University of Pangasinan

College of Nursing

Dagupan City, Philippines

A Case Study on ________________

Presented to the

College of Nursing

In Partial Fulfillment in

Related Learning Experience III

Submitted by:

Submitted to:

University of Pangasinan

College of Nursing

Dagupan City, Philippines

TABLE OF CONTENTSI. Acknowledgement:

II. Introduction: Explain the disease condition (Client-centered). Reason of choosing his/her case

III. Significance of the study: Nursing Education

Nursing Practice

Nursing Research

IV. ObjectivesGeneral:

Specific:1.2.3.

V. Patient’s Profile:Nursing Health History (Follow the Provided Interview Sheet)Physical Assessment (Follow the Provided Checklist)Developmental Data (Choose 1 between the theories of Freud, Erickson, Piaget,

Kohlberg)

VI. Anatomy and Physiology (Discuss the related system with regards to the disease)

VII. Pathophysiology (In Paradigm form with explanation) VIII. Diagnostic test (Explain the aim of the procedure and discuss the significance of the results, give interpretations)

IX. Medical-Surgical Management(Refer to any latest MS-Books)Drug Study (Follow the table provided)

X. Nursing Management(Refer to any latest MS-Books)Nursing Care Plan (Follow the table provided)

XI. Discharge PlanMedication- (What are the important thing to keep in mind in taking medication)Economy/Exercise- (What are the alternative/cheaper ways on how to manage the

disease)Treatment/Therapy- (What are recommendations of the doctor in treating the

disease)Health Teachings/Hygiene (What health practices should be emphasized to prevent progression of

the disease)

Out-patient consultation- (Instructing the client to visit the doctor if symptoms persist)

Diet- (Discuss what are the foods to be taken and avoid)SEX-(Suggestions in keeping the client potent)

XII. Evaluation

Definition of Terms

Bibliography:

NURSING HEALTH HISTORY(Interview Sheet)

I. Biographic Data

A. Name/Alias:

B. Address:

C. Age

D. Birth Date

E. Sex

F. Race

G. Martial Status

H. Occupation

I. Religious Orientation

J. Health Care Financing and usual source of medical care

II. Chief Complaint and Reason of Visit:

A. What brought you to the hospital/clinic?

B. What is troubling you?

III. History of Present Illness

A. Ask what was the chronological sequence of events in reference to the client’s

chief complaints:

1. When was the start of the symptom?

2. How often?

3. Type of activity when before problem occurred?

4. Was help/ consultation sought?

5. Medication used?

B. Asks how the problem interfered with activities of daily living.

IV. Past History

A. Child hood diseases

B. Immunizations

C. Allergies

D. Accidents and injuries

E. Hospitalization (when and why?)

F. Medication

V. Family History of Illness

A. Health and ages of patient’s sibling, children, or ages at death and causes.

B. Illness in the family similar to the patient.

C. Familial incidence of rheumatic fever, hypertension, tuberculosis, diabetes, mental

illness, others especially as suggested by the present illness.

VI. Functional Health Pattern

A. Health Perception and Health Management Pattern

1. How has the general health been?

2. Any colds in the past?

3. Most important things done to keep health? You think these things make a

difference to health? (Include Family, folk, remedies if appropriate.)

4. Use of cigarettes, alcohol, drugs? (Perform Breast examination?)

5. In the past, has it been easy to find ways to follow things nurses/doctors

suggestions?

6. If appropriate: What do you think caused the illness? Actions taken when

symptoms were perceived? (Results of action)

7. If appropriate: things important to you while you are here in the hospital or

clinic? How can we be most helpful?

8. Traditional Concepts of health and illness? Beliefs and practices? (Classify

what ill-health model is being used by the patient.)

B. Nutritional and Metabolic pattern

1. Typical daily food intake? (Specify) Supplements?

2. Typical daily fluid intake? (Specify)

3. Weight loss/ gain? Amount?

4. Appetite?

5. Food or eating discomfort? Diet restrictions?

6. Wound healing?

7. Skin problems? Lesions? Dryness?

8. Dental Problems?

C. Elimination Pattern.

1. Bowel elimination pattern. (describe) Frequency? Characteristics? Discomfort?

2. Urinary elimination pattern. (Describe) Frequeny? Discomfort? Problem in

control?

3. Exessive perspiration? Odor problems?

D. Acivity- Exercise Pattern

1. Sufficient energy for completing desired required activities?

2. Exercise pattern? Types? Regularity?

3. Spare time: leisure activities? Child: activities?

4. Perceived ability for (Code Level)

FEEDING GROOMING

BATHING GENERAL MOBILITY

TOILETING COOKING

BED MOBILTY HOME MAINTENACE

DRESSING SHOPPING

Level (0) - Full self care

Level (1) - Requires use of equipment or device

Level (2) - Requires assistance or supervision from another person

Level (3) - Requires assistance or supervision from another person or device

Level 4- Dependent and does not participate

E. Sleep- Rest Pattern

1. Approximately how many hours do you sleep at night?

2. Any problem falling asleep? Do you take any sleep medications?

3. Is your sleep continuous? Tired?

4. Take naps? When? (Morning/Afternoon)

5. What do you do for relaxation? (Watch TV, listen to radio, read, dance, shopping)

F. Cognitive - Perceptual Pattern

1. Hearing difficulty? Hearing Aid?

2. Vision/ Wear eyeglasses?

3. Any change in memory lately?

4. Easiest way to remember/learn things? Difficulties?

5. Any discomfort? Pain? How do you manage it?

G. Self-Perception and Self-Concept Pattern

1. How do you describe you self? Most of the time, feel good (not so good) about yourself?

2. Changes in your body or the things you can do? Problem to you?

3. Changes in way you feel about yourself/ of your body? (Since illness started)

4. Find things frequently make you angry? Annoyed? Tearful? Anxious? Depressed? What

helps?

H. Role – Relationship Pattern

1. Live alone? Family? Family Structure (Diagram)

2. Any Family problems you have difficulty handling? (Nuclear/Extended)

3. How does family usually handle problems?

4. Family depends on you for things? If appropriate: how are the managing?

5. If appropriate: How Family / others feel about your illness/hospitalization?

6. If appropriate: problem with children? Difficulty handling?

7. Belong to social groups? Close Friends? Feel lonely frequently?

8. Things generally go well with you at work? (School/college)? If appropriate income

sufficient to needs?

9. Feel part of (or isolated in) neighborhood where you are living?

I. Sexuality- Reproductive pattern

1. If appropriate: any changes or problems in sexual relations?

2. If appropriate: use of contraceptives? Problems?

3. Female: When menstruation started? Last menstrual period? Menstrual

problems? Para? Gravida?

J. Coping- Stress Tolerance Pattern

1. Tense a lot of the time? What helps? Use of any medicines, Drugs, alcohol?

2. What is most helpful in talking things over? Available to you now?

3. Any big changes in your life in the past year or two?

4. When you have big problems (any problems) in your life, how do you handle them?

5. Most of the time, is this (are these) methods successful?

K. Value Belief Pattern

1. Generally get things you like out of life? Most important things?

2. Importance of religion in your life? If appropriate: does this help when difficulties

arise?

3. If appropriate will being here interfere with any of your religious practices?

VII. Others

1. Any other things that we have not talked about that you would like to mention?

2. Questions?

Physical Examination

(Checklist)

Name___________________ Age______ Gender__________Medical Diagnosis____________________

I. Vital SignsTemperature = Pulse Respiration= Blood

Pressure=Site: Site: Rhythm: Site:Oral Apical regular ArmAxilla Carotid irregular ThighRectal Brachial Amplitude Position:Tympanic Radial Normal Lying

Femoral Rapid Shallow

Standing

Other Site,Specify

Rapid deep Sitting

Rhytm: Slow

Regular: Others, specify_____

Irregular:

Amlitude:

Thready

Small/weak

Large/boundingOthers,Specify

II. GENERAL SURVEY

Physical Appearance

Anthropometric Measurement

Height= Weight=

Level of Consciousness Orientation

Alert Time:Lethargic Place:Confused Person:Obtunded

Stuporous

Appearance in Relation to Chronological AgeLooks younger than the stated ageLooks older than the stated ageLooks appropriate to the stated age

Nutritional StatusFairly NourishedOver NoursishedUnder Nourished

Signs of DistressNo apparent signs of acute distresspainanxietyOthers, specify

Body StructureStructure (Standing heght of the

body)Posture

Tall Stands ErectShort Rigid Spine and neck

Symmetry Stiff and TenseSymmetrical Slumped

Asymmetrical Others, Specify

MobilityGait Range of Motion Location

Normal Full RomExceptionally wide base Limited ROMStaggered ParalysisShuffling Others, SpecifyLimpingDifficulty of Stopping

III. System Assessment

Integumentary

Skin Color Temperature TurgorSmooth Pale Hot GoodRough Red Warm Poor

Obvious Physical Deformities (Specify location)Congenit

alAcquire

dType Location

Missing Extremities Missing DigitsWebbed Digits Extra Digits

Aids/ Supportive DevicesCrutches ProsthesisWheel ChairCaneOthers, Specify

BehaviorAppropriate to weather and temperatureInappropriate to weather and temperature Appropriate to the situationInppropriate to the situationCleanDirtyProperly buttonedImproperly buttoned Properly zippedImproperly zippedKemptUnkemptProperly tied lacesUntied lacesWearing Slippers or cut out holes on shoeOut-grown nail polishDifferent pair of footwearHair coloringWearing any unusual accessoryOthers, Specify

Breath and Body OdorPleasant body odorUnpleasant boy odorAlcoholic breathAcetone breathOthers, specify

Facial ExpressionSmilingStaringSerious relaxTense TearfulCrying Others, specify

SpeechClearNormal PitchNormal PaceFast PaceSlow PaceAphasiaDysarthriaStammeringSlurredOthers, Specify

Mood & AffectAngrySadSuspiciousHostileDistrustfulFlatGrandiosityOthers, specify

Dry Bluish Cool PruritusMoist Yellowish UrtiariaFlaky Others, SpecifyWrinkled

Other, Specify

LesionsPrimary Secondary

Macule CrustPapule ScalePatch FissurePlaque ErosionNodule UlcerWheal ExcoriationHives ScarPustule KeloidBulla LichenificationCyst Others, SpecifyTumors

Head And FaceNornocephalicSymmetricalAsymmetricalOthers, Specify

HairTexture Color DistributionSmooth Brown Evenly DistributedShiny Black PatchesDry White AlopeciaOily Gray RegrowthCoarse Dyed Others, SpecifyBrittle

NailsNail Color Nail Beds Nail Folds

Pinkish Pink IntactBrown Bluish AbsentYellow Bluish InflamedWith Nail Polish Others, Specify With Cuts

Texture Capillary Refill Nail Bed AngleHard 1-2 Seconds >160 DegreesSoft <1-2 Seconds <160 Drgrees

Ohters, Specify

Eyes( External Ocular Structure)Eye Brows Eyelids and Lashes

Present Symmetrical Entropion____Symmetrical____Asymmetrical

Asymmetrical Periorbital Edema

Intact Upward palpebral Edema

Absent Lid lag RedPtosis SwollenEctropion Stye or Hordeolum

ScalpDandruffScalyLiceWounds/ScarsErythemaOthers,Specify

Eyes (Visual Acuity)

Eye GlassesNearsightednessFarsightedness

Others, Specify

Eyes( Internal Ocular Structure/Function)Eyeballs Conjunctiva

Normally aligned PinkAbsent PaleSunken YellowishExophthalmia ReddishEnophthalmia MoistTender DryingSpongy With ExudatesFirm Others, SpecifyOthers, Specify

Sclera Lacrimal ApparatusWhite SwollenYellow (Icteric Sclera) Excessive TearingRed PatentBluish BlockedOthers, Specify Red

TenderOthers, Specify

Cornea And Lens IrisSmooth RegularClear IrregularNo Spacity

Blink Reflex

Eye Color Distribution

Peripheral Vision Pupils

Absent Even Intact Size______Present Uneven Coloration Not Intact PERRLA____

EarsExternal Pinna Discharge Low Set Ears

Symmetrical Absent AbsentAsymmetrical Present,

SpecifyPresent

Extra Auricle

Skin Conditions

Right Ear

Left Ear

SwellingThickeningTendernessDischargeRednessOthers, Specify

Tympanic Membrane

Hearing Acuity Test Findings

Intact Normal Left Right Weber’s TestPerforated Difficult

yOthers, Specify Loss

Ear CanalCerumen Cerumen Texture Foreign

ObjectAbsent Waxy AbsentPresent Moist Present

Color_________Consistency_______Odor___________

DryImpacted

Others, Specify

Rinne Test

NoseSymmetry Septum Turbinates Discharge Discharge

ColorSymmetrical Divided Red Absent Red

Asymmetrical Perforated Pink Present BloodyDiscoloration Divided to the

RightPolyps Watery Gray

Swelling Divided to the Left

Copious Purulent

Green-YellowOthers, Specify

TeethPrimary Number of

TeethDefects &

DeformitiesCount Location

Secondary

Upper Teeth Plaques

Lower Teeth CariesCrowdedTooth Loss

Gums Tongue Buccal Mucosa

Tonsils Palate Uvula

Color Condition Midline Pink Pink Pinkish

Present

Pinked Swollen Deviated__L __R

Dry Red Smooth

Deviated__L __R

Red Bleeding Pinkish Moist Swollen Others, Specify

Absent

Discolored

Lesions Moist Lesions

Enlarged

Others, Specify

Moist Dry With Exudates

FurrowCrakedLesionsOthers, Specify

Neck and Lymph NodesNeck Lymph Nodes Thyroid

ROM Symmetry Pulsation Lymphadenopathy (Location)_________

Non PalpableBruist

Full Symmetrica Present Tenderness Palpable

NoseNostrils Right Left Nasal Mucosa Sinuses

Patent Pale TenderObstructed

Pink Non-tender

Flaring MoistDry

MouthLips

Symmetry Lesion Lip Color Lip TextureSymmetrical Absent Pink DryAsymmetrical Present Bluish Smooth

Black CrackedPale Swollen

MoistOthers, Specify

Buccal Accessories

BracesDenturesRetainersJacket

l (Location)_________Partial Asymmetric

alAbsent Swollen

(Location)_________Clump______

Bilateral_______

Absent

Others, Specify

Thorax and Lungs___AP ___L Ratio

Lung Expansion

Tactile Fremitus

Percussion Notes Breath Sounds

Funnel Chested

Symmetrical

Symmetrical

Resonant Normal

Pigeon Chested

Asymmetrical

Asymmetrical

Hyperresonant

Abnormal

Location

Barrel Chested

Dull Crackles

Others, Specify

Others, Specify

Ronchi

WheezesPleural Friction RubOthers, Specify

BreastSymmetry Areola Breast Skin Nipples Mass/es [ ] Solitay [ ] MultipleSymmetrical

Color Hyperpigmentation

Flat Location: Consistency

Asymmetrical

Bronish Redness Inverted Size: Soft

Pinkish Bulging Fissure Diameter: FirmOthers, Specify

Dimpling Ulceration Tender Non-tender

Hard

Edema Bleeding Shape Movable

Orange-Peel Looking Skin

Displaced Oval Fixed

Others, Specify Retacted Round

Discharges: Describe

Lobulated

Indistinct

HeartFlat Pericardial Area Heart SoundsBulging BPMPericardial Area RegularHeaves IrregularThrills DistinctPulsation Location Faint

PMI Location at: MurmursPericardial Friction RubThird Heart Sound or S3Fourth Heart Sound or S4Others, Specify

AbdomenSymmetry Contour Skin Umbilicus Obvious

PulsationAbdominal

SoundsSymmetrica Flat Pale Midline Presen Flat

l tAsymmetrical

Rounded Red Inverted Absent

Tympanic

Scaphoid Yellow Averted DullProtuberant

Striae DiscolorationSpecify____

GlisteringMasses of bulgesSurgical Scars, Location:

Liver Span SpleenApprox. Size_____6-12 cms_____over 12 cms

DullnessTenderness

Rebound Tenderness

Other ObservationsFluid WaveMuscle GuardingDirect TendernessIndirect Tenderness

Female Reproductive Vaginal Bleeding _____Profuse _____ScantyMassesDischargesLesionsScarEdemaOdor, Describe_________

Male ReproductivePenis_____Present_____AbsentUncircumcisedCircumcisedDischargesLesionsScarsScrotum_____Present_____AbsentDiscolorations

Pubic Hair____Present Specify Characteristics____Absent

AnusHemorrhoids____Present ____Absent ____Tender ____Non-Tender

Musculo-SkeletalArms and legs SymmetricalJoint Swelling, LocationMuscle Spasm, LocationMuscle weakness, LocationMuscle Atrophy, LocationMuscle Wasting, LocationTenderness, LocationDeformities, LocationFasciculation, LocationInvoluntary Movement, LocationOthers, Specify

Spine

MidlineKyphosisScoliosis____Deviated to the Left____Deviated to the RightTendernessSwellingSpasm

NeurologicCRANIAL NERVES

INTACT

NOT INTACT

Cranial Nerve ICranial Nerve IICranial Nerve IIICranial Nerve IVCranial Nerve VCranial Nerve VICranial Nerve VIICranial Nerve VIIICranial Nerve IXCranial Nerve XCranial Nerve XICranial Nerve XII

SensoryResponds to Light touchResponds to PainAble to Maintain Standing Position with Feet Together and Eyes ClosedStereognosisGraphesthesiaTwo point DiscriminationOthers, Specify

MotorRange of Motion (ROM)

LegendGrade Percent Interpretation

5- Full ROM against Gravity, Full Resistance

100 Normal

4- Full ROM against Gravity, Some Resistance

75 Good

3-Full ROM with Gravity 50 Fair2-Full ROM with Gravity eliminated, Passive Motion

25 Poor

1-Slight Contraction 10 Trace0-No Contraction 0 Zero

Muscle Strength

Legend:0 -absent+1or+ - decreased+2or++ - normal+3or+++ - hyperactive+4or++++ - clonus

SIGNIFICANT FINDINGS & INTERPRETATION:

Examined by:

__________________________University of PangasinanCollege of NursingStudent-Nurse

Date: _____________________

Noted by:

_________________________University of PangasinanCollege of NursingClinical Instructor

Date: ____________________

University of PangasinanCollege of Nursing

Dagupan City, Philippines

NURSING CARE PLANAlias/age: Date Handled:Medical Dx: Date Submitted:

Assessment Nursing Diagnosis

Nursing Analysis Expected Outcome

Nursing Interventions Rationale Evaluation

________________________ __________________ Clinical Instructor/Agency UPCN-SN/Shift

University of PangasinanCollege of Nursing

Dagupan City, Philippines

DRUG STUDYAlias/age: Date Handled:Medical Dx: Date Submitted:

Drug Name

Action Indication Contraindication Interaction Adverse Effect Nursing Consideration

________________________ _________________ Clinical Instructor/Agency UPCN-SN/Shift