VISION MISSION

Republic of the Philippines Cavite State University shall provide

A premier university in historic
Cavite recognized for
excellence in the development
of morally upright and globally
competitive individuals.
CAVITE STATE UNIVERSITY
Don Severino Delas Alas Campus
Indang, Cavite
excellent, equitable and relevant
educational opportunities in the arts,
science and technology through
quality instruction and relevant
research and development activities.
It shall produce professional, skilled
and morally upright individuals for

College of Nursing global competitiveness.

TITLE OF THE CASE

Presented by:

YEAR LEVEL / SECTION / GROUP #:

Members

Presented to:

Prof. _________________ , RN, MAN

Prof. _________________ , RN, MAN
Prof. _________________ , RN, MAN
Prof. _________________ , RN, MAN
Clinical Instructors, Level II or III

Date:

Month xx, year

In Partial Fulfillment of the Requirement in NURS 50/55 or NURS 60/65 for the Degree Bachelor of
Science in Nursing
 TABLE OF CONTENTS

I. Demographic Data………………………………………………………………………………….1

II. Reason for Seeking Health Care…………………………………………………………………1

III. History of Present Illness…………………………………………………………………………..1

IV. Past Medical

History………………………………………………………………………………...1

V. OB-Gynecological History………………………………………………………………………….1

VI. Heredo-familial History…………………………………………………………………………...1-2

VII. Developmental History……………………………………………………………………………...2

VIII.Gordon’s Functional Health Patterns…………………………………………………………..2-5

IX. Physical Examination…………………………………………………………………………….5-12

X. Diagnostic Test…………………………………………………………………………………..12-13

XI. Review of System……………………………………………………………………………………13

XII. Concept Maps………………………………………………………………………………………..13

XIII.Case Management…………………………………………………………………………………..14

A. Medical……………………………………………………………………………………………14

B. Surgical……………………………………………………………………………………………14

C. Nursing…………………………………………………………………………………………15-16

XIV. Ongoing Appraisal………………………………………………………………………………….16

I. DEMOGRAPHIC DATA
A. Initials of Clients’ Name Date of Admission:
B. Address Time of Admission:
C. Age
D. Birth Date Date of Interview:
E. Birth Place Primary Informant:
F. Gender Secondary Informant:
G. Civil Status Other Data Sources:
H. Religion
I. Highest Educational Attainment
J. Occupation
K. Monthly Income / Budget
II. REASON FOR SEEKING HEALTH CARE

III. HISTORY OF PRESENT ILLNESS

(Critical characteristics: setting, timing, location, quality, quantity, associated factors: aggravating /
alleviating; client’s perception)
IV. PAST MEDICAL HISTORY
A. Childhood / Adult Diseases
B. Injuries / Accidents
C. Hospitalization
D. Operation
E. Allergies
F. Medication
G. Immunization (to be tabulated for Pedia clients to keep track of time interval and dose, but for
Adult clients state if they have been fully immunized or not)
H. Last Examination
V. OBSTETRIC-GYNECOLOGICAL HISTORY (if applicable)
A. Menarche
B. Menstruation
- LMP
- Usual amount
- Usual Duration
- Cycle
- Associated discomforts and relief measures
C. EDC, AOG, GP-TPALM
VI. HEREDO-FAMILIAL HISTORY
A. Genogram
Paternal Side Maternal Side
CT DU DM MR

64 y/o 65 y/o 59 y/o 55 y/o

A&W CVA CA A&W

JT DM LB
unknown LEGENDS: will depend on what is used.
25 y/o 26 y/o 36 y/o
A&W PIH COPD

NDT ET GB

5 y/o 3 y/o 8 y/o

 A&W A&W A&W

B. Family APGAR
Constructs Questions Almost Some of Hardy
Always the Time Ever
(2) (1) (0)
Adaptation I am satisfied with the help that I receive
from my family when something is
troubling me.
Partnership I am satisfied with the way my family
discusses items of common interest and
shares problem-solving with me
Growth I find that my family accepts my wishes
to take on new activities or make
changes in my lifestyle.
Affection I am satisfied with the way my family
expresses affection and responds to my
feelings such as anger, sorrow and love.
Resolve I am satisfied with the way my family and
I spend time together.
TOTAL

VII. DEVELOPMENTAL HISTORY (Determine the exact stage based on client’s age and his
milestone and provide some justifications that would be most applicable to the specified
developmental stage)
A. J. Piaget’s Cognitive Development
Stage Specific Task(s) Evidences of Milestone Achievement

B. E. Erikson’s Psychosocial Development

Stage Specific Task(s) Evidences of Milestone Achievement

C. S. Freud’s Psychosexual Development

Stage Specific Task(s) Evidences of Milestone Achievement

D. J. Fowler’s Spiritual Development

Stage Specific Task(s) Evidences of Milestone Achievement

E. L. Kholberg’s Moral Development

Stage Specific Task(s) Evidences of Milestone Achievement

F. R. Havighurst’s Developmental Task

Stage Specific Task(s) Evidences of Milestone Achievement
 G. Williams’ Metro Manila Developmental Screening Test (MMDST)

Personal-Social Score Justification

1. Task for a particular month Passed /
2. Failed /
3. Refused /
No Opportunity

Fine-Motor Adaptive Score Justification

1. Task for a particular month Passed /
2. Failed /
3. Refused /
No Opportunity

Language Score Justification

1. Task for a particular month Passed /
2. Failed /
3. Refused /
No Opportunity

Gross-Motor Behavior Score Justification

1. Task for a particular month Passed /
2. Failed /
3. Refused /
No Opportunity

VIII. GORDON’S 11 FUNCTIONAL HEALTH PATTERNS

A. Health Perception – Health Management
 Interaction
 Observation
 Measurement
B. Nutritional – Metabolic
 Interaction
 Observation
 Measurement
*3-day Diet Recall
MEALS Date & Day Date & Day Date & Day
Breakfast (time) - amount per serving - amount per serving - amount per serving
Snacks (if any) - amount per serving - amount per serving - amount per serving
 Lunch (time) - amount per serving - amount per serving - amount per serving
Snacks (if any) - amount per serving - amount per serving - amount per serving
Dinner (time) - amount per serving - amount per serving - amount per serving
Snacks (if any) - amount per serving - amount per serving - amount per serving
Total Fluid Intake ___mL ___mL ___mL
C. Elimination
 Interaction
 Observation
 Measurement

D. Activity – Exercise
 Interaction
 Observation
 Measurement
*7-Day Activity Table
Time Days of the Week & Date
Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7
1 am
2 am
3 am
4 am
5 am
6 am
7 am
8 am
9 am
10 am
11 am
12 nn
1 pm
2 pm
3 pm
4 pm
5 pm
6 pm
7 pm
8 pm
9 pm
10 pm
11 pm
12 mn

*Katz Index of Independence in Activities of Daily Living

Activities Independence = 1 point Dependence = 0 point
Points (1 or 0) No supervision, direction or personal With supervision, direction or
assistance needed personal assistance or total care
Bathing
Dressing
Toileting
Transferring
 Continence
Feeding
TOTAL POINTS:

E. Sleep – Rest
 Interaction
 Observation
 Measurement
*7-Day Sleep Diary
Constructs Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7
Hours of Sleep
Sleeping Time
Waking Time
Bedtime Rituals
Feeling upon
waking up
Problem
Encountered

F. Cognitive – Perceptual
 Interaction
 Observation
 Measurement
G. Self-Perception – Self-Concept
 Interaction
 Observation
 Measurement
H. Role-Relationship
 Interaction
 Observation
 Measurement
*Ecomap

I. Sexuality - Reproductive
 Interaction
 Observation
 Measurement
 J. Coping-Stress
 Interaction
 Observation
 Measurement

K. Value-Belief
 Interaction
 Observation
 Measurement

IX. COMPREHENSIVE PHYSICAL EXAMINATION

A. Vital Signs Date / Time of Exam: ____________
O
T = __ C
PR = __ bpm
RR = __ cpm
BP = __/__ mmHg
Pain (if any…since this is the 5th vital sign, using the PQRST method)
Provoking factor
Quality
Region/radiation
Severity (using pain or face pain scale)
Time
B. Anthropometric Data (only those applicable)
Height = __ cm (for both adult & pedia) BMI = __ (for adult)
Weight = __ Kg (for both adult & pedia) IBW = __ (for adult & pedia)
Head Circumference = __ cm (for pedia)
Chest Circumference = __ cm (for pedia)
Abdominal Circumference = __ cm (for pedia0
C. General Appearance
1. Body build and height-weight proportionality
2. Posture and Gait
3. Over-all hygiene and grooming
4. Body and breath odor
5. Obvious signs of distress / illness
6. Mental status
7. Attitude
8. Affect/mood; appropriateness of responses
9. Quantity and quality of speech
10. Relevance and organization of thoughts

D. Focused Assessment
Body Part Examined Actual Finding Normal Finding Clinical Significance
INTEGUMENT
Skin
I: color, uniformity,
edema, lesions
P: moisture, temp.
turgor
Hair
I: evenness of growth
 thickness, texture,
oiliness, infection
or infestation, body
hair
P: smoothness
Nail
I: plate shape, texture,
bed color,
surrounding tissues
P: Blanch test
HEAD
Skull and Face
I: size, shape ,
symmetry
: facial features
: eyes for edema
and hollowness
P: nodules, masses,
depressions
Eyes and Vision
I: eyebrows for
distribution &
alignment, quality &
movement
: eyelashes for
evenness of
distribution &
direction of curl
: eyelids for surface
characteristics,
position in relation to
cornea, ability to
blink & frequency
: bulbar & palpebral
conjunctiva for
color, texture, and
lesion
I/P: lacrimal gland
sac, nasolacrimal
duct for edema,
tenderness / tearing
I: cornea for clarity,
texture & sensitivity
I: pupils for color,
shape, symmetry of
size, direct and
consensual reaction
to light, &
accommodation
* Visual Acuity (near
& far vision test)
* Visual Field Test
* EOM Test
Ears and Hearing
I: auricles for color,
symmetry and
position
: external canal for
cerumen, lesions,
pus or blood
P: auricles for texture,
elasticity and areas
of tenderness
* Gross Hearing Acuity
Tests: normal voice
tone and whispered
voice
* Watch Tick Test
* Tunning Fork Tests:
- Weber for bone
conduction
- Rinne’s to compare
air and bone
conductions
Nose and Sinuses
I: nose deviation in
shape size, color,
flaring, discharge;
: nasal mucosa for
redness, swelling,
growth or discharge
Pa: tenderness,
masses,
displacements;
: nasal patency
: maxillary and
frontal sinuses for
tenderness
Pe: the above sinuses
for tenderness
Transillumination Test
Mouth / Oropharynx
I: lips for symmetry of
contour, color,
texture, moisture,
lesion
: teeth for alignment,
loss, dental filings
and caries;
: gums for bleeding,
color, retraction,
lesions, swelling
: tongue for position,
color & texture;
 movement, as well
as the base of the
tongue, mouth floor
and frenulum
: salivary gland
ducts for swelling,
redness
: palates for color,
shape, texture,
presence of bony
prominences
: uvula for position &
mobility
: oropharynx for color
& texture
: tonsils for color,
discharge, and size
Test for Gag Reflex
P: nodules, lump and
excoriated areas
NECK
Neck Muscles
I: abnormal swelling or
masses, head
movement, and
muscle strength
Lymph Nodes
P: enlargement
Trachea
P: lateral deviation
Thyroid Gland
I: symmetry and visible
masses, rise during
swallowing
P: smoothness
A: bruit
THORAX & LUNGS
Posterior Thorax
I: shape & symmetry
from posterior-lateral
views; spinal
alignment for
deformities
Pa: temperature,
bulges, tenderness,
abnormal
movements,
respiratory
excursion, vocal
fremitus
Pe: for symmetry of
resonance;
 diaphragmatic
excursion
A: breath sounds

Anterior Thorax
I: breathing pattern,
coastal and
costovertebral angle
Pa: respiratory
excursion, tactile
fremitus
Pe: symmetry of
resonance
A: breath sounds
Heart
I: precordium for
pulsations & lifts or
heaves
A: heart sounds (S1,
S2, etc.)
Central Vessels:
Carotid Arteries
P: volume, quality
A: bruit
Jugular Veins
I: distention
Peripheral Vessels
I: presence or
appearance of
superficial veins,
signs of phlebitis
*Buerger’s Test
*Capillary Refill
Breast & Axillae
I: breast for size,
symmetry, contour or
shape, discoloration,
retraction,
hypervascularity,
swelling, edema
: areaola for size,
shape, symmetry,
color, surface
characteristics,
masses, lesions
: nipples for size,
shape, position,
color, discharge,
lesion
P: lymph nodes,
breast, areola &
 nipples for
tenderness, masses,
nodules, discharge
ABDOMEN
I: skin integrity, contour
& symmetry, hernia,
distention (girth),
movements
associated w/
respiration,
peristalsis & aortic
pulsations
A: bowel, vascular, &
peritoneal friction rub
sounds
Pe: all quadrants /
regions for tympany
and deviations
Pa: light to deep
palpations ALL
quadrants from least
painful to most
painful for masses,
tenderness, muscle
guarding; liver
(bimanual) and
bladder palpation
* Leopold’s Maneuver
for OB clients for
presentation, lie,
engagement,
attitude, position If necessary /
MUSCULOSKELETAL applicable / significant
Muscles
I: size, contractures,
fasciculations,
tremors
P: tonicity, flaccidity,
spasticity,
smoothness of
movement, strength
Bones
I: structure, deformity
P: edema, tenderness
Joints
I: swelling
P: tenderness,
smoothness of
movement, swelling,
crepitation, nodules
NEUROLOGIC
Mental Status
- Language
- Orientation
- Memory
- Attention Span /
Calculation
Consciousness Level
Glassgow Coma Scale
Cranial Nerves
- I to XII
Reflexes
- Deep, superficial & For Adult
pathologic
- Neonatal Reflexes For Pedia
Gross Motor/Balance
* Walking Gait
* Romberg
* Standing on 1 foot w/
eyes closed
* Heel-toe walking
Fine Motor
- Upper Extremities:
* Finger-Nose Test
* Alternate Supination
& Pronation of hands
on knees
* Finger to Nose & to
RN finger
* Fingers-to-fingers
* Fingers-to-thumb
- Lower Extremities:
* Heel down opposite
skin
* Toe / Ball of Foot to
RN’s finger
Sensory Function
* Light/Deep Touch
* Pain Sensation
* Temperature
* Position / Kinesthetic
* Tactile Discrimination If necessary /
GENITALS applicable / significant
*For males:
I: pubic hair for
distribution, amount,
characteristics
: penis shaft and
glans for lesions,
nodules, swelling,
inflammation
: urethral meatus for
swelling,
inflammation,
 discharge
: inguinal areas for
bulges or swelling
P: penis for
tenderness,
thickening, nodules
: scrotum for
appearance, size and
symmetry, and
underlying testes,
epididymis and
spermatic cord
: inguinal areas for
palpable bulge If necessary /
* For females: applicable / significant
I: pubic hair
distribution, amount,
characteristics; its
areas for parasites,
inflammation,
swelling, lesions
: clitoris, urethral
and vaginal orifices
for inflammation or
discharge
P: bartholin’s glands,
lymph nodes for
enlargement,
tenderness, swelling
* Internal Exam for OB
clients for cervical
dilation, effacement
and AP pelvic If necessary /
diameter applicable / significant
RECTUM & ANUS
I: anus and
surrounding tissue
for color, integrity,
lesions
P: anal spinchter
tonicity, nodules,
masses and
tenderness
: if male, prostate
gland for tenderness
: if female, cervix
through the anterior
rectal wall for
tenderness

X. Diagnostic Test
A. Non-Invasive
 Specific Test Actual Finding Normal Finding Clinical Significance
Sputum Microscopy
Urinalysis
Fecalysis
Radiology
Other: ECG, MRI, CT
B. Invasive
Specific Test Actual Finding Normal Finding Clinical Significance
Blood Chemistry
Hematology
Electrolytes
ABG
Visualization
procedures (surgical
approach)
Note: Please indicate ONLY those diagnostic tests that were actually performed to confirm the
identified pathology. For OB and Pedia clients, please utilize the appropriate tools for labor and
delivery as well newborn assessment.
XI. Review of System (include only those that are significant to the case under study)
A. Neurologic
B. Pulmonary
C. Cardiovascular
D. Hematologic
E. Immunologic
F. Gastrointestinal
G. Renal
H. Musculoskeletal
I. Reproductive
J. Integumentary
XII. Concept Maps
A. Theory-based Physiology (for 2nd year) / Pathophysiology (for 3rd year)
Predisposing Factors: Precipitating Factors:
- Age, gender, family history, genetics - Lifestyle, diet, exercise, medication,
etc.

Main Etiology

Effect Effect

Sub-effect
Sub-effect Sub-effect
Sub-effect

Clinical manifestations:
Clinical manifestations: - s/sx
- s/sx - s/sx
- s/sx - s/sx
 DISEASE CONDITION

B. Client-based (only those facts related to the case are included)

XIII. CASE MANAGEMENT

A. Medical (present only those that are applicable and w/c have been done for the patient)
1. Pharmacologic Intervention
Drug Features Therapeutic Effects Nursing
Responsibilities
- Brand / Generic Name Indication Contraindication Desire Untoward
- Classification d
- Prescribed Dosage
- Route
- Frequency
2. Dietary Prescription / Restriction
3. Procedures (If any)
a. Oxygenation by nasal prong, venture/face mask, mist-tent, ambubag, ventilator, T-
piece
b. Suctioning
c. Osteorized Feeding
d. Intravenous Fluids
e. Catheterization
- Gastric
- Urinary
- Intravenous
Lavage
f. Enema
g. Diversional Ostomies
h. Drains i.e. Hemovac, Pleurovac, JP, Ventriculostomy, etc.
i. Others

B. Surgical (for 3rd year)

1. Pre-operative
2. Intra-Operative
3. Post-Operative

C. Nursing Management
1. List of Nursing Problems (minimum of 5 for 2nd year; minimum of 10 for 3rd year)
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
2. Prioritization of Nursing Problems
Criteria Weight Multiplier Computatio Justification
n
Nature and 3 Actual Problem 1 3/3 x 1 Situational
Extent 2 Risk / Potential Urgency based
1 Wellness State on:
- ABC Principle
- Maslow’s HON
- Nursing Concept
Modifiabilit 2 Easily Modifiable 2 2/2 x 2 Availability of
y 1 Partially Modifiable resources and
0 Not Modifiable interventions
Peventive 3 High 1 3/3 x 1 Likelihood of
Potential 2 Moderate occurrence of
1 Low complication w/
respect to
measures taken
Salience 2 Needs immediate attention 1 2/2 x 1 Client’s
action perception and
1 Not needing immediate recognition of the
attention problem
0 Not perceived as a problem/
condition needing change
TOTAL 5 Priority # 1
3. Plans for Nursing Actions
a. Nursing Care Plan
Assessment Diagnosis Planning Implementation Evaluation
Subjective: Problem r/t At the end After 4 hours of
The client Etiology, w/ of 4 hours nursing care,
verbalized, Sign/symptom of rendering goal was met /
“_______” (defining nursing unmet /
characteristics)
care, the partially met,
client will be as evidenced
Objective: *Choose the able to: by:
 PE applicable: 1.________ Independent Rationale & 1.
Findings 1. Actual Dependent Reference
 Lab 2. Probable Collaborativ
Findings 3. Risk e
4. Syndrome 2.________ Rationale & 2.
5. Wellness Dx Independent Reference
Dependent
Collaborativ
3.________ e Rationale & 3.
Reference
Independent
Dependent
 Collaborativ
e

b. Teaching Plan
Intended Outcomes Content Strategies Resources Evaluation
1. Cognitive Topic Teaching Learning * Materials Pen and paper
2. Affective Subtopic Activity Activity * Human test
3. Psychomotor - concept Resources
- concept * Time Recitation
Subtopic
- concept Return
- concept demonstration

Observation
c. Discharge Plan
Medication Exercise Treatment Health OPD Diet Signs and
Education Follow- Symptoms
up
Generic/Brand - Type - Nebulization - Pertinent - What - Limits - Things that
- Dose - - Chest Knowledge, - W/ - Inclusion need to be
- Frequency Frequency physiotherapy Skill, or whom reported
- Route - Physical / Attitude - When immediately to
- Time Occupational / - Where primary care
- Side effects Speech / provider
Psychotherapy

XIV. ONGOING APPRAISAL

 Day 1
- Medical and Nursing Care provided for managing the case
- Significant conditions or improvements noted
 Day 2
- Medical and Nursing Care provided for managing the case
- Significant conditions or improvements noted
 Day 3 (last day of duty or encounter with the patient / day of discharge)
Prepared by: Noted by:

Leah Ann Beltran, RN, MAN Nenita B. Panaligan, RN, MAN

Over-all Clinical Coordinator

Kriegel P. Bihasa, RM, RN

Reyner Joseph L. Catle, BSBio, RN Approved by:

Sunny Rose M. Ferrera, RN, MAN© Lenila A. De Vera, RN, MPH, MAN©
Dean, College of Nursing

Arachelle Francisco, RN, MAEd©

Czar Genreigh G. Genuino, RN, MAN©

Annie Ramos, RMT, MD, RN

Karen Louela Rint, RN, MAN©

Raymond Kristopher Samonte, RN, MAN©

Julius U. Tepora, RN, RM, MSN, MHPEd©

Level II Clinical Instructors