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 CONTENTS
I. 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. Objectives
General:

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 Plan

Medication- (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 Signs
Temperature = Pulse Respiration= Blood
Pressure=
Site: Site: Rhythm: Site:
Oral Apical regular Arm
Axilla Carotid irregular Thigh
Rectal Brachial Amplitude Position:
Tympanic Radial Normal Lying
Femoral Rapid Shallow Standing
Other Site, Rapid deep Sitting
Specify
Rhytm: Slow
Regular: Others,
specify_____
Irregular:
Amlitude:
Thready
Small/weak
Large/boundin
g
Others,
Specify

II. GENERAL SURVEY

Anthropometric Measurement
Height= Weight=

Physical Appearance

Level of Consciousness Orientation

Alert Time:
Lethargic Place:
Confused Person:
Obtunded
Stuporous

Appearance in Relation to Chronological Age

Looks younger than the stated age
Looks older than the stated age
Looks appropriate to the stated age

Signs of Distress Nutritional Status

No apparent signs of acute Fairly Nourished
distress Over Noursished
pain Under Nourished
anxiety
Others, specify
 Body Structure
Structure (Standing heght of the Posture
body)
Tall Stands Erect
Short Rigid Spine and neck
Symmetry Stiff and Tense
Symmetrical Slumped
Asymmetrical Others, Specify

Obvious Physical Deformities (Specify location)

Congenit Acquire Type Location
al d
Missing
Extremities
Missing Digits
Webbed Digits
Extra Digits
Mobility
Gait Range of Motion Location
Normal Full Rom
Exceptionally wide base Limited ROM
Staggered Paralysis
Shuffling Others, Specify
Limping
Difficulty of Stopping Aids/ Supportive Devices
Crutches
Behavior Prosthesis
Appropriate to weather and Wheel Chair
temperature Cane
Inappropriate to weather and Others, Specify
temperature
Appropriate to the situation
Inppropriate to the situation Breath and Body Odor
Clean Pleasant body odor
Dirty Unpleasant boy odor
Properly buttoned Alcoholic breath
Improperly buttoned Acetone breath
Properly zipped Others, specify
Improperly zipped Facial Expression
Kempt Smiling
Unkempt Staring
Properly tied laces Serious relax
Untied laces Tense
Wearing Slippers or cut out holes on Tearful
shoe Crying
Out-grown nail polish Others, specify
Different pair of footwear
Hair coloring
Wearing any unusual accessory
Others, Specify

Speech
Clear
Mood & Affect Normal Pitch
Angry Normal Pace
Sad Fast Pace
Suspicious Slow Pace
Hostile Aphasia
Distrustful Dysarthria
Flat Stammering
Grandiosity Slurred
Others, specify Others, Specify
III. System Assessment

Integumentary

Skin Color Temperature Turgor

Smooth Pale Hot Good
Rough Red Warm Poor
Dry Bluish Cool Pruritus
Moist Yellowish Urtiaria
Flaky Others, Specify
Wrinkled
Other, Specify

Lesions
Primary Secondary
Macule Crust
Papule Scale
Patch Fissure
Plaque Erosion
Nodule Ulcer
Wheal Excoriation
Hives Scar
Pustule Keloid
Bulla Lichenification
Cyst Others, Specify
Tumors

Scalp
Head And Face Dandruff
Nornocephalic Scaly
Symmetrical Lice
Asymmetrical Wounds/Scars
Others, Specify Erythema
Others,Specify

Hair
Texture Color Distribution
Smooth Brown Evenly Distributed
Shiny Black Patches
Dry White Alopecia
Oily Gray Regrowth
Coarse Dyed Others, Specify
Brittle Nails
Nail Color Nail Beds Nail Folds
Pinkish Pink Intact
Brown Bluish Absent
Yellow Bluish Inflamed
With Nail Polish Others, Specify With Cuts
Texture Capillary Refill Nail Bed Angle
Hard 1-2 Seconds >160 Degrees
Soft <1-2 Seconds <160 Drgrees
Ohters, Specify
Eyes (Visual Acuity)
Eye Glasses
Nearsightedness
Farsightedness

Eyes( External Ocular Structure)

Eye Brows Eyelids and Lashes
Present Symmetrical Entropion
____Symmetrical Asymmetrical Periorbital Edema
____Asymmetric Intact Upward palpebral Edema
al
Absent Lid lag Red
Ptosis Swollen
Ectropion Stye or Hordeolum
Others, Specify

Eyes( Internal Ocular Structure/Function)

Eyeballs Conjunctiva
Normally aligned Pink
Absent Pale
Sunken Yellowish
Exophthalmia Reddish
Enophthalmia Moist
Tender Drying
Spongy With Exudates
Firm Others, Specify
Others, Specify

Sclera Lacrimal Apparatus

White Swollen
Yellow (Icteric Sclera) Excessive Tearing
Red Patent
Bluish Blocked
Others, Specify Red
Tender
Others, Specify

Cornea And Lens Iris

Smooth Regular
Clear Irregular
No Spacity

Blink Eye Color Peripheral Vision Pupils

Reflex Distribution
Absent Even Intact Size______
Present Uneven Coloration Not Intact PERRLA____

Ears
External Pinna Discharge Low Set Ears
Symmetrical Absent Absent
Asymmetrical Present, Present
Specify
Extra Auricle

Skin Right Left

Conditions Ear Ear
Swelling
Thickening
Tenderness
Discharge
Redness
 Others,
Specify

Ear Canal
Cerumen Cerumen Texture Foreign
Object
Absent Waxy Absent
Present Moist Present
Color_________ Dry
Consistency______ Impacted
_
Odor___________

Tympanic Hearing Acuity Test Findings

Membrane
Intact Normal Left Right Weber’s
Perforated Difficult Test
y
Others, Specify Loss
Others, Rinne Test
Specify

Nose
Symmetry Septum Turbinates Discharge Discharge
Color
Symmetrical Divided Red Absent Red
Asymmetrical Perforated Pink Present Bloody
Discoloration Divided to the Polyps Watery Gray
Right
Swelling Divided to the Copious Purulent
Left
Green-
Yellow
Others,
Specify

Nose
Nostrils Right Left Nasal Mucosa Sinuses
Patent Pale Tender
Obstructe Pink Non-
d tender
Flaring Moist
Dry

Mouth
Lips
Symmetry Lesion Lip Color Lip Texture
Symmetrical Absent Pink Dry
Asymmetrical Present Bluish Smooth
Black Cracked
Pale Swollen
Moist
Others, Specify
 Teeth
Primary Number of Defects & Count Location
Teeth Deformities
Seconda Upper Teeth Plaques
ry
Lower Teeth Caries
Crowded
Tooth Loss

Gums Tongue Buccal Tonsils Palate Uvula

Mucosa
Color Condition Midline Pink Pink Pinkis Present
h
Pinked Swollen Deviated Dry Red Smoot Deviate
__L __R h d
__L __R
Red Bleeding Pinkish Moist Swollen Others Absent
,
Specif
y
Discolor Lesions Moist Lesion Enlarge
ed s d
Others, Moist Dry With
Specify Exudate
s
Furrow
Craked
Lesions
Others,
Specify

Buccal
Accessories
Braces
Dentures
Retainers
Jacket

Neck and Lymph Nodes

Neck Lymph Nodes Thyroid
ROM Symmetry Pulsation Lymphadenopathy Non Palpable
(Location)_________ Bruist
Full Symmetrica Present Tenderness Palpable
l (Location)_________
Partial Asymmetric Absent Swollen Clump Bilateral
al (Location)_________ ______ _______
Absent

Others,
Specify

Thorax and Lungs

___AP ___L Lung Expansion Tactile Fremitus Percussion Notes Breath Sounds
Ratio
Funnel Symmetrica Symmetrica Resonant Normal
Chested l l
Pigeon Asymmetric Asymmetric Hyperresonan Abnorm Location
Chested al al t al
Barrel Dull Crackles
Chested
 Others, Others, Ronchi
Specify Specify
Wheeze
s
Pleural
Friction
Rub
Others,
Specify

Breast
Symmetry Areola Breast Skin Nipples Mass/es [ ] Solitay [ ] Multiple
Symmetric Color Hyperpigmentati Flat Location: Consistency
al on
Asymmetri Bronish Redness Inverted Size: Soft
cal
Pinkish Bulging Fissure Diameter: Firm
Others, Dimpling Ulceration Tender Non- Hard
Specify tender
Edema Bleeding Shape Movable
Orange-Peel Displaced Oval Fixed
Looking Skin
Others, Specify Retacted Round
Discharge Lobulated
s:
Describe
Indistinct

Heart
Flat Pericardial Area Heart Sounds
Bulging BPM
Pericardial Area Regular
Heaves Irregular
Thrills Distinct
Pulsation Location Faint
PMI Location at: Murmurs
Pericardial Friction Rub
Third Heart Sound or S3
Fourth Heart Sound or S4
Others, Specify

Abdomen
Symmetry Contour Skin Umbilicus Obvious Abdominal
Pulsation Sounds
Symmetrica Flat Pale Midline Presen Flat
l t
Asymmetric Rounded Red Inverted Absen Tympanic
al t
Scaphoid Yellow Averted Dull
Protubera Striae Discolorati
nt on
Specify____
Glistering
Masses of
bulges
Surgical
Scars,
Location:

Liver Span Spleen

Approx. Size Dullness
_____6-12 cms Tenderness
_____over 12 cms Rebound
Tenderness
Other Observations
Fluid Wave
Muscle Guarding
Direct Tenderness
Indirect Tenderness

Male Reproductive
Penis
_____Present
_____Absent
Uncircumcised
Circumcised
Female Reproductive Discharges
Vaginal Bleeding Lesions
_____Profuse Scars
_____Scanty Scrotum
Masses _____Present
Discharges _____Absent
Lesions Discolorations
Scar
Edema
Odor, Describe_________

Pubic Hair Anus

____Present Specify Hemorrhoids
Characteristics ____Present ____Absent
____Absent ____Tender
____Non-Tender

Spine
Midline
Kyphosis
Scoliosis
____Deviated to the Left
____Deviated to the Right
Tenderness
Musculo-Skeletal Swelling
Arms and legs Symmetrical Spasm
Joint Swelling, Location
Muscle Spasm, Location
Muscle weakness, Location
Muscle Atrophy, Location
Muscle Wasting, Location
Tenderness, Location Neurologic
Deformities, Location CRANIAL INTAC NOT INTACT
Fasciculation, Location NERVES T
Involuntary Movement, Location
Cranial Nerve I
Others, Specify Cranial Nerve II
Cranial Nerve III
Cranial Nerve IV
Cranial Nerve V
Cranial Nerve VI
Cranial Nerve VII
Cranial Nerve
VIII
Cranial Nerve IX
Cranial Nerve X
Cranial Nerve XI
Cranial Nerve XII
 Sensory
Responds to Light touch
Responds to Pain
Able to Maintain Standing Position with Feet Together and Eyes
Closed
Stereognosis
Graphesthesia
Two point Discrimination
Others, Specify

Motor
Range of Motion (ROM)

Legend
Grade Percent Interpretation
5- Full ROM against Gravity, Full 100 Normal
Resistance
4- Full ROM against Gravity, Some 75 Good
Resistance
3-Full ROM with Gravity 50 Fair
2-Full ROM with Gravity eliminated, 25 Poor
Passive Motion
1-Slight Contraction 10 Trace
0-No Contraction 0 Zero

Muscle Strength

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

SIGNIFICANT FINDINGS & INTERPRETATION:

Examined by:

__________________________
University of Pangasinan
College of Nursing
Student-Nurse

Date: _____________________

Noted by:

_________________________
University of Pangasinan
College of Nursing
Clinical Instructor

Date: ____________________
 University of Pangasinan
College of Nursing
Dagupan City, Philippines

NURSING CARE PLAN

Alias/age: Date Handled:
Medical Dx: Date Submitted:

Assessment Nursing Nursing Analysis Expected Nursing Interventions Rationale Evaluation

Diagnosis Outcome
 

________________________ __________________
Clinical Instructor/Agency UPCN-SN/Shift
 University of Pangasinan
College of Nursing
Dagupan City, Philippines

DRUG STUDY
Alias/age: Date Handled:
Medical Dx: Date Submitted:

Drug Action Indication Contraindication Interaction Adverse Effect Nursing Consideration

Name

________________________ _________________
Clinical Instructor/Agency UPCN-SN/Shift