in diameter and reactive to light and accommodation. Both eyes are coordinated; move in unison w/ parallel alignment (8 ocular movements. She is able to recognize objects that are 20 feet away from her.H. Ears

Auricle is in normal racial tone (brown in color), symmetric and elastic. Symmetrical and aligned with outer canthus of the eye, about 10 degrees from vertical view. Upon palpation, auricles are mobile, firm and non tender. Pinna recoils when folded. Using an otoscope, the tympanic membrane has semi-transparent and pearly gray membrane.

I. Nose

With symmetrical and straight nares. Without discharge, flaring and uniform in color. Air moves freely through the nares as the client breathe. Nasal mucosa is pink. Nasal septum is intact and at the midline. Nasal sinuses are non tender. No epistaxis (nose bleeding) noted.J. Mouth and Oropharynx

Lower and upper lips has uniform pink color. Soft, dry and smooth in texture and able to purse lips. Inner lips and buccal mucosa is pink, moist, smooth, soft and elastic. Have 12 incomplete milk teeth. The tongue is at the midline. Pink in color with smooth lateral margins, no lesions and moves freely w/o tenderness. Salivary glands intact, pinkish in color without any lesions. With light pink colored hard and soft palate positioned in the midline with smooth posterior wall. Tonsils and uvula are not inflamed. Gum bleeding noted.

K. Neck

Neck muscles are equal in size. Head is in the center. Head movement has coordinated movement, smooth and without any discomfort. There is equal muscle strength 5/5 and has palpable lymph nodes (pre auricular). Trachea is in midline. Thyroid gland is not palpable but ascends during swallowing.

L. Breast and Axilla

Skin is smooth, breast are flat. No masses palpated. Nipples are pink and symmetrical.

M. Chest and Lungs

Shape is AP to transverse diameter has a ratio 2:1, chest expansion is symmetrical. Skin is intact with uniform color and temperature. No tenderness and masses upon palpation. With bilateral symmetry of vocal tactile fremitus. Resonance is heard over the lung thorax. Diaphragmatic excursion is 3 mm. Costal angles is 80 and the ribs is 45. Upon auscultation, Bronchial (trachea) sounds bronchovesicular (main bronchi) sound.

N. Heart

There are no masses and lesions in the skin. Here is palpable pulsation at the left ICS (5th) MCL; in an area of 1-2 cm in diameter. Carotid pulse is bounding regularly synchronous w/ S1. Apical and radial pulse has equal rate and rhythm.

O. Abdomen

The skin is uniform and the skin is unblemished. The shape is protuberant. There is symmetric movement caused by respiration. Bowel sound is 3/min and without arterial bruit and friction rub. No tenderness. The bladder is not distended. Liver and spleen are not palpated. P. Musculoskeletal system

The muscles have equal size and both sides of the body. There are no contractures or fasciculation present. Muscles are firm, smooth with coordinated movement. Bones does not have any deformity, tenderness or Swelling.

Q. Genital

No public hair present.

CASE 2 COMMUNITY CASE STUDY


PERSONAL DATA

Viktoria is a 4-year-old girl who resides at # 129, Palangue 3, Naic, Cavite. She was born last January 1, 2008. She is a Filipino, a Roman Catholic and she is not yet studying. Their source of Health Care is the Health Center near their house. The date of interview was January 26, 2011 at the client's house.CHIEF COMPLAINT

"May ubo po ako," as verbalized by the client.

PRESENT HEALTH STATUS

Three days prior to the day of interview, the client had cough and cold. Her mother said that her daughter had difficulty in breathing. Sometimes the coughs continuously occur within three minutes. Her mother also said that maybe she got cough and cold because of her playmate that has this illness. Her mother claimed that she gave the client Paracetamol as her medication. She also claimed that her daughter takes Ceelin everyday as her Vitamins.FAMILY HISTORY

There is no heredofamilial disease noted.

SOCIAL HISTORY

The client is not going to school yet. She enjoys watching cartoons and playing with their neighbors.

PAST HISTORY

Prenatal

The client's mother reported that she took ferrous sulfate when she was pregnant. There was no exercise done. The mother didn't drink any milk. She does not smoke nor drink alcoholic beverages. She said that the pregnancy was planned. She gained weight during the pregnancy but she forgot how much she gained during the pregnancy.

Natal

She gave birth to the client around 8:30 in the morning last January 1,2009. Client was delivered through NSVD and a cephalic presentation. Her grandmother was the one responsible for the delivery of the baby at their parent's house of the client.

Postnatal

The client's birth weight was 3.5 kilograms. There were no complications after the delivery and there were no illnesses present. She had a weak cry. She was breastfed. Her mother said that the client always cries whenever she is hungry and wants to sleep. Sometimes the client's mother sings to help the client sleep. The client was healthy generally according to her mother.

Nutrition

The client loves to eat chicken whether it is fried or cooked in different meal. She eats four times a day, which includes breakfast, lunch, merienda and dinner. Sometimes she only eats rice without any viands. She loves to eat biscuits or any snacks whenever she doesn't do anything or anytime of the day. The client loves to drink milk from the bottle while watching cartoons,however, according to the mother, the client cant tolerate sucking on the bottle at present because shes having a hard time breathing due to the clogged nostrils.

REVIEW OF SYSTEMGrowth and Developmental Theories (1-3 years old)

Psychosocial Theory (Erik Erickson),

According to Erik Erikson's psychosocial theory, at this age, the social task of the child is to develop autonomy versus shame and doubt. This is important to the child's development in ability to balance between love and have, cooperation and willfulness, freedom of expression or suppression. If the child develops autonomy, they are practicing more on self-government or independence, like they want to do everything on their own. On the other side, when they develop shame and doubt;

Analysis

In relation to our client, the mother stated that her daughter was trying to do things on her own. One 'example of it is when the child is trying to stand on her own; her mother just let her do it, for her to become independent on what she is doing.

Psychosexual Theory (Sigmund Freud)

In psychosexual theory, Freud describes toddler as the anal stage. In this stage, children have widened interest and mainly focused on their anal region. The children find pleasure in controlling and expelling feces, and provide a sense of control. The process of toilet training is regarded as the solution of this conflict.

Analysis

In relation to our client, her mother stated that they were trying to toilet train their daughter. However client in some instances client defecates anywhere on her cloth diaper (lampin).Cognitive Theory (Piaget)

According to Piaget's cognitive theory, at the age of 12-18months, the children is under the stage of tertiary circular reaction in which instead of reproducing accidental events, the child chooses to vary them thereby finding new solution to old problem. In relation to our client, the mother verbalized that the client is having fun playing toys that has a different colors and shape. She tries to put the right shape that was the same as the hole in the box. This kind of toy helps the child develop his problem.

Analysis

According to the mother, the client likes to play rubic's cube toy and has different shapes and colors of toys.

Moral Developmental Theory (Kohlberg)

Kohlberg defines toddlerhood in pre-conventional level Stage 2, in which the child develops individualism. Child carries out action to satisfy own needs rather than society. Toddler may not obey request from other people because they do not view their authority as being the same as their parents' authority.Analysis

Mother states that the client likes to buy candies on her own so they just give her money.

Spiritual developmental Theory (Fowler)

James Fowler view the toddlerhood as intuitive projective faith, in which children at this age has no real understanding of spiritual concept. They view faith as magical, inventive, and derived primarily from significant others or parents.

Analysis

The mother told us that they used to bring their daughter to the church, but still the child wasn't able to know the reason why they go to church. The only thing that the child knows is to behave inside the church.

B. PHYSICAL ASSESSMENT

A. General AppearanceThe client has a small frame body built. She has an upright posture and a smooth rhythmic gait. The client is appropriately dressed and is not well groomed. Pungent odor was noted. She weighs 15 kg and has no obvious physical deformity. The client is wearing a sando and a soaked cloth diaper (lampin) Rashes on the perianal area was seen and itchiness was noted. Vital signs are as follows: Temp 38.2 C, HR= 104bpm ; RR= 28cpm; BP 100/70 mmHg

B. Mental StatusThe patient is conscious, coherent and cooperative With mood affect and oriented to place, time and person. Responds appropriately and slowly in an understandable manner. Uses simple words to communicate.C. SkinThe skin is of normal racial tone (brown). Warm to touch, dry and smooth. Elastic and mobile skin turgor. With rashes on the perianal area.

D. Hair

With shoulder length black hair, evenly distributed, thin silky and resilient. No infestation and dandruff seen.

E. Nails

Nail plate shape is convex. Approximately 160 in curvature. Nails are cut short; nail bed color is pink, capillary refill within 3 seconds upon administration of blanche test. The texture is smooth.F. Head and Face

With rounds, normocephalic and symmetrical with frontal, parietal, and occipital prominence . Hair is evenly distributed. Facial features are symmetrical and so is the facial movement. G. Eyes

Thin eyebrows and eyelashes are evenly distributed and symmetrical. Skin surrounding the eyes are intact without any discoloration, lids close symmetrically with 15-20 blinks/min. The sclera is white, palpebral conjunctiva is shiny, smooth and pinkish while bulbar conjunctiva is clear. No edema or tenderness on the lacrimal glands. The pupils are equally round (2-3mm) in diameter and reactive to light and accommodation. Both eyes are coordinated; move in unison w/ parallel alignment (8 ocular movements. She is able to recognize objects that are 20 feet away from her.

H. Ears

Auricle is in normal racial tone (brown in color), symmetrical and elastic. Symmetrical and aligned with outer canthus of the eye, about 10 degrees from vertical view. Upon palpation, auricles are mobile, firm and non-tender. Pinna recoils when folded. Using an otoscope, the Tympanic membrane has semi-transparent and pearly gray membrane. There is presence of cerumen in the external canal and the client can respond to whispered voice.

I. Nose

With symmetrical and straight nares. With greenish nasal discharge. Nasal flaring was observed. There is difficulty in the clients breathing pattern due to the nasal discharges. Nasal mucosa is pink. Nasal septum is intact and at midline. Nasal sinuses are non-tender. Client has difficulty recognizing the smell of coffee.

J. Mouth and Oropharynx

Client coughs from time to time. Outer lips has uniform pink color. Soft, dry and smooth in texture and able to purse lips. Inner lips and buccal mucosa is pink, moist, smooth, soft and elastic. Have 12 incomplete milk teeth. The tongue is at the center. Pink in color with smooth lateral margins, no lesions and move freely without tenderness. Salivary glands are intact, pink in color without any lesions. With light pink colored hard and soft palate positioned in the midline with smooth posterior wall. Tonsils and uvula are inflamed.

K. Neck

Neck muscles are equal in size. Head is in midline. Head movement is coordinate, smooth and without any discomfort. There is equal muscle strength with a grade of 5/5 and has palpable lymph nodes in the pre auricular area. Trachea is in the midline. Thyroid gland is not palpable but ascends during swallowing.L. Breast and Axilla

Skin is smooth, breasts are flat. No masses palpated. Nipples are pink in color, dry symmetrical. Brown color axilla.

M. Chest and Lungs

Shape is AP io transverse diameter has a ratio of ratio 2:1, chest expansion is symmetrical. Skin is intact with uniform color and temperature. No tenderness and masses upon palpation. With bilateral symmetry of vocal tactile fremitus. Crackles (halak) were heard and she uses accessory muscle to aid in breathing.N. Heart

There are no masses and lesion in the skin. Heart has palpable pulsation at the left ICS (5th) MCL; in an area of 1-2 cm in diameter. Carotid pulse is bounding regularly synchronous with Sl. Apical and radial pulse has equal rate and rhythm.

O. Abdomen

The skin is uniform and the skin is unblemished. There is symmetric movement caused by respiration. Bowel sound is 3/min and without arterial bruit and friction rub. No tenderness. Liver, bladder and spleen are not palpatedP. Musculoskeletal System

The muscles have equal size in both sides of the body. There is no contractures or fasciculation present. Muscles are firm, smooth with coordinated movement. Bones does not have any deformity, tenderness or swelling.

Q. Genital

No pubic hair present. Rashes on the labia majora extending to the buttocks were noted.C. DIAGNOSTIC PROCEDURE

No diagnostic procedure done to the clientCASE 3 - CLINICAL CASE STUDY

A. NURSING HEALTH HISTORY

Personal Data

Name: Jeremy

Age: 15 years old

Sex: Male

Race: Fiipino

Religion: Iglesia ni Cristo Birth Date: March 27, 1994 Birth Place: Tarlac

Present Address: Unit E-3 Bldg 10, Ilang- Ilang St. Sta. Mesa, Manila

Provincial Address: Anonas St. Panique, Tarlac

Usual Source of Health Services: Capitol Medical Center Date of Interview March 30, 2008 at 7: 00 amChief Complaint

"Nahihiya na ako kasi hindi pa ako tuli, takot kasi ako maoperahan", as verbalized by the client.


1 day prior to surgery, clients parents decided to bring their child in Capitol Medical Center for circumcision Jeremy was brought then the next day for surgery at 10 am on March 31, 2008, .

Past Medical Illness

Client claims that he has no history of hospitalization but had a chicken pox when he was 9 years old that was treated at home. His mother reported that Jeremy had the following immunization: BCG, DPT3, HepaB3, OPV3, and MMR before he reached 10 years of age.Family History

Client's parents denied for any hereditary disease. (Genogram not applicable)

Social History

Client Jeremy is the only child in the family, living with her father and mother in Sta. Mesa, Manila. Jeremy verbalized `Hindi na magkakaanak si Mama pero ok lang kasi masaya na kaming tatlo sa bahay_' They have an open communication with each other and with harmonious family living pattern. They have an adequate space at 3rd floor of a condo unit type. Both his parents are working as government employees in their City. Health Centers/ Hospitals are accessible such as Ospital ng Sampaloc, Capitol Medical Center and De Ocampo Medical Hospital.

Nutritional DataBreakfast Fried Rice

Boiled Egg

Bacon

Milk1 cup

1 piece

3 strips

1 glassHigh in Carbohydrates with

High in Protein and Fats

High in calcium

Fats

Snacks Cake1 sliceHigh in Calories

LunchSteamed Rice

Pork Sinigang1 cup

1 servingCarbohydrates

High in Protein

DinnerSteamed Rice

Chopseuy1 cup

1 servingHigh in Carbohydrates

High in Vitamins and Minerals

REVIEW OF SYSTEMSGrowth and Development

Psychosexual Theory by SIGMUND FREUD

Client is a 15 years old male. He is on the Genital stage. The ego in the genital stage is well-developed. It uses secondary, process thinking, which allows for symbolic gratification. This symbolic gratification may include the formation of love relationships, development of families, or acceptance of responsibilities associated with adulthood Analysis:

In relation to the patient, he is now adjusting from adolescent ot adulthood changes. His parents are supportive but keeping their childs privacy. Client's mother verbalized Ayaw pasabi sa girlfriend nya na nandito kami ngayon, nahihiya".

Psychosocial Theory by ERIC ERICKSON

Client is in Identity vs role confusion Stage. The adolescent is newly concerned with how they appear to others. As they make the transition from childhood to adulthood, adolescents ponder the roles they will play in the adult world. Initially, they are apt to experience some role confusion- mixed ideas and feelings about the specific ways in which they will fit into society- and may experiment with a variety of behaviors and activities.

Analysis:

In relation to the patient, Jeremy is always getting into a fight because his classmates get to tease him the uncut kid. He tend to feel that he doesnt belong because most of his male classmates have already been circumcised.Cognitive Theory by JEAN PIAGET

Jeremy is in the Formal Operation Phase. During concrete operation They can solve concrete problems. Formal operation Phase describes that child uses rational thinking, reasoning is deductive and futuristic. (Kozier and Erb ed pg 357, 2008) Analysis:

Client demonstrated logical reasoning when assessed about the concepts such as time, money and application of addition and subtraction. This implies that the client acquires knowledge from his formal education and applies it to the real situation of life.

Moral Development by LAWRENCE KOHLBERG

Most of the adolescent is spent in the Conventional Phase. Behavior is based on familial and peer group beliefs, and conformity the norm is common. Following school regulations, respecting teachers, and viewing justice as a means of fair play are all important

Analysis:

He has good relationship with his fiends 'Sa bahay minsan kumakain mga classmates ko lalo na pag gumagawa kami ng project.

Spiritual Development by JAMES FOWLER

Jeremy is in the Synthetic conventional stage wherein faith is characterized by conformity. The process by which an individual's attitudes, beliefs, and behaviors are influenced by what is conceived to be what other people might perceive. This influence occurs in both small groups and society as a whole, and it may be the result of subtleunconscious influences, or direct and overtsocial pressure.Analysis:

Client is a member of Iglesia ni Cristo who attends worship service every Thursday without fail. He is also an active officer in their church as a member of their choir. He believes that words of God written in the bible must be obeyed in order to be saved from the Day of Judgment.

B. PHYSICAL ASSSESSMENT

(03/30/08 P.A. done before and after surgery)

A. GENERAL APPEARANCE

Client has a small body built with an upright posture. He is appropriately dressed. Client has neither body odor nor bad breath odor. No obvious physical deformity. His height is 4'11' and weighs 90 lbs obtained on the day of surgery. Vital signs: T-36.5 C(axilla), RR 24cpm, PR 110 bpm, BP- 1 00/80 mm/Hg

(done after circumcision)

Vital Signs: 37.4 C, RR-22cpm, PR 77bpm, BP- 100/80mmHgLooks weak with discomfortWith surgical bandage on the perineal area, clean and dry

B. MENTAL STATUS

The client is conscious and coherent, with good affect, oriented to date, time, person, and place. He looks nervous due to impending surgery but answers questions appropriately. Uses simple words.(done after circumcision)

> conscious, coherent and Irritable

C. SKIN

The client's skin is of normal racial tone, which is brown, has warm temperature except palm, which is cold to touch. Client's skin is smooth and has good skin turgor. No lesions noted and hair is fine that is evenly distributed.


> clients skin is warm to touch, has a smooth texture and skin turgor is elastic and mobile

D. HAIR

With black hair, straight barber's cut, evenly distributed. No infection or infestation and dandruff seen. Pubertal hair starts to grow.


> pubertal hair shaved off

E. NAILS

The clients nail plate shape is concave 1600. it has a smooth texture, pinkish nail bed. Capillary refill exceeds 30 seconds. No presence of Beaus line.(done after circumcision)>capillary refills within 3 seconds upon doing the blanche test

F. HEAD AND FACE

The client's skull is proportionate to his body size and has a smooth texture. The scalp is non-tender and white. Hair is equally distributed, thin and is free from any infestations. No presence of nodules or masses noted. The face as well as the facial movements is symmetrical. Head has a hard consistency.

(done after circumcision)>Facial grimace observed

G. EYES

The client's eye condition is straight normal and eyebrows are thick. He has equal distribution of eyelashes. The eyelids has no discharge and close symmetrically. He has a bilateral blink response. Eyeballs are symmetric and firm. Bulbar and palpebral conjunctivas are clear. Pupils are equally reactive to light and accommodation. Lacrimal apparatus are moist.

H. EARS

Client's auricle are of normal racial tone, whitish is brown, same with the color of the face, symmetrical in size and position. The alignment of pinna is in line with the outer canthus of the eye. It is elastic and nontender. Pinna recoils when folded. Theres presence of some cerumen, which is light brown in the extemal meatus. Absence of discharge and there no swelling or redness observed.

I. NOSE

The patient's extemal nose is of normal racial tone color, brown, the same as with the face, septum at midline, nares are symmetrical. Pink nasal mucosa, nares both patent and nasal cavity is moist. Sinuses are nontender.J. MOUTH AND OROPHARYNX

The patient's lips are symmetrical and dry. Buccal mucosa is dry. The tongue is at midline, moves freely, rough and pink. Client's permanent tooth has erupted. Gums are pink, tonsils are not inflamed.

K. NECK

The client's neck muscles are equal in size. Preauricular, post auricualar, cervical, and supraclavicular lymph nodes are not palpable. Trachea is at midline of neck with no deviation noted and thyroid gland is not palpable.

L. BREAST AND AXILLA

There no masses palpated. Nipples are light brown in color, dry and symmetrical. The axilla is color brown, dry and presence of hair starts to grow.

M. CHEST AND LUNGS

The client's chest is of normal racial tone, brown color. Lung shape is AP lateral ratio of 1:2. Lung expansion is symmetrical anterior to posterior. Fremitus is found to be symmetrical and decreasing in both sides. Vesicular, bronchial, and bronchovesicular breath sounds are heard. He has a regular breathing pattern. Resonance was heard upon percussion. The costal angle of the client is 45 degrees. Aortic valve sound was heard at the 2"d right intercostals space, pulmonic valve sound was auscultated ant 2"d left intercostals space; mitral valve was heard at the 5'' midclavicular line, tricuspid valve sound was heard at the 4h right intercostals space. Apical pulse has a rhythm that is regular with 80bpm; during the interview client's HR was 110 due to anxiety for the impending surgery- No murmurs were heard.

N. HEART

The client's apical pulse is equal in rate and symmetrical with regular rhythm and strength. HR-80 bpm, however it was only observed to be increased during the interview but it was reassessed after 15 minutes and the result went back to 80 bpm. The apical and radial pulse has equal rate and rhythm.

O. ABDOMEN

The client's abdomen is of normal racial tone color that is brown, flat contour and with symmetrical abdominal movements. it has a hyperactive bowel sounds which is 25 bowel sounds per minute, Bladder is not distended. Liver is not palpable. Upon percussion, tympany was heard. Muscle guarding is nort present(done after circumcision)

> normal bowel sounds heard

P. UPPER EXTREMITIES

The client's motor strength is 5/5. Client can move his extremities freely. She has no physical deformity. Bronchial and radial pulse is present. Lymph nodes are not palpable. No inflammation noted.

Q. LOWER EXTREMITIES

The client's motor strength is 5/5. He needs assistance in moving. Neither lesions nor physical deformities observed. Dorsalis pedis, posterior tibial and inguinal pulses are present. Lymph nodes are not palpable.

R. GENITALIAPubic hair starts to grow. There is no presence of lesions. Penis is not yet circumcised.(done after circumcision)

>Pubic hair shaved off, upon the removal of sterile dressing and elastic bandage, (for assessment purposes), sutures sorrounding the glans penis are present. The glance penis is slightly swollen and bruises on the shaft to the scrotum are starting to develop. Redness on the area was also seen.

S. RECTUM AND ANUS

The client's rectum and anus is patent. Gluteal folds are symmetric. Active anal reflex.

CASE 4 - COMMUNITY CASE STUDY


1. Personal Data

The client is J. C. 15 y/o male client. He is Filipino and was baptized as a member of the Roman Catholic Church. He was born on March 27, 1994 in Batangas. He is the only child of Mr. and Mrs. N.C. He is presently residing with his parents in Sta. Mesa, Manila. The usual source of health services of his family is in Barangay Health Center & Sto. Thomas Medical Hospital The interview was conducted last April 14, 2008 at 7:00 am.

2. Chief Complaint

"Nahiya na ako kasi di pa ako tuli, takot kasi ako maoperahan", as verbalized by the client.

3. History of Present Illness

1 day prior to circumcision, client's parents decided to bring their child in Barangay clinic for a free Operation tuli conducted by medical volunteers. J.C. was brought then the next day for circumcision at 10 am on April 4, 2008.

4. Past Medical Illness

Client claims that he has no history of hospitalization but had a chicken pox when he was 9 y/o that was treated at home. His mother reported that J.C. had the following immunization: BCG1, DPT3, HepaB3, OPV3, and MMR before he reached 10 years of age.

5. Family History

Client's parents denied for any hereditary disease.

6. Social History

Client J. C. is the only child in the family, living with her father and mother in Sta. Mesa, Manila J.C. verbalized "Hindi na magkakaanak si Mama pero ok lang kasi masaya na kaming tatlo sa bahay". They have an open communication with each other and with harmonious family living pattern.

According to J.C.,Their house is small but made of concrete cement and is spacious enough for them. Both his parents are working as government employee in their City. Health center / hospital are accessible such as Barangay Health Clinic in San Roque & Sto. Thomas Medical Hospital. According to J.C. they also believe in the practice of the herbularyos and also believes in superstitions.7. Nutritional Status

The client tolerated food well; he did not experience or exhibit any eating problems.

24-hour food recall as follow:

BreakfastFried rice

Boiled eggs

Bacon

milk1 cup

1 piece

3 strips

1 glassHigh in carbohydrates with fats

High in protein

High in protein & fats

High in calcium

SnacksCake1 sliceHigh in calories

LunchSteamed rice

Pork Sinigang1 cup

1 servingCarbohydrates

High in Protein

DinnerSteamed rice

Chopsuey1 cup

1 servingHigh in carbohydrates

High in vitamins and minerals

Growth and DevelopmentPsychosexual Theory by SIGMUND FREUD

Client is a 15 years old male. He is on the Genital stage. The ego in the genital stage is well-developed. It uses secondary, process thinking, which allows for symbolic gratification. This symbolic gratification may include the formation of love relationships, development of families, or acceptance of responsibilities associated with adulthood Analysis:

In relation to the patient, he is now adjusting from adolescent ot adulthood changes. His parents are supportive but keeping their childs privacy. Client's mother verbalized Ayaw pasabi sa girlfriend nya na nandito kami ngayon, nahihiya".

Psychosocial Theory by ERIK ERICKSON

Client is in Identity vs role confusion Stage. The adolescent is newly concerned with how they appear to others. As they make the transition from childhood to adulthood, adolescents ponder the roles they will play in the adult world. Initially, they are apt to experience some role confusion- mixed ideas and feelings about the specific ways in which they will fit into society- and may experiment with a variety of behaviors and activities.

Analysis:

In relation to the client, J.C. is now on the third year high school and has verbalized that he wants to have a circumcision because he wants to get taller. Cognitive Theory by JEAN PIAGET

J.C. is in the Formal Operation Phase. During concrete operation They can solve concrete problems. Formal operation Phase describes that child uses rational thinking, reasoning is deductive and futuristic. (Kozier and Erb ed pg 357, 2008)Analysis:

Client demonstrated logical reasoning when assessed about the concepts such as time, money, and application of addition and subtraction. This implies that the client acquires knowledge from his formal education and applies it to the real situation of life.

Moral development by LAWRENCE KOHLBERG

Most of the adolescent is spent in the Conventional Phase. Behavior is based on familial and peer group beliefs, and conformity the norm is common. Following school regulations, respecting teachers, and viewing justice as a means of fair play are all important

Analysis:

Client has no records of misbehavior on their class. He has also a good relationship with his friends. "Sa bahay minsan kumakain mga classmates ko lalo na pag gumagawa kami ng project," client reported.Spiritual Development by JAMES FOWLER J.C. is in the Synthetic conventional stage wherein faith is characterized by conformity. The process by which an individual's attitudes, beliefs, and behaviors are influenced by what is conceived to be what other people might perceive. This influence occurs in both small groups and society as a whole, and it may be the result of subtleunconscious influences, or direct and overtsocial pressure.Analysis:

Client is a member of the roman catholic church who attends worship service every Sunday without fail. He is also an active officer in their church as a member of the choir. He believes that words of God written in the bible must be obeyed in order to be saved come the Day of Judgment.

B. PHYSICAL ASSESSMENT

A. GENERAL APPEARANCE

Client has a small body built with an upright posture. He is appropriately dressed. Client has neither body odor nor bad breath odor. No obvious physical deformity. His height is 4'11' and weighs 90 lbs obtained on the day of surgery. Vital signs: T-36.5 C(axilla), RR 24cpm, PR 110 bpm, BP- 1 00/80 mm/Hg


Vital Signs: 37.4 C, RR-22cpm, PR 77bpm, BP- 100/80mmHg

With herbs wrapped in a handkerchief and wrapped on his head

Looks weak with discomfort, still chewing bayabas leaves

With elastic bandage on the perineal area, clean and dry

B. MENTAL STATUS

The client is conscious and coherent, with good affect, oriented to date, time, person, and place. He looks nervous due to impending surgery but answers questions appropriately. Uses simple words.(done after circumcision)

> conscious, coherent and Irritable

C. SKIN

The client's skin is of normal racial tone, which is brown, has warm temperature except palm, which is cold to touch. Client's skin is smooth and has good skin turgor. No lesions noted and hair is fine that is evenly distributed.


> clients skin is warm to touch, has a smooth texture and skin turgor is elastic and mobile

> herbal oil is applied on the clients back, arms and legs by the mother

D. HAIR

With black hair, straight barber's cut, evenly distributed. No infection or infestation and dandruff seen. Pubertal hair starts to grow.


> pubertal hair shaved off

E. NAILS

The clients nail plate shape is concave 1600. it has a smooth texture, pinkish nail bed. Capillary refill exceeds 30 seconds. No presence of Beaus line.(done after circumcision)>capillary refills within 3 seconds upon doing the blanche test

F. HEAD AND FACE

The client's skull is proportionate to his body size and has a smooth texture. The scalp is non-tender and white. Hair is equally distributed, thin and is free from any infestations. No presence of nodules or masses noted. The face as well as the facial movements is symmetrical. Head has a hard consistency.

(done after circumcision)>Facial grimace observed

G. EYES

The client's eye condition is straight normal and eyebrows are thick. He has equal distribution of eyelashes. The eyelids has no discharge and close symmetrically. He has a bilateral blink response. Eyeballs are symmetric and firm. Bulbar and palpebral conjunctivas are clear. Pupils are equally reactive to light and accommodation. Lacrimal apparatus are moist.

H. EARS

Client's auricle are of normal racial tone, whitish is brown, same with the color of the face, symmetrical in size and position. The alignment of pinna is in line with the outer canthus of the eye. It is elastic and nontender. Pinna recoils when folded. Theres presence of some cerumen, which is light brown in the extemal meatus. Absence of discharge and there no swelling or redness observed.

I. NOSE

The patient's extemal nose is of normal racial tone color, brown, the same as with the face, septum at midline, nares are symmetrical. Pink nasal mucosa, nares both patent and nasal cavity is moist. Sinuses are nontender.J. MOUTH AND OROPHARYNX

The patient's lips are symmetrical and dry. Buccal mucosa is dry. The tongue is at midline, moves freely, rough and pink. Client's permanent tooth has erupted. Gums are pink, tonsils are not inflamed.

K. NECK

The client's neck muscles are equal in size. Preauricular, post auricualar, cervical, and supra davicular lymph nodes are not palpable. Trachea is at midline of neck with no deviation noted and thyroid gland is not palpable.

L. BREAST AND AXILLA

There no masses palpated. Nipples are light brown in color, dry and symmetrical. The axilla is color brown, dry and presence of hair starts to grow.

M. CHEST AND LUNGS

The client's chest is of normal racial tone, brown color. Lung shape is AP lateral ratio of 1:2. Lung expansion is symmetrical anterior to posterior. Fremitus is found to be symmetrical and decreasing in both sides. Vesicular, bronchial, and bronchovesicular breath sounds are heard. He has a regular breathing pattern. Resonance was heard upon percussion. The costal angle of the client is 45 degrees. Aortic valve sound was heard at the 2"d right intercostals space, pulmonic valve sound was auscultated ant 2"d left intercostals space; mitral valve was heard at the 5'' midclavicular line, tricuspid valve sound was heard at the 4h right intercostals space. Apical pulse has a rhythm that is regular with 80bpm; during the interview client's HR was 110 due to anxiety for the impending surgery- No murmurs were heard.

N. HEART

The client's apical pulse is equal in rate and symmetrical with regular rhythm and strength. HR-80 bpm, however it was only observed to be increased during the interview but it was reassessed after 15 minutes and the result went back to 80 bpm. The apical and radial pulse has equal rate and rhythm.

O. ABDOMEN

The client's abdomen is of normal racial tone color that is brown, flat contour and with symmetrical abdominal movements. it has a hyperactive bowel sounds which is 25 bowel sounds per minute, Bladder is not distended. Liver is not palpable. Upon percussion, tympany was heard. Muscle guarding is nort present(done after circumcision)

> normal bowel sounds heard

P. UPPER EXTREMITIES

The client's motor strength is 5/5. Client can move his extremities freely. She has no physical deformity. Bronchial and radial pulse is present. Lymph nodes are not palpable. No inflammation noted.

Q. LOWER EXTREMITIES

The client's motor strength is 5/5. He needs assistance in moving. Neither lesions nor physical deformities observed. Dorsalis pedis, posterior tibial and inguinal pulses are present. Lymph nodes are not palpable.

R. GENITALIAPubic hair starts to grow. There is no presence of lesions. Penis is not yet circumcised.(done after circumcision)

>Pubic hair shaved off, upon the removal of sterile dressing and elastic bandage, (for assessment purposes), sutures sorrounding the glans penis are present. The glans penis is slightly swollen and bruises on the shaft to the scrotum are starting to develop. Redness on the area was also seen.

S. RECTUM AND ANUS

The client's rectum and anus is patent. Gluteal folds are symmetric. Active anal reflex.

CASE 5 - COMMUNITY CASE STUDY


Personal Data

The client is Mr. Yu a 22 ylo male, born on April 22, 1986 and was baptized in a Roman Catholic Church. He is presently residing at Sta. Cruz, Sto. Tomas, Batangas. He is the third among the 7 siblings. His mother stays at home as a plain housewife while his father died when he was still young. He works as a construction worker and earn for the entire family as the sole breadwinner. Chief Complaint"Masakit ang katawan ko at nanghihina ako" as verbalized by the client. Past Medical Illness

Patient has no known allergies on food or medications. As far as he could remember, he was on his 3rd grade when he completed all his vaccines. The client has undergone circumcision and tooth extraction as the only form of surgery.


There are no known heredofamilial diseases in the family.

Social History

According to the client, he is working as a construction worker from Mondays through Fridays at 4 o'clock in the morning until 12 o'clock in the midnight depending on the given schedule to him. He also works as a welder every Saturday. He usually sleeps at around 1 am and wakes up at around 3:30 am. The patient states that he rest during Sundays but spends most of his time with his friends drinking Red Horse until they will get drunk. He does not engage to any form of gambles. Everyday the client smokes 3 sticks of cigarettes every after meals.

Review of Systems

PSYCHOLOGICAL

The client assesses himself as a very hardworking person with a happy lifestyle but is not that contented. He is not feeling alright today because his entire body is aching and he is feeling very weak. When people discriminate him and his family, he gets mad. He values his family the most. He is the sole breadwinner of the family. According to him, he earns 5000 Php every 15th of the month but it is not enough to feed 8 mouths three times a day and he sends three siblings to school. His mother and his eldest brother are the ones who make decisions at home. He is not active in barangay meetings and does not want to be a part of it. They utilize the community health center, when a member of the family is sick. The client has no difficulty in hearing and vision. He is complaining of body pain and he is so weak and tired. He drinks alcoholic beverages to manage his stress, along with his "barkadas". According to him, if his two elder brothers will also work and help the family, he will not get stressed. The client wants his younger siblings to finish their study and have a stable job. He wants to have someone to love (girlfriend) but he knows it is difficult. The family cares about everything, especially on their health, but for him, they won't be able to afford the expenses when a member of the family gets sick. The client is a Roman Catholic and also believes in superstition.

ELIMINATION

The client defecates once a day, every morning. He doesnt experience any discomfort or pain. He urinates four times a day with approximately 630 cc and does not perspire excessively. Going to work is his daily routine.

REST

The client sleeps at 1:00 am and wakes up at around 3:30 am every day; he does not have enough sleep and rest. He only rest during Sundays but spends most of his time drinking and chatting with his friends.

SAFE ENVIRONMENT

The client lives in Sta. Cruz, Sto Tomas Batangas. The place is very peaceful and clean, and has been awarded as one of the CLEANEST COMMUNITY in the country. According to the client, he gets tired easily. He puts pillows under his head and back to be able to breathe easier because its easier for him to breathe when seated. He often eats vegetables because according to the client it is cheap. Sometimes, when he has a lot of work to do and when he doesn't have money to buy food, the client skips his meals and he does not take any vitamins.

24 Hour Dietary RecallMeal Food Quantity Fluid Quantity Biochemical Appraisal

Breakfast 2 cups of rice 1 cup of coffee Rich in carbohydrates I medium sized tuyo Rich in Proteins Lunch 2 cups of rice 2 glasses of water Rich in Carbohydrates I small can of Rich in Proteins sardines Rich in Calcium

Dinner 2 cups of rice 2 glasses of water Rich in Carbohydrates 1 serving of vegetables(pakbet) Rich in Fiber andVitaminsB. PHYSICAL ASSESSMENT

a. General Appearance

The client has a medium frame body built. He has an upright posture and walks with a smooth rhythmic gait. He looks very weak and tired. He is appropriately dressed but is in need to be reminded about proper hygiene. No obvious physical deformities but there are noted insect bites.Vital signs:

Temp = 37.0 'C

CR= 85 bpm

RR = 20 cycles per minute

BP= 120/80

b. Mental Status

He is conscious and coherent. The client is oriented to time, place and person.

c. Skin

The client's skin is dark brown in color. His temperature is warm and is smooth to touch. His skin turgor is elastic and mobile. His hair is evenly distributed.

d. Hair

The client's hair color is black, thick and evenly distributed. No noted infection or infestation on his head but flakes was observed.e. Nails

The client's nail bed is yellowish in color. He has convex 160 but long and dirty finger nails. The capillary refill within three seconds, upon administration of blanche test and texture is smooth.

f. Head and Face

The client's skull is proportionate to his body size. H e has a symmetrical face and it moves easily

g. Eyes

He has straight normal eyes with white sclera and his pupils are 2-3 mm in diameter. Blink response is present and there are no observed fallen eyelashes or eyebrows. His eyeballs are symmetrical and firm. He is able to see objects 20 feet away. His conjunctiva is pale and has moist lacrimal apparatus.

h. Ears

The client has normal ear tone. Pinna recoils when folded, it is elastic and nontender. Some cerumen was noted on the external and he can respond to normal voice.

i. Mouth and Oropharynx

He has pale symmetrical lips. His tongue rest in the midline, uvula is in the midline. Oral mucosa is pink. Hard and soft palate are intact and his tonsils are not inflamed. Present gag reflex was observed and teeth are complete.

j. Nose

The client's external nose has a normal racial tone. The septum rests at the midline and his nostrils are both patent. There are no nasal secretion observed and sinuses are not tender.

k. Neck

The client has a strong neck muscle. Lymph nodes are not palpable as well as the thyroid gland. Trachea is at the midline.

I. Breast and Axilla

He has a flat symmetrical breast. There are no masses observed and palpated.

m. Chest and Lungs.

The client has regular breathing pattern. Both anterior and posterior lung expansions are symmetrical. During auscultation, normal breath sounds were heard. He does not use accessory muscle.

n. Abdomen

The client has a normal racial tone abdomen. It is flat. Bowel sounds were heard and it is within normal range. His bladder is not distended.

o. Upper and Lower ExtremitiesThe client's muscle is strong and firm. At present, muscle tone is poor. Peripheral pulses are present and there are no palpable lymph nodes.

p. Genitals

This part was not assessed.C. Diagnostic Procedure Not applicable

CASE 6 -- CLINICAL CASE STUDY

ASSESSMENT

NURSING HEALTH HISTORY

Personal Data

Ms. Y is a 26 year old female. She lives at Las Pinas City. She stands 5'4" tall and weighs 115 pounds. Ms. Y is the eldest among 4 siblings. The client's father is a retired accountant while her mother is a college professor in a prestigious university. She is a Roman Catholic and was born on February 22, 1971. She is a call center agent in Ortigas.

Chief Complaint

"I feel so weak and wobbly that I can't get up from bed to go to work" as verbalized by the client.


The client has been reporting to work from 12mn to 8am a week prior to admission. Ms. Y gets home by 10am and does household chores. She was able to get some sleep at around 5pm and wakes up at 8pm to prepare for work.

The client experienced lingering headaches 2 days prior to admission. She was relieved by a pain reliever which she has been taking every 4 hours 1 day prior to admission.

4 hours prior to admission, she felt body weakness and headache which prompted her to seek consultation at Las Pinas Doctor Hospital.Upon admission, her body temperature is 37.8 C and appears to be pale and weak.


Ms. Y has no known food or medication allergies. As far as she can remember, she has completed all her vaccines when she was in grade 3. She had undergone appendectomy when she was a 3rd year high school student.


There is no heredo-familial disease from both parents according to Ms. Y.

Social History

Ms. Y has irregular working hours as a call center agent, depending on the schedule given to her. She reports to work from 11 pm to 7am of the next day most of the time. She helps with the household chores first when she gets home from work and cooks lunch for her father. She goes to sleep the earliest at 3pm. She needs to wake up at 7pm to start preparing for work. She needs to allot 2 hours of travel time going to her workplace.

Review of Systems PSYCHOLOGICAL

The client says she is a very hardworking person. She is happy with her life even though she is single. She feels really very weak.

Ms. Y values her family the most, She works and earn for herself and she helps in the finances of their family. She sends her 2 nieces to a public school. Her parents shares in decision-making for their family. She earns 18000 PHP every payday.

She is an active lector of their Parish Church. She serves every Sunday mass and holy days of obligation. They immediately bring their family member to the hospital for consultation when someone of their family member is sick.

She has no hearing and visual difficulty. She just feels so weak and tired.

She manages stress by going out with friends, barhopping or hanging out with them the whole night. She simply enjoys conversation with her friends though she is not an alcohol drinker.

She had several boyfriends but she havent found the right one yet. She is in a relationship with a co-call center agent at present. They had been together for 6 months already.

Their family pays particular attention to one's health that they take vitamin supplements regularly and immediately seeks consultation as soon as they get to feel something unusual in their system. All of their family members have health insurance.

ELIMINATION

MS. Y urinates four to five times a day with approximately 550 cc. She does not experience any pain or discomfort. She defecates once a day, every morning. The client doe not perspire excessively.

REST AND ACTIVITY

She rests during her day off only which is one day within a week. She spends her whole day chatting with her friends in the internet. She approximately gets a minimum sleep of 4 hours a day.

SAFE ENVIRONMENTMs. Y lives in an exclusive subdivision in Las Pinas. The place is peaceful and safe.

OXYGENATION

Ms. Y gets tired easily according to her. It is easier for her to breathe when seated. She puts pillows under her head and back to be able to breathe easier.

NUTRITION

She often eats vegetables because she wants to maintain her body figure. She sometimes skips meal when she has a lot of work to do. She takes vitamin supplements and Stresstabs regularly.

24 hour diet recall

Dinner: She bought McChicken Sandwich meal with a Large Fries and Coke and ate it inside the taxi on her way to work.

Breakfast: She was not able to eat breakfast because she gets home almost lunch time already and she gets pre-occupied with the household chores.

Lunch: She had small bowl of a vegetable salad.

PHYSICAL ASSESSMENT

General Appearance

She has a medium frame boy built and has an upright posture. She walks with a smooth rhythmic gait. She looks weak and tired. She is appropriately dressed and well groomed. She has no obvious physical deformity. There is presence of insect bites. She stands 5'4" tall and weighs 115 pounds. She has the following vital signs: temperature is 37.8 C, respiratory rate of 20 breaths per minute, cardiac rate of 85 beats per minute and her blood pressure is 120/80.

Mental Status

She is conscious and coherent. She is well- oriented of the time, place and person she is with.Skin

She has a brown skin color. Skin is warm and smooth to touch, turgor is elastic and mobile and hair is evenly distributed.

Hair

She has a black and shiny hair. Her hair is thick and evenly distributed. There are no infestations and infections present on her head but there is a presence of flakes in her scalp.

Nails

Ms. Y has pale nail beds. Her nails are long and have a blue nail polish on it that's why capillary refill is not observed. Her nail plate shape is convex 160 and has a smooth texture.

Head and Face

Her skull is proportionate to her body size. Her face is symmetrical and her face moves easily.

Eyes

She has straight normal eyes. There are no fallen eyelashes or eyebrows observed and blink response is present. Eyeballs are symmetrical and firm. Her sclera is white and pupils are 2-3 mm in diameter. The client is able to see objects clearly that are 20 feet away. She has pale conjunctiva and moist lacrimal apparatus.Ears Her ears are of normal racial tone. The pinna recoils when folded. It is elastic and non-tender. There is presence of some cerumen on the external canal. She responds to whispered voice.

Mouth and Oropharynx

Her lips are symmetrical but pale. Her tongue rests at midline. Oral mucosa is pink in color. Her hard palate and soft palates are intact. The uvula is located in the midline and her tonsils are not inflamed. Her gag reflex is present and she has a complete teeth.Nose

Her nose is of normal racial tone. Septum is located in the midline and her nostrils are both patent. Sinuses are not tender and there are no nasal secretions.

Neck

The client has a strong neck muscles. Trachea is located in the midline. Thyroid gland and lymph nodes are not palpable.

Breast and Axilla

She has asymmetrical breasts and no masses observed and palpated.

Chest and Lungs

She has regular breathing pattern. Lung expansion is symmetrical both in anterior and posterior. Normal breath sounds are heard on auscultation. She does not use accessory muscle when breathing.

Abdomen

She has a normal racial tone abdomen and is flat. Bowel sounds were heard and is within the normal range. Her bladder is not distended.

Upper and Lower Extremities

She has strong and firm muscles. Her muscle tone at present is poor. Lymph nodes are not palpable and peripheral pulses are present.

Genitals

This part was not assessed.CASE 7 -- CLINICAL CASE STUDYA. Nursing Health History

Personal Data

Ms. Sy, 65 years old, Female residing at Quiapo, Manila. She is single, Filipino citizen and a Roman Catholic believer. Her usual source of healthcare is at Ospital ng Maynila.Chief Complaint

"I noticed a significant delay on my bowel, and I don't know why?" as claimed by the client.


Five days prior to consultation, the client noticed a delay on her bowel habits. The client cannot remember the exact date when the symptoms started. But according to her it started gradually since she turned 60 years old. There is no associated symptoms or aggraviating factors related to her symptom. On the day of consultation, the client suddenly worried about her change in bowel habit, which prompted to consult. She was examined at Ospital ng Maynila, Out patient department.


Ms. Sy has a complete immunization when she was a child. Common illness include fever, flu, then cough and colds which is usually relieved at home. She never experienced any injuries. No records of hospitalization and she does not take any form of medications.

Family History-

No heredofamilial disease such as asthma, diabetes, hypertension, alcoholism, tuberculosis etc.

Social History

She lives alone in her house and believe in the effects of herbal medications she does not have any superstitious belief that can affecther health status. Ms. Sy finished her primary education in Cebu and used to work as a sewer, even up to the present. According to her she never had any conflicts with her neighbor. She also receive monthly pension from SSS and Philam Life.Review of SystemsPyschological

The client views herself as a simple person gifted with a peaceful life. Even though she lives all alone by herself she thinks that it is good enough for her. Sometimes she feels lonely when listening to love songs since she never had a chance to get the best man for her. She also prefers to be alone for some time and does not want to socialize when she is sad since most of her neighborhood have their own family.

Elimination

The client urinates 5-6 times a day in scanty amounts with yellowish color without any discomfort. She defecate 2 times a week, color brown in scanty amount and hard. According to her this is not her usual characteristic of her bowel. She feels incomplete every time she defecates as if she wants to excrete more. She does not perspire a lot.

Rest and Activity

She used to watch television and listen to the radio when she gets tired. Her usual Activity of Daily Living includes cleaning her house, doing the chores and gardening. But for the last month she had lessened her activity and prefers to stay inside her house because of glare on lights.

Safe Environment

Ms. Sy feels secure in her place since the Barangay Hall is just adjacent to her house. According to her she seldom hear some trouble in their place since the Barangay Tanods are very active. She lives in a house made of concrete material. She has no allergies to food, drugs and environment.

Oxygenation

She does not have any signs of respiratory distress and never had symptoms of difficulty of breathing.

Nutrition

The client used to eat root crops and tomato from her garden since this is one of her favorite foods. She seldom drinks water and would prefer to have nganga in her mouth all day long. She also verbalized, "Gusto ko nga matuto magluto at kumain ng masusustansyang pagkain eh, para libangan na rin, as verbalized by the client.

24 Hour Diet RecallBreakfast: 1 Pandesal, 1 cup of coffee

Lunch: 1 cup rice, 1 tilapia,

1 glass of water

Dinner: 1 cup rice, 1 tinapa,

1 glass of water

B. Physical Examination

GENERAL APPEARANCE

The client has small body built, thin with stooped posture and coordinated body movement. She is appropriately dressed, neat without body odor. No obvious signs of physical deformity or illness noted. Her vital signs are: temperature= 36.1 OC (axilla), PR=65 bpm, RR= 17cpm, BP= 110/80mmHg. Clients height is 147cm and weighs 90 lbs.

MENTAL STATUS

She is conscious, coherent and cooperative with good affection. Oriented to time, place, date and person. She responds appropriately and slowly in an understandable manner. Uses simple words in communicating.

SKIN

Clients skin color is light to deep brown, uniform in color with prominent veins on the arms and toes. Sagging and wrinkling were noted. Brownish, circular age spots (lentigo senilus) was noted on the volar area of both arms ranging from 1-2cm width. Skin temperature is warm within normal range. Decreased skin turgor is noted. There are no lesions and fine white hairs are evenly distributed all over the body.HAIR

With white, straight hair at shoulder level, evenly distributed, thin silky resilient. No infection/manifestation and dandruff seen. Absence of nasal, ear, eyebrow and axillary hair coarse is noted.

NAILS

The nail plate had 160 angle, smooth texture, and pinkish with longitudinal ridges. Epidermis is intact, capillary refills within 3 seconds.

HEAD AND FACE

With round normocephalic and symmetrical with frontal, parietal and occipital prominence. Hair is evenly distributed, head contour is smooth with uniform consisteny; without nodules or masses. With symmetrical facial movements and features. Wrinkles are also present.EYE

Thin eyebrows and eyelashes are evenly distributed and symmetrical. Skin surrounding the eyes is intact without any discoloration; lids close symmetrically with 15-20 blinks per minute. The sclera is white, palpebral conjunctiva is shiny and pinkish while bulbar conjunctiva is clear. No edema or tenderness on the lacrimal glands. Opaque white ring around the iris (arcus senelis) is noted. There is some opacity present on the lens. The pupils are equally round (3-4mm) and reactive to light and accommodation. When looking straight ahead, client has difficulty in recognizing objects in the periphery. Both eyes are coordinated; move in unison with parallel alignment (8 ocular movements). The client is unable to read font 12 of printout and has a vision of 20/100. Glaring into lights is one of her concerns.EAR

The auricles are brown in color, symmetrical and aligned with outer canthus of eye, about 10 from vertical view. Upon palpation, auricles are mobile, firm and non-tender; pinna recoils after it is folded. Using an otoscope, distal 3~d contains thin hair follicles and glands; semitransparent and pearly gray tympanic membrane. The client has difficulty in responding to normal voice and negative for watch tick test. Normal for Rinnes and Webers test

NOSEWith symmetrical and straight nares, without discharge, flaring and uniform in color. Air moves freely through the nares as the client breathe. Nasal mucosa is pink, clear without any lesions. Nasal sinuses are non-tender. (deleted cant recognize coffee)MOUTH AND OROPHARYNX

Outer lips has uniform pink color, soft, dry, smooth in texture and able to purse lips. Inner lips and buccal mucosa is pink, moist, smooth, soft, glistening and elastic. She has 32 smooth and intact dentures, moist and firm. The tongue is. at the center, pink color, with smooth lateral margins, no lesions, raised papillae, moves freely without tenderness and nodules. Absence of papillae is noted. Salivary glands is intact, pinkish in color without any lesions with light pink hard and soft palate positioned in the midline with smooth posterior wall. Tonsils and uvula is not inflamed. Gag reflex is present.NECK

Muscles are equal in size, head is in the center. Head movement is coordinated, smooth without discomfort. There is equal muscle strength and non-palpable lymph nodes. The trachea is in the midline. Thyroid gland is not palpable but ascends during swallowing.BREAST AND AXILLA

With brown, saggy,asymmetrical with fine glandular texture. There are no masses palpated. Nipples are pinkish in color, dry and symmetrical. The axilla is color brown, dry without hair.

CHEST AND LUNGS

The anteroposterior to transverse diameter is in ratio of 2:1. with symmetrical chest expansion and kyphotic spine. Skin is intact with uniform color and temperature. No tenderness and masses upon palpation. With bilateral symmetry of vocal and tactile fremitus. Resonance is heard over the thorax. Diaphragmatic excursion is 3cm. Costal angle is 80 and the ribs are 45. Upon auscultation, bronchial (trachea) sounds, bronchovesicular (main bronchi) sound and vesicular sounds (terminal bronchi) were heard.

HEART

There are no masses and lesions in the skin. There is palpable pulsation at the left ICS (5th) MCL; in an area of 1-2 cm in diameter. The carotid pulse is bounding regularly synchronous with S1. The apical and radial pulse has equal rate and rhythm. Systolic murmur was heard during auscultation.

ABDOMENThe color is uniform and the skin is unblemished. There are symmetric movements caused by respiration. Aortic pulsations were also noted at the epigastric' area. Bowel sounds is 3/min without arterial bruits and friction rub. Tympanic sounds were heard during auscultation. No tenderness, relaxed abdomen with smooth, consistent tension. The liver, bladder and spleen are not palpable.


The muscles have equal size on both sides of the body. There are no contractures or fasciculation present. Muscles are firm, smooth with coordinated movements and equal strength on both sides of the body. The bones do not have any deformities (rlt injury), tenderness or swelling. Joints move easily .There are no signs of tenderness, swelling, crepitation of the joints.

CASE 8 COMMUNITY CASE STUDYA. NURSING HEALTH HISTORY

Personal Data:

Ms. Sy is a 65 years old, female, and residing at Quiapo, Manila. She is single, a Filipino citizen and a Roman Catholic believer. Her usual source of health care is at the Barangay Health Center.

Chief Complaint:

"My joints are painful and it seems so hard to move especially when I get stuck in one position and I don't know why."

History of Present Illness:

The client cannot remember the exact date when the symptoms started. But according to her it started gradually since she turned 60 years old. The symptoms seem to worsen especially when it's cold at night.Past Medical History

Ms. Sy had a complete immunization when she was a child. Common illnesses include fever, flu, then cough and colds, which are usually relieved at home. She never experienced any injuries. No records of hospitalization and she does not take any form of medication.Family History

No heredofamilial diseases such as asthma, diabetes, hypertension etc.

Social History

She lives alone in her house and believes in the effects of herbal medications. She does not have any superstitious belief that can affect her health status. Ms. Sy finished her primary education in Cebu and used to work as a sewer, up to present. According to her, she never had any conflicts with her neighbor. She also receives monthly pension from SSS and Philamlife.

REVIEW OF SYSTEMS

Psychological

The client views herself as a simple person, gifted with a peaceful life. Even though she lives all alone by herself, she thinks that it is good enough for her. Sometimes she feels lonely when listening to love songs since she never had a chance to meet the man if her life. She also prefers to be alone for some time and does not want to socialize when she is sad since most of her neighbor have their own family.

Elimination

The client urinates 5-6 times a day scanty in amount, yellowish color with no accompanying discomfort. She defecates 2 times a week, brown in color, scanty in amount and is hard. According to her, this is the usual characteristic of her bowel. She perspires a lot.

Rest and Activity

She used to watch television and listens to the radio whenever she gets tired. Her usual activities of daily living Include cleaning her house, doing the chores and gardening. She expresses concern like learning simple exercises that she can do inside the house but she does not know where or who to seek information.

Safe Environment

Ms. Sy feels secure in her place since the Barangay Hall is just adjacent to her house. According to her, she seldom hears troubles in their place since the Baranggay Tanods are very active. She lives in a house made of concrete material. There are no allergies to food, drugs and to the environment.

Oxygenation

She does not have any signs of respiratory distress and never had symptoms of difficulty in breathing.

Nutrition

The client used to eat root crops and tomatoes from her garden since these are her favorite foods. She seldom drinks water and would prefer to have "nganga" in her mouth all day Iong. Client verbalized "Gusto ko nga matuto magluto at kumain ng masusustansyang, pagkain eh, para libangan na rin."

24-Hour Diet Recall:

Breakfast: 1 pandesal, 1 cup of coffee

Lunch: 1 cup of rice, 1 tilapia, 1 glass of water

Supper: 1 cup of rice, 1 tinapa, 1 glass of water

B. PHYSICAL EXAMINATIONGeneral Appearance

The client has small body built, thin, with stooped posture and coordinated movement. She is appropriately dressed, neat, without body odor. No obvious signs of physical deformity or illness noticed. Client's height is 4'9" and weighs 901bs.

Her vital signs:

Temperature= 36.1'`C

PR= 65 beats per minute

RR= 17 cycles per minute

BP= 110/180 mmHg

Mental Status

She is conscious, coherent and cooperative with good affect oriented to time, place, date and person. She responded appropriately and slowly in an understandable manner. She used simple words in communicating.

Skin

Client's skin color is light to deep brown, uniform in color with prominent veins on the arms and toes. Sagging and wrinkling were noted. Brownish, circular "age spots" (lentigo senilus) was noted on the area of both arms ranging from 1-2cm width. Skin temperature is warm within normal range. Decreased skin turgor is noted. There are no lesions and fine white hairs are evenly distributed all over the body.

Hair

With white, straight hair at shoulder level, evenly distributed, thin, silky and resilient. No infection/infestation and dandruff seen. Absence of nasal, ear, eyebrow and axillary hair coarse is noted.Nails

The nail plate has 160 angle smooth texture, and pinkish w/ longitudinal ridges. Epidermis is intact, capillary refills within 3 seconds.

Head and Face

She has round normocephalic and symmetrical w/ frontal, parietal and occipital prominence. Hair is evenly distributed; Head contour is smooth w/ uniform constituency; without nodules or masses and with symmetrical facial movements and features.

Eyes

Thin eyebrows and eyelashes are evenly distributed and symmetrical. Skin is intact w/o any discoloration; lids close symmetrically w/ 15-20 blinks/min. The sclera is white, palpebral conjunctiva is shiny smooth and pinkish, while bulbar conjunctiva is clear. No edema or tenderness on lacrimal glands. Opaque white rings around the iris (arcus senilis) is noted. There are some opacities present in the lens. The pupils are equally round (5mm) and reactive to light and accommodation. When looking straight ahead, client has difficulty in recognizing objects in the periphery. Both eyes are coordinated; moves in unison w/ parallel alignment (8 ocular movements). The client is unable to read font 12 of printout and have a vision of 20/100. Glaring into lights is one of her concern.

EarsThe auricles are brown in color, symmetrical and aligned w/ outer canthus of eye, about 10' from vertical view. Upon palpation, auricles are mobile, firm and not tender; pinna recoils after it is folded. Using an otoscope, distal 3rd contains thin hair follicles and glands; semi-transparent and pearly gray tympanic membrane. The client has difficulty in responding to normal voice and negative for watch tick test. Normal for Rinne's and Weber's test.

Nose

She has symmetrical and straight nares, without discharge, flaring and uniform in color. Air moves freely through the nares as the client breathe. Nasal mucosa is pink and clear without any lesions. Nasal septum is intact and in midline. Nasal sinuses are non-tender. The client had difficulty in recognizing the smell of coffee.

Mouth and Oropharynx

Outer lips have uniform pink color, soft, dry, smooth in texture and able to purse lips. Inner lips and buccal mucosa is pink, moist, smooth, soft, glistening and elastic. She had 32 smooth and intact dentures, moist and firm. Absence of papillae is noted. Salivary glands are intact, pinkish in color w/o any lesions. Light pink hard and soft palate and are positioned in the midline w/o smooth posterior wall. Tonsils and uvula is not inflame0. Gag reflex is present.

Neck

Neck muscles are equal in size; head is at the center. Head movement is coordinated, smooth w/o discomfort. There is equal muscle strength and non-palpable lymph nodes. The trachea is in the midline. Thyroid gland is not palpable but ascends during swallowing.

Breast and Axilla

With brown, flat, symmetrical w/ fine glandular texture. There are no masses palpated. Nipples are pinkish color, dry and symmetrical. The axilla is brown in color, dry, w/o hair.

Chest and Lungs

The anteroposterior to transverse diameter is 2:1 ratio. She has a symmetrical chest expansion and a kyphotic spine. Skin is intact, with uniform color and temperature. No tenderness and masses upon palpation. She has bilateral symmetry of vocal and tactile fremitus. Resonance is heard over the thorax. Diapragmatic excursion is 3cm. Costal angle is 80, and the ribs is 45. Upon auscultation, bronchial (trachea) sounds, bronchovesicular (main bronchi) sound and vesicular sounds (terminal bronchi) were heard.HeartThere are no masses and lesions in the skin. There is palpable pulsation at the left ICS (5th) MCL; in an area of 1-2 cm in diameter. The carotid pulse is bounding regularly synchronous with S1. The apical and radial pulse has equal rate and rhythm. Systolic murmur was heard during auscultation.

AbdomenThe color is uniform and the skin is unblemished. There are symmetric movements caused by respiration. Aortic pulsations were also noted at the epigastric' area. Bowel sounds is 3/min without arterial bruits and friction rub. Tympanic sounds were heard during auscultation. No tenderness, relaxed abdomen with smooth, consistent tension. The liver, bladder and spleen are not palpable.


Muscles are firm, smooth with coordinated movements and equal strength on both sides of the body. The clients fingers have swollen joints. Stiffness on the joints on the clients hands were noted. Patient claimed that the bones and joints on her hands, legs and feet are painful. Crepitations on the joints were also present.

NCM 100 CASE STUDIES (edited 01_28_2011)Page 6

Complete Set of Edited Case Studies Jan_28_2011

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