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A Medical/Surgical Case
Presented to the
Faculty of the Philippine Women’s
University-CDCEC Bataan,
City of Balanga, Bataan


In Partial Fulfillment of the Requirements for the Course

Practical Nursing



Ven Jonas M. Maniago

March 18, 2019
I. Introduction

Background of the study


Significance of the study:

Scope and limitation of the study:
Goal and objectives:
Overview of disease:
Anatomy and physiology of affected system: (both normal and abnormal. With illustration or

II. Biographic Data

Name: Romualda Roxas Ceralde
Address: Ma. Fe Orani Bataan
Age: 59
Gender : Female
Civil status: Widowed
Educational level: High School Graduate
Religious affiliation: Roman Catholic
Occupation: Housewife

III. Nursing History

Past Health history

1. Childhood Illness: Chicken Pox, Shaking of lips
2. Immunizations: Fully Immunized
3. Allergies: None
4. Accidents: No
5. Hospitalizations: No
6. Medications used or currently taken:

History of present illness

1.What happened to patient prior to hospitalization?
 After drinking coffee, she had an argument with her niece and suddenly
she felt dizziness and irritability.

2.Sign and symptoms observed prior to hospitalization

 The patient experienced dizziness and irritability.

3.Medication given prior to hospitalization

 The patient did not take any medicine, instead, they gave her water to
drink and placed a wet towel in her head. And then brought her to the
Family History
Hereditary disease of family
 According to the patient her father and her mother had hypertension.

IV. Activities of daily living

ADL Before Actual Interpretation and
Hospitalization Hospitalization Analysis
Nutrition Coffee Fried fish,Rice and
Elimination Normal Normal
Activity Household Chores Resting
Hygiene Clean Not Presentable
Substance Use None
Sleep and Rest Always late Always late
Sexual Activity None None

V. Physical Activity
Normal Actual Findings Interpretation and
1. General
Appearance ✔
 Mood and

 Signs of

 Posture Slightly Curved

 Body

 Hygiene and Not Presentable


 Types of

 Quantity and
Quality of


 Relevance
Organization ✔
of thoughts

Vital Signs
 Body Temp 36.3

 Pulse Rate 73

 Respiratory
Rate 21

 Blood 220/130
Pressure Hypertensive

VI. Laboratory Test and Diagnostic Exam

VII. Drug Study

Generic Dosage / Classification Indication Contraindication Side Nursing
/ Trade Frequency Effects Responsibilities

VII. Pathophysiology
(Connect it to identified Nursing Problem/s)

VIII. Prioritization

Nursing Problem Cues Justification

Hypertension Irritability, Dizziness The patient experienced this
cues due to increase blood
BP: 220/130 pressure
RR: 21
PR: 73
(One NCP per Nursing Problem)
Assessment Diagnosis Planning Intervention Evaluation

XII. Discharge Summary