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CENTRAL LUZON DOCTORS HOSPITAL EDUCATIONAL INSTITUTION San Pablo, Tarlac City

CASE STUDY FORMAT


I. Introduction II. Objectives Nurse centered III. Nursing Process A. Data Base a. Nursing health history A 1. Demographic data 2. Chief complaint 3. History of present illness 4. Past medical history 5. Family history 6. Social and personal history 7. Review of system b. Nursing health history B 1. General Description Of Client 2. Health Perception-Health Management Pattern 3. Nutritional-Metabolic Pattern 4. Elimination Pattern 5. Activity-Exercise Pattern 6. Sleep-Rest Pattern 7. Cognitive-Perceptual Pattern 8. Self-Perception Self-Concept Pattern 9. Role-Relationship Pattern 10. Sexuality-Reproductive Pattern 11. Coping-Stress Tolerance Pattern 12. Value-Belief Pattern c. Physical examination d. Laboratory Findings e. Review of anatomy and physiology f. Pathophysiology (highlight patient manifestation) B. NCP C. Drug Study D. Medical and Nursing Management E. METHOD IV. Evaluation a. Narrative evaluation of the objectives b. Patient condition upon discharge V. Recommendation VI. References/Bibliography

CENTRAL LUZON DOCTORS HOSPITAL EDUCATIONAL INSTITUTION San Pablo, tarlac city

CASE STUDY FORMAT


I. Introduction a. Introduction about patient/background Age Gender Address b. Significance/relevance to the concept c. Background knowledge Definition Causative agent Clinical manifestation Mode of transmission d. Current/target population e. Risk factors/contributing factors f. Prognosis and complications

II. Nurse centered a. Objectives

NURSING HEALTH HISTORY A Demographic data Patient: Date: Age: Examiner: Informant: I. II. III. Chief complaint History of present illness Past medical history (include dates and complications, if any) A. Pediatric and Adult Illness Pertussis Rheumatic Pneumonia Tuberculosis HPN Heart Disease Hepatitis Others Ward: C/S: Bed: Religion :

Sex:

Mumps Measles Chicken Pox Rubella

B. Immunizations/Tests BCG DPT OPV HEP B Measles For Flu For Pneumonia Others

C. Hospitalizations D. Injuries E. Transfusions F. Obstetrics/gynecologic History G. Medications

H. Allergies

IV.

Family history AGE L D List: Parents, Spouse, Children Health Status or Cause of Death Diseases Present in the Family

L D HD

= = =

Living Deceased Heart Disease

TB DM MI

= = =

Tuberculosis Diabetes Mellitus Mental Illness

HPN CA KD

= = =

Hypertension Cancer Kidney Disease

OB J O

= = =

Obesity Jaundice Others

V.

Social And Personal History Birthplace: Education: Age and Sexes of Children (if any): Clients position in the family: Residence Home Environment: Occupation Nature of present occupation: (stresses, hazards, etc.) Financial Support System: Habits (tobacco/alcohol use, others): Diet (meal distribution, others) Physical Activity/Exercise, if any: Birthday: Ethnic Background:

Brief Description of Average Day:

VI.

Review of system
General Description: Weight Loss: __________ Fatigue: ____________ Weakness: __________ Bruising: ________________________ Bleeding: ________________________ Color Change: ____________________ Vision Loss Excessive Tearing Anorexia: ____________

Night Sweats: ____________ Skin:

Itch: _________________________ Rash: ________________________ Lesions: ______________________ Eyes: Pain Diplopia Glasses/Contact Lenses Ears: Earaches Nose: Obstruction Throat and Mouth: Sore Throats Neck: Swelling Chest: Cough Wheeze Breast: CVS: Chest pain PND GIT: Food tolerance Vomiting Constipation GU: Dysuria Nocturia Hematuria Flank pain Male: Penile Discharge Female: Menarche: (age) Extremities: Joint pains Edema Neuro: Headaches Heartburn Pain Change in BM Palpitation Orthopnea Discharge Epistaxis Bleeding Gums Dysphagia Itch Blurring

Tinnitus Discharges Tooth Aches Hoarseness

Hearing Loss

Decay

Sputum: (Amount & Character) Hemoptysis Pain on Respiration Dyspnea: Rest/Exertion Lumps Pain Bleeding Discharge Dyspnea on exertion Edema Others: _________________________ Nausea Bloating Melena Retention Lesion LMP: (date) Polyuria Testicular pains Cycle: _____ Jaundice Excessive Gas

Dribbling others: others:

varicose veins Stiffness Dizziness

Claudication Deformities

Memory Loss Fainting

Numbness Tingling Paralysis: ____________ Paresis: _________ Seizures Others: ______________________________ Mental Health Status: Anxiety Sexual Problems Depression Fears Insomnia

NURSING HEALTH HISTORY B General Description Of Client

Health Perception-Health Management Pattern

Nutritional-Metabolic Pattern

Elimination Pattern

Activity-Exercise Pattern

Sleep-Rest Pattern

Cognitive-Perceptual Pattern

Self-Perception Self-Concept Pattern

Role-Relationship Pattern

Sexuality-Reproductive Pattern

Coping-Stress Tolerance Pattern

Value-Belief Pattern

PHYSICAL EXAMINATION
GENERAL SURVEY: Height: ______ Weight: ______ Body Makeup: ______ Communication Pattern: ______ Skin: Eyes: Color: __________ Turgor: ___________ Pupils: Bruises: __________ ______________________ No Distress Temperature: ___________ mmHg ___________ mmHg ___________ mmHg ____________ State of Hydration: _____________ Sclera: _____________________ Easy Breathing in Distress Respiratory: VITAL SIGNS: HR ___________ / min BP Supine R/L arm Sitting R/L arm Standing R/L arm Capillary Refill: ____________ RR: _____________________

Others: ______________________________ BODY POSITION/ALIGNMENT: Supine: _______ Fowlers: ________Semi-Fowlers: _______ others: _________________ Alignment: MENTAL ACUITY: Oriented Disoriented Amputation Gait EMOTIONAL STATUS: Euphoric Angry/Hostile Depressed Apprehensive Others: ___________________________ coherent incoherent deformity appropriately responsive inappropriately responsive paresis speech paralysis fracture others: ___________ Appropriate Inappropriate

SENSORY/MOTOR RESTRICTIONS: hearing disorder others: ______________________

MEDICALLY IMPOSED RESTRICTIONS: CBR w/out BRP_____ BR w/ BRP_____ OOB Chair_____ Restricted Ambulation _____ OTHER HEALTH RELATED PATTERNS: Fatigue Dyspnea ENVIRONMENT: Room Temperature: Adequate Inadequate Restlessness Dizziness Weakness Pain Insomnia Coughing Others: ______________________

Lighting: SAFETY:

Adequate

Inadequate

Violations of medical asepsis: ________________________________________________ Violations of safety measures: ________________________________________________ ACTIVITIES OF DAILY LIVING: Can/Cannot perform Feeding Dressing Brushing teeth Combing Bathing Transferring Others: __________________________________

PHYSICAL EXAMINATION FINDINGS HEAD/SKULL: EYES/VISION: EARS/HEARING: NOSE, MOUTH AND THROAT: NECK AND LYMPH NODES: THORAX (CHEST AND LUNGS): Anterior: Posterior: HEART AND CARDIOVASCULAR SYSTEM: ABDOMEN: NEUROLOGICAL: MUSCULOSKELETAL: GENITALIA:

EXTREMETIES: (Follow IPPA format when documenting Physical Examination findings) LIST OF IDENTIFIED NURSING PROBLEMS PRIORITIZATION OF NURSING PROBLEM 1. 2. 3. 4. 5. 6. 7. 8. Oxygenation Nutrition Elimination Activity and Exercise Comfort and Safety Sexual- Reproductive Psychological Psychosocial

LABORATORY FINDINGS

Review of anatomy and physiology

Pathophysiology (highlight patient manifestation)

NCP ASSESSMENT CUES NURSING DIAGNOSIS SCIENTIFIC EXPLANATION PROBLEM STATEMENT (GOAL) INTERVENTION EVALUATION NURSING INTERVENTION RATIONALE

Drug Study
DRUG NAME/ GENERIC CLASSIFICATION DOSAGE/ STOCK DOSE ACTION INDICATION CONTRA INDICATION SIDE EFFECTS ARVERSE REACTION NURSING RESPONSIBILITIES

Medical Management (

Nursing Management

Discharge Planning METHOD (Example) M (Medications): Lasix (Furosemide). Decreases swelling and blood pressure by increasing the amount of urine. Expect increased frequency and volume of urine. Report irregular heartbeat, changes in muscle strength, tremor, and muscle cramps, change in mental status, fullness, ringing/roaring in ears. Eat foods high in potassium such as whole grains (cereals), legumes, meat, bananas, apricots, orange juice, potatoes, and raisins. Avoid sun/sunlamps. Take with breakfast to avoid GI upset. Digoxin (Lanoxin). Used to treat CHF. Taking too much can result in GI disturbances, changes in mental status and vision. Report the following signs/ symptoms to your doctor: Nausea, vomiting, lack of appetite, fatigue, headache, depression, weakness, drowsiness, confusion, nightmares, facial pain, personality changes, sensitivity to light, light flashes, halos around bright objects, yellow or green color perception. Take pulse rate for one minute before dose and call doctor if pulse is below 60 before taking medication. Dont increase or skip doses. Dont take over the counter medications without talking to MD. Report for follow-up visits with your doctor to monitor lab values. E (Exercise/Environment): Your eldest daughter will provide help with activities of daily living in the home. She will transport you to followup appointments. It is important to take steps to prevent falls: use of a 3-point cane for stability with ambulation; removing objects like throw rugs, cords that may cause fall; pausing before standing and again before walking to prevent drop in blood pressure. The life line allow you to access 911 for emergency help. You may resume activities as tolerated and you have a follow-up appointment with the doctor in 1 week. T (Treatments): Apply A & D ointment to reddened coccyx and heels three times a day. Keep pressure off of these areas by keeping off of back and elevating heels off of bed. Keep skin clean and dry. Report any changes in skin condition to doctor. (i.e. open areas, drainage, elevated temp.) H (Health knowledge of disease): Lasix can cause a loss of potassium. It is important to eat foods high in potassium and to have regular blood levels drawn to make sure potassium level stays normal. Monitoring the pulse rate before taking digoxin is important because this medicine can cause the pulse to drop. Call the doctor if pulse rate is below 60 beats per minute. New signs and symptoms should be reported to the physician, because they may indicate electrolyte imbalance &/or digoxin toxicity. Sodium causes water retention so it is important to limit sodium intake by eating a no added salt diet. Be careful to check labels for hidden salt content. O (Outpatient/inpatient referrals): (include resources such as websites and organizations): American Heart Association www.americanheart.org Visiting Nurses Association for F/U skin assessment. Referral made to outpatient dietician for diet planning. Meals on Wheels. D: (Diet): Do not add salt to your diet. Eat foods high in potassium such as bananas. We will arrange for you to meet with the dietician.

Evaluation a. Narrative evaluation of the objectives b. Patient status after discharge Recommendation References/Bibliography