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
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