Health Assessment

2nd Semester
2019-2020

SECTION 1-A

Instructions:
Download, Answer using this file then save as SURNAME_HA1 (Eg. ESPIRITU_HA1)
send to neilfespiritu@gmail.com on or before 10AM. Thanks!

Case 1: Hypercalcemia secondary to Vit D intoxication (15pts)

A 28 year old woman is brought to the ER department due to progressive

lethargy. For the last 3 weeks, she has also had loss of appetite, constipation, muscle
weakness, and increased thirst and urination. The patient’s medical history is
unremarkable. She takes no prescription medications but has been taking large doses of
vitamin D supplements in the belief that they are beneficial for her health. The patient
does not use tobacco, alcohol, or illicit drugs. On physical examination, she is stuporous
and has dry mucous membranes. VS: BP:80/50mmHg, RR: 20cpm, PR: 110bpm.

1. Identify subjective and objective cues from the scenario

2. Identify cue clusters or clinical manifestations that is associated with the
identified given medical diagnosis
3. Identify possible Nursing diagnoses based from the case above.
 RUBRIC FOR HEALTH ASSESSMENT – CASE STUDY SCENARIO
ACTIVITY ONE

Scales of Very Good Good Fair Poor Very poor

Measurement (5) (4) (3) (2) (1)
Identify Appropriately Noted most Listed some of Inaccurately Obviously
Subjective and recognized all of the the subjective identified incomplete
Objective cues client’s subjective and objective subjective data input
subjective and cues presented and or totally
cues and objectives from the case objective incomplete
objective cues cues scenario cues
presented presented presented
from the case from the from the
scenario. case case
scenario scenario
Cluster data Accurately Partially Incoherent Cues Bizarre
associated to noted certain identified cues noted presented cues that
the given cues/defining cues which minimally are totally
Medical characteristics related to indirectly inaccurately not related
Diagnosis to support the referring to the related to to the
with the recognized problem the problem problem
identified problem or totally
problem. based on incomplete
Cues the case
identified scenario
shall be given
related to the
problem
recognized.
Propose Generated Partly Inappropriately Identified Identified
possible smartly identified made list of list of totally
Nursing identified list list of nursing nursing unclear
Diagnosis of nursing nursing diagnosis and diagnosis nursing
diagnosis diagnosis not related which is diagnosis
maybe in with the cues completely and not
wellness, or congruence and inferences not related utilized
health with but supported to the cues NANDA
promotion NANDA with NANDA and
diagnosis; risk related inferences
diagnoses; or with cues drawn from
actual and NANDA
diagnoses and inferences
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diagnosis
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with NANDA
ANSWERS:

Case 1: Hypercalcemia secondary to Vit D intoxication

1. Identify subjective and objective cues from the scenario

Subjective data:
Loss of appetite
Constipation
Increase thirst and urination

Objective data:
Vital signs: BP:80/50mmHg,
RR: 20cpm,
PR: 110bpm
Hypotension
Stupor
Dry mucous membranes
Muscles weakness
Fractures and Pain

2. Identify cue clusters or clinical manifestations that is associated with the

identified given medical diagnosis

“.. NO PRESCRIPTION MEDICATIONS BUT TAKES A LOT OF VITAMIN D…. “

“NOT SMOKING/NOT ALCOHOLIC/TAKING ILLICIT DRUGS”

= Increase uptake of Calcium & VIT D SUPPLEMENTS causes an OVERACTIVE PARATHYROID

GLANDS.
= Loss of appetite due to imbalance of electrolytes that loses body fluids through diarrhea or
vomiting.
= Due to high levels of Hypercalcemia causes abnormalities in heart and kidneys.
= not effectively hydrated due to excess of Calcium in the body leading to urinate more. Also
causes dry mucous membranes.
= Due to an increase of Parathyroid hormone secretion it lowered the blood pressure.
= Due to excretion of excess Calcium in the body leads to thirst, fractures and muscle pain.

3. Identify possible Nursing diagnoses based from the case above.

Drug: Calcitonin Furosemide

Diet: High-phosphate and Increase fluids
Nursing diagnosis: monitor for Renal
stones