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CASE STUDY FORMAT I.

PATIENT DEMOGRAPHIC PROFILE Name: ____________________________ Age/Gender:_______ Status:_______ Home Address: ____________________________________________________ Religion: ____________ Nationality:___________ Occupation:______________

II. HEALTH HISTORY PROFILE Past Medical History 1. Pediatric and Adult Illness Date Illness Medication Remarks

2. Immunization Immunizati on Doses Dates Remarks

3. Hospitalization Date/Yea r Hospital Diagnosis Duration

4. Injuries and Accidents 5. Transfusions

6. Allergies (specify) Family History (support with genogram and limit to two (2) generation if patient can recall)

Social and Personal History 1. 2. 3. 4. 5. 6. 7. 8. Occupation Number of Children Military experience, foreign travel Habits Diet Type of Family Cultural and Religious Beliefs Brief description of average day

Review of System (for past 6 months). Physical Assessment General Weight loss Chills Fatigue Fever Anorexia Night Sweats

Weakness

Skin

Itch

Rash

Lesions

Bruising

Bleeding

Color Change

Eyes

Pain tearing

Discharge

Itch

Vision loss

Diplopia

Excessive

Glasses/contact lens

Date of last exam

Ears Nose Throat and Mouth

Earaches Obstruction Sore throats

Discharge

Tinnitus

Hearing loss

Discharges

Epistaxis Toothache Dentures

Bleeding gums

Neck and Head Chest

Swelling Cough

Dysphagia

Hoarseness Wheeze

Sputum: Amount and Character Hemoptysis Dyspnea

Pain on respiration

Cardiovascular

Precordial pain Thrombophlebitis

Palpitation Orthopnea

Dyspnea on Exertion

Paroxysmal

nocturnal dyspnea

Edema Heart murmur

Claudication

Gastrointestinal

Nausea

Vomiting Diarrhea

Food Intolerance

Excessive gas or

indication Constipation Bloating Melena Extremities Joint pains

Change in bowel movement Jaundice

Hemorrhoids Hernia Claudication Back Pain Edema

Varicose veins

Stiffness Deformities Endocrine Hot flashes Goiter Neurology Numbness Tingling loss Dizziness Tremor Fainting Headaches Muscle Memory Hair loss Temperature intolerance Polydipsia

weakness Ataxia Unconsciousness Paralysis/ paresis Seizure

Psych

Anxiety

Depression

Sexual problems Insomnia Nightmares

III.

CURRENT HEALTH PROFILE A. Presenting complaints and medical diagnosis to include intervention

done prior to hospitalization Application of the Nursing Process 1. Assessment Findings (Head to Toe)

Body Parts / Technique
Head
Palpation Size, shape or contour, symmetry and curvature.

Actual Findings

Normal Findings Interpreta tion
Proportion to the size of the body, round, with prominences in the frontal area interior and the occipital are posterior, symmetrical in all planes, gently curved.

1.Skull

Inspection Carefully separate the hair at various locations. Inspect for color, White, clean, free from masses, lumps, scars,

2.Scalp

appearance, and presence of masses, lice nits, and dandruff. Palpation Areas for tenderness

lice, nits, dandruff, and lesions.

3.Hair
Inspection Inspect for the color, distribution, thickness, and lubrication or appearance. Palpation Palpate for texture

No areas of tenderness.

Black evenly distributed and covers the whole scalp, thick, shiny and free from split ends.

Coarse of fine

4.Face
Inspection Observe for the symmetry, shape, facial expression, movement and appearance. Oblong or oval or round or square or heartshape, symmetrical, facial expression that is dependent on the mood or true feelings, smooth and free from wrinkles and no involuntary muscle movements.

5.Eyes
Inspection Observe for placement, symmetry, protrusion, clarity, and lacrimations. *Eyebrows Inspection Observe for color, symmetry, and quantity of hair, distribution and placement unparallel. *Eyelashes Inspection Observe for the color, distribution and direction *Eyelids Inspection Ask the client to close eyes. Observe for position and symmetry and then ask him to open eyes again. Palpation Using the tip of the index

Parallel and evenly placed, symmetrical, non protruding, with scant amount of secretions, both eyes bright and clear. Black, symmetrical, thick, raise and lower symmetrically, evenly distributed and parallel with each other. Black evenly distributed and tuned outward.

Upper lid covers a small portion of the iris and the cornea and sclera when the eyes are open. When the eyes are closed---the symmetrical

finger, palpate the lacrimal gland. Non-palpable, non tender. *Lower palpebral conjunctiva Inspection Ask the client to look up and pull the lower lid down, Observe for color and appearance. *Sclera Inspection Color and clarity *Cornea Inspection Clarity and texture *Pupils Inspection Size, shape, symmetry, reaction to light and accommodation. Transparent, shiny, smooth. Round, equal constrict when light is pointed to the eyes and dilated when light is removed, constrict when object is close to the eyes and dilated when object is removed away.

Salmon pink, shiny, moist.

White and clear, no visible blood vessels.

Iris Inspection Size, color, shape

*Testing for eye movement Inspection Stand directly in front of the client and hold the finger at about one foot in front of the client’s eyes. Ask the client to refrain from moving his head and follow the direction of the examiner’s fingers with his eyes only. Move the finger in a slow manner though the cardinal fields of gaze. *Testing for visual fields Inspection Stand 2-3 ft. from the client. Ask (one ear at a time and then at the back of the client for both ears).

Proportional to the size of the eyes, round, black brown, symmetrical.

Able to move eyes in full ranges of motion or able to move in all direction.

Able to see 60 degrees superiority.

Midline, symmetrical and patent.

Able to repeat the words

Instruct the client not to move his head and to repeat the words that you will say.

6.Nose
Inspection Placement, symmetry and patency. *Internal nares Inspection Appearance, color of mucus membrane, presence of cilia. In the correct placement, Patent and symmetrical

Clean, pinkish, with few cilia.

*Septum Inspection Appearance

7.Mouth
*Lips Inspection Observe for color, shape, symmetry, lip margin and appearance *Gums Inspection Observe for color, appearance, discharge and swelling or contraction. *Teeth Inspection Number, color, alignment, general condition, breath *Tongue Inspection Inspect for size, color, surface, appearance and movement *Frenulum Inspection Position and appearance *Checks (buccal mucosa) Inspection Color and appearance

Straight.

Pinkish, symmetrical with lip margin well defined, smooth and moist.

Pinkish, smooth, moist, no reseeding, no swelling and no discharge

32 permanent teeth, well-aligned, free from caries or filling and no halitosis. Large, medium, red or pink, slightly rough in top, smooth along the lateral margins, moist shiny and freely movable. Midline, straight end thin

8.Palate
*Soft palate Inspection Color and appearance *Hard palate Inspection Color and appearance. *Uvula Inspection Position, color, size, symmetry, And mobility *Tonsils Inspection Detect if there is hoarseness of voice

Pinkish, moist and smooth

Pinkish, moist, smooth

Slightly pinkish

At the center Symmetrical and freely movable

9.*Neck
Inspection Size, symmetry, position *Palpation Palpate for lumps, masses or areas of tenderness Palpates the Adam’s apple (for male)

Pinkish, non-inflamed

Proportional to the size of the body and head, symmetrical and straight. No palpable lumps, masses or areas of tenderness Palpable Freely movable without difficulty

Range of motion Chin to chest Ear to shoulder Muscular strength Inspection Symmetry and strength of the sternocleidomastoid muscle Force/strength of the trapezius muscle

Symmetrical and able to resist applied force(both muscle)

10. Thorax
(Anterior and posterior) Inspection Have the client all comfortably. Inspect for the shape, position of the spine, slope of the ribs, retraction of

Able to resist applied force symmetrical in structure of size and muscular strength

The chest contour is symmetrical and the

the intercostals spaces (ICS) on the inspiration, and bulging of the ICS on experimentation.

Observe for symmetry of the chest wall during respiration

chest is twice as wide as deep (anteriposterior diameter in a 1:2 ratio) the spine is straight posteriorly, the ribs tend to slope across and down the ribs are prominent in a thin person there is no bulging or retraction of breathing. The chest wall moves symmetrically during respiration

Palpation Palpate for lumps, masses, areas of tenderness. Measure chest excursion (to determine the depth of breathing). Place hands on the lower portion of the rib cage with the thumbs 2 inches apart pointing toward the spine so a small fold of the skin appears between the thumbs. Ask the client to take a few deep breaths. Elicit lacille fromitus (a thrill felt by the hand on the chest wall while the client is speaking). Place the palms of the hands bilaterally symmetrical on the chest. Start from the top of the chest wall going down .each time the hands move down, ask the client to say ninetynine or one-one –one with the same intensity of voice. Percussion: Anterior thorax. The client is preferably in a lying position. Posterior thorax. The client is sitting position with the arms folded forward across the chest. This position will separate scapulae further to expose more lung to assessment. Using the direct percussion,

No lumps, masses, areas of tenderness sides of the thorax expand symmetrically. the examiners thumb separate approximately 2 inches during breathing

The vibrations are feeling most strongly between the first and second ribs along the sternum interiorly and between the scapulae posteriorly.

Vesicular sounds are heard over lung periphery particularly at

percuss in the ICS over symmetrical areas of the chest starting from the supraclavicular area. Compare one side of the chest with the other.

Auscultation: Use the flat-disc diaphragm. Use the systematic zigzag procedure used in percussion. Ask the client to take slow deep breaths through the mouth. Listen at each point to the breath sounds during a complete respiration. Compare findings at each point on the opposite side of the chest.

the base of the lungs, they are soft intensity, low pitched gentle sighing sounds created by hair moving through smaller airways bronchovessicular so this are heard at the 1st and 2nd IC at the sternum interiorly and between the scapulae posteriorly

No pulsations.

*Heart
Inspection and palpation: Place the client in supine position. Stand in the client’s right side. Ask client not to talk. Inspect and palpate the valve areas of the heart. *Aortic areas Around at the 2nd ICS on the right angle of Louis as a dominance on the Sternum *Pulmonic Area- at the 2nd ICS on the left of Louis. Note: Observe these areas at an angle to the side to improve the chance of seeing pulsations. *Tricusspid Area – move the fingers along the client’s left sternal border to the 5th ICS. *Apical Area – moves the fingers laterally to the left mid-clavicular line (LMCL), which is slightly below the nipple. This point where the apex touches the anterior chest wall is known as the

Pulsations visible and palpable

Abdominal aortic pulsation visible and palpable. The 2 heart sounds are audible in all areas but loudest at apical area.. CR ranges from 60-100 beats per minute.

Females: variable in size depending on body build, rounded shape, symmetrical Males: Flat,

point of maximal impulse (PMA)

symmytrical, if obese, may be slightly rounded.

*Epigastric Area – at the tip of the sternum. Auscultation: Auscultate the hearth in all 4 anatomic sites: aortic, pulmonic, tricuspid and apical (mitral) Eliminate all sources of room noise. Heart sounds are of low intensity and other noise hinders the nurse’s ability to hear them. Identify the first sounds described and “lub”. Then, identify the 2nd sound. This is higher – pitched that SI, described as “dub” Use the bell-shaped diaphragm. Once SI and S2 are identified, count the heart rate for one minute. Each combination of S1 and S2 counts as one heart beat.

11.Breast
Inspection Ask the client to remove the top gown or drape to allow simultaneous visualization of the breast. Have the client sit comfortably with arms at the sides. Inspect the breast for size, symmetry and contour or shape. Skin is the same in color in the abdomen, no retractional dimpling.

Inspect the skin of breast for color, retraction, or dimpling.

Palpation Assist the client in supine position. This position allows the breast tissues to flatten evenly against the chest wall facilitating palpation. Ask client to false his/her hand and place it under the head palpate the breast for lumps or masses, tenderness, and consistency of breast tissues.

No masses or lumps, tenderness, breast tissues are firm and elastic.

The palmar surface of the first three fingers is used to compress breast tissues against the chest wall. Perform palpation in a clockwise rotary motion from the borders going inward. *Areola Inspection Inspect for size, shape, color and summetry.

Round or oval, color darker that surrounding skin, symmetrical

No masses and tenderness.

Palpation Palpate for masses and tenderness

*Nipples
Inspection Inspect for size, shape, position, discharge and lesions.

Round, averted, equal in size, similar in color. Both nipple points in one direction, no discharge, no lesion

No masses, tenderness and discharge.

Palpation Use thumb and index finger to compress the nipple to determine any discharge.

12.Abdomen
Divide the abdomen into 4 imaginary quadrants. Draw a vertical line from the xipoid process to the symphysis pubis and a horizontal line across the umbilicus. These quadrants are labeled right upper quadrants (RUQ).left lower quadrants (LLQ), and right lower quadrant (RLQ) Ask the client if he/she needs to void. Drape the upper chest and legs. Explore the abdomen from the xipoid process to the symphisis pubis. The client lies in supine position with arms down at the sides. A small pillow may be placed under the head. Inspection Inspect the abdomen for skin integrity, color, contour, symmetry, movement or

Skin is unblemished, no scars, color is uniform, flat, rounded or scapoid, symmetrical movement caused by respiration, nortic pulsation at epigastric are visible thin persons, umbilicus is flat or concave positioned midway between the xipoid process and the symphisisd pubis, color is the same as the

pulsations and color and placement of umbilicus. Auscultation Warm the diaphragm of the sytethoscope. Cold stethoscope may cause the client to contact the abdominal muscles and the contractions may be heard during auscultation. Diaphram is used because intestinal sounds are high pitched sounds. Place the diaphragm in each of the 4 quadrants over all auscultation sites. It may take minute to hear bowel sounds. Palpation Perform light palpation first to detect areas of tenderness, muscle guarding (voluntary tightening of muscles), lumps or masses, constancy, and organomegaly. Depress the abdominal wall lightly, about 1 cm with the pads of your fingers. Move the finger pads in a sight circular motion. Palpate all 4 quadrants. Palpate the liver using deep palpation. Stand on the client’s right side. Place your left hand on the posterior thorax at about the 11th and 12th rib and then apply upward pressure. This maneur makes it easier to feel the liver anteriorly. With the fingers of the right hand pointing upward, place the hand on the RUQ well below the liver’s lower border, then press gently until you reach a depth of 1 ½ - 2 inches. Ask the client to take a deep breath using the abdominal muscles. As he inhales, try to palpate the liver’s edge as it descends. Percussion Percuss each of the 4 quadrants starting from the

surrounding skin.

Liver’s edge feels firm and non-tender

Tympanic ground predominated because of the air in the stomach and intestines. Percussion sound is dull at the liver’s lower portion.

Perform with ease

Perform with ease

RUQ going clockwise. Symmetrical in size and length, no abnormalities, fine hair equally distributed, no visible varicose vein

*Wrist
Ask the client to flex and extend hands at the wrist and then perform radial and ulnar flexion. *Hands and fingers Ask the client to do flexion, extension, abduction of fingers,

Warm and smooth

13.Lower Extremities
Inspection Inspect for symmetry of size and length and the presence of abnormalities. Note the pattern of hair distribution, color and presence of varicose veins. Palpation Palpate from thighs to logs for temperature, and texture. *Feet and Toes Inspection Inspect for cleanliness, skin lesion and number of toes

Clean no lesions, 5 toes on each foot.

Performs with ease

Performs with ease

Performs with ease

*Hips
*Range of Motion Ask the client to do flexion, extension, abduction, adduction, and internal external rotation of the legs *Knees Ask the client to flex and extend each leg *Ankle Ask the client to do flexion, extension, aversion, and inversion of each foot. *Foot and Toes Ask the client to flex, extend,

Performs with ease

abduct and adduct toes

Laboratory/Diagnostic Results Date Lab exam Patient result Normal Findings Interpretatio n/ Significant

2. NCP 3. Drug Study 4. Discharge Plan (M-E-T-H-O-D-S)