ANGELES UNIVERSITY FOUNDATION

College of Nursing
Health Assessment
2nd Semester
2019-2020

Case 1
Rabies
Mr. Nak A. Gat, 28-year-old, veterinarian visits an out-patient department facility with a
laceration on the right ankle. The laceration occurred 1 month prior to consult and was due to a bite of a
cat that was being observed in the facility that the patient was working at. The laceration was violaceous
in color, measuring 6 cm with pus around the periphery of the wound. Together with the laceration
were two puncture sites at the lateral aspect of the ankle. Upon further assessment and interview, Mr.
Nak A. Gat mentioned that he cleaned his wound with running water and applied garlic to the wound. 1
week after the incident, he went to a nearby health center and was given one dose of Tetanus Toxoid
Injection. He is also drinking Paracetamol every 4 hours and no other medication taken. He now goes to
you because of a change in behavior. He verbalizes that “nauulol na ata ako.” He is accompanied by his
workmate and says that the patient is exhibiting a change in behavior a week prior to this consult. His
workmate shares: “He is acting strange; he is not like that before. He is afraid of water and screams even
with the slightest waft of air felt” His vital signs are Temp: 38.8 degrees Celsius, Respiratory Rate: 19
BPM, Pulse Rate: 98 BPM and a BP of 90 mmHg

1. Identify and group subjective cues from objectives cues from the case scenario

2. Identify cue clusters or clinical manifestations that is associated with the identified given medical
diagnosis

3. List possible nursing diagnosis that can be inferred from the case. (Actual, Risk and Health
Promotion)

Reminders:

1. Make a new document, type your whole name and section on top, next

2. Copy and paste the questions above and type your answers below each question, next

3. When you are done, save file name as Your Last Name, Your First Name, Your Section
Example: GalangMiguelSectionZ

4. Activity rubric is found below, use it as a guide in answering your activity. This is how you
will be graded. Note: Activity is from 9:00 -10:30 am only, sending email beyond 10:30 am is
considered late submission
 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 Subjective Appropriately Noted most of the Listed some of the Inaccurately Obviously incomplete
and Objective cues recognized all client’s subjective and subjective and identified subjective data input or totally
subjective cues and objectives cues objective cues and objective cues incomplete
objective cues presented from the presented from the presented from the
presented from the case scenario case scenario case scenario
case scenario.
Cluster data Accurately noted Partially identified Incoherent cues Cues presented Bizarre cues that are
associated to the certain cues/defining cues related to the noted which minimally totally not related to
given Medical characteristics to recognized problem indirectly referring to inaccurately related the problem or totally
Diagnosis support with the based on the case the problem to the problem incomplete
identified problem. scenario given
Cues identified shall
be related to the
problem recognized.
Propose possible Generated smartly Partly identified list of Inappropriately made Identified list of Identified totally
Nursing Diagnosis identified list of nursing diagnosis in list of nursing nursing diagnosis unclear nursing
nursing diagnosis congruence with diagnosis and not which is completely diagnosis and not
maybe wellness, or NANDA related with related with the cues not related to the utilized NANDA
health promotion cues and inferences and inferences but cues and inferences
diagnosis; risk supported with drawn from NANDA
diagnoses; or actual NANDA
diagnoses and
syndrome diagnosis
supported with
NANDA