Patient Case Study Packet

Group Member Names:

Instructions:

During the course students will work as a group to complete Patient Case Packet as follows:

Full Care Plan (Care Plan Parts I-VII) based on a patient case your group creates based on the disease process assigned to you by your instructor.

Care Plan/Client Concept Map Components:

* Care Plan Part I History and Physical
a. Patient data base- health history
 Basic Conditioning Factors
 Chief complaint
b. Health History
c. Physical Assessment
 Vital signs
 General physical exam
* Care Plan Part II: Medications
* Care Plan Part III: Diagnostic Studies & Interpretation
* Care Plan Part IV: Nurses note
* Care Plan Part V: Client Concept map
a. Client Concept Map Part I: Assessment/Recognize Cues
b. Client Concept Map Part II: Patient Problem & Care Plan
* Care Plan Part VI: Interdisciplinary Plan of Care
* Care Plan Part VII: Client Educational Handout for the disease
process
NSG120 Patient Case Study I Care Plan & Client Concept Map Packet Group Member Names:
Nursing Care Plan Part I: Basic Conditioning Factors
Patient Demographics: Chief Complaint (Go into detail on the next page)
Physician (s): Albert Mcarthy
Age:57 Gender: Male Ht:6fts 4” Wt.60 Code Status:
Isolation: None Kgs Active
Allergies: (include type of reaction)
Type I-Anaphylactic, immediate-
type hypersensitivity
Health States
Date of visit: August 04,2023 Client’s past medical surgical history
Activity level: Shows high level of activity
Diet: Mediterranean The client had pulmonary surgeries three years ago to repair
Fall risk: Moderate the swollen blood vessel in the lungs due to falls.

Client’s description of health status (define chronic state) Completed therapies:

They have completed pulmonary rehabilitation within last 6
Client exhibits higher systolic pressure with some history of breathing difficulties months

Current therapies:
Socio-cultural Orientation Receives Oxygen therapies due to secondary infections on the
clients left lungs
Cultural and Ethnic

American - Hispanic

Background Socialization:

He is easy to socialize and

grandson and treated as a

NSG120 Patient Case Study I Care Plan & Client Concept Map Packet
family head Group Member Names:

Family system Elements (Support system):

Lives in an extended family, under care

grandson and his elderly wife

Spiritual:

Member of Orthodox faith

Occupation (across the lifespan)

He has worked as an automobile mechanic for over 15 years

NSG120 Patient Case Study I Care Plan & Client Concept Map Packet Group Member Names:

Part I a.
Patient Name: Alverez Fernandez
Date: August 04,2023
Chief Complaint:
Chest pains: Pressure and tightness on the chest with notable level of fatigue and shortness of breath

Current Complaint Given in Detail (PQRSTU):

P: The pain increase with increase in physical activity such as walking and light work outs

Q: Stabbing pain-usually sharp and brief

R: Chest and sometimes on the neck, arm and back

S: The severity of pain can be equated to 8 in the scale of 1-10

T: It is periodic, but client notes that it started a year ago

U: The pain might be caused by previous complication due to pulmonary surgery. It high affects performance in strenuous work and reduce the
patients work out time

Use the below acronym and definitions to complete the section above.
Provocative or Palliative: What makes your symptoms better or worse?
Quality: sharp, Dull, Constant, Intermittent, Ache, Burn, etc.
Region or Radiation: Where specifically are you having your symptoms/pain? Does it move?
Severity: On a scale of 0-10, how bad is it?
Timing: When did it start? How often does it occur? How long does it last?
Understanding: What do you think is causing your symptoms? How are your daily activities affected?
 NSG120 Patient Case Study I Care Plan & Client Concept Map Packet Group Member Names:

Part I b. Focused Health History

Patient Name: Alverez Fernandez _______________August 07,1963_________________Date of Birth:
_____________________ Age: ____60 years

Do you have, or have you ever List details to these or List any SURGERIES you have had and, if known, the
had, any of the following Circle your any OTHER Medical YEAR :
MEDICAL PROBLEMS: answer: Problems you have or
have had: Pulmonary surgery(heart)- 2020
Heart attack YES NO Nausea
High blood pressure YES NO
High cholesterol YES NO Fatigue
Diabetes YES NO Body pains
Stroke YES NO Shortness of Breath
Asthma YES NO
Emphysema/COPD YES NO
Ulcers/Reflux YES NO
Rheumatoid arthritis YES NO
Gout YES NO
Seizures/Epilepsy YES NO
Thyroid disease YES NO
Hepatitis YES NO FAMILY HISTORY
HIV/AIDS YES NO Do any of your grandparents, parents or siblings have
Cancer YES NO any of the following:
Diabetes YES NO Other Significant
List any DRUG ALLERGIES:
High blood pressure YES NO Family History:
Reported allergies for drugs with Sulphur /sulphates/syrphids Heart attack YES N/A
Circle any of the following if you are ALLERGIC: Stroke YES NO
Iodine IV Contrast Shellfish Latex Rheumatoid YES NO
arthritis Bleeding YES NO
disorders Cancer YES NO
NO
SOCIAL HISTORY:
Are you employed? YES NO REVIEW OF SYSTEMS:
Occupation Mechanic Date last worked: 2022 Do you have NOW, or have you had
RECENTLY, problems with any of the Circle your
Do or did you ever smoke? YES, NO Packs per day for 2 years following: answer:
Did you quit? YES NO If so, when did you quit?_ Fevers, chills, weight loss Eyes YES NO
Other tobacco/nicotine products? YES NO Ears, Nose, Throat YES NO
Teeth, Mouth YES NO
What kind? N/A Chest pain, Heart YES NO
Problems Shortness of YES NO
Drink alcohol? YES NO How much and how often? 1-2 bottles
History of illegal drugs/substance abuse? YES NO Breath, Lungs YES NO
What kind? N/A Constipation, Diarrhea YES NO
Urinary tract infection YES NO
Are you: Single Married Divorced Separated Joint pain, Joint stiffness YES NO
Widowed Skin rashes, lesions YES NO
Migraines, Headaches YES NO
Do you live alone? YES NO Blackouts/Falling YES NO
Do you Exercise? Never Rarely Weekly Balance problems YES NO
Daily What type? Walking Psychological problems/Depression YES NO
High cholesterol YES NO
Diabetes YES NO
Bleeding disorders YES NO
Perception of Own Health (circle one): Blood clots, DVT YES
Seasonal allergies NO
Excellent Good Fair Poor
 NSG120 Patient Case Study I Care Plan & Client Concept Map Packet

Part I c.: Physical Assessment

Vital Pulse RR BP Temp O2Sat Pain Assessment: Self-care assessment:
Signs: 70 14 120/70 37 Magnitude 8 Include identified knowledge
/minutes degrees 65mmHg deficits in self-care
Intake Output IV Location Assessment

Chest /back/Neck
Level of consciousness and orientation: Normal
LOC-Orientation/
Cognition General survey/appearance/facial expression/mood/affect/speech:

Normal

Glascow Coma Scale (If appropriate): _____________N/A_________________________________

Vital Signs (normal or abnormal) daily weight if indicated 60

HEENT/
Sensory Perception Pain level (0-10 numeric scale OR other appropriate scale) 8
PERRLA: Pupils looks and functions normally
Oral mucous membranes, oral cavity, dentition: Notable and periodic mucus noted

Presence of hearing aids or eyeglasses: Uses eye glass to aid sights

Respiratory effort & use of oxygen: Shortness of breath noted
Respiratory/
Oxygenation Oxygen Saturations:
_______________________65mmHg_________________________________________
Effort of breathing: considerable efforts

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NSG120 Patient Case Study I Care Plan & Client Concept Map Packet

noted_____________________________________________________

Lung Sounds: Right: Strider

LungSounds: Left: None

Cough & Deep Breathe, any mucous? Color & amount? White phlegm

Cardiac - Peripheral Skin Color: White

Vascular/ Perfusion
Heart sounds:
__________S4_____________________________________________________________

Capillary refill: N/A

Pretibial edema: R _______N/A_______L ___N/A________________

Dorsalis pedis pulse: R_________N/A__________ L ___N/A______________

CMS (circulation, motion, sensation) 5 P’s : ____________________________________

___________________________Pain level of 8, normal paralysis, stridor during
chest movements, level 4 pulse
____________________________________________________________

DVT assessment (TED hose or SCD hose):

_____None__________________________________

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NSG120 Patient Case Study I Care Plan & Client Concept Map Packet

Musculoskeletal-Skin/ Skin Integrity: Good

Mobility
Skin Turgor:
_______Normal_________________________________________________________________

Wounds, tube insertion sites, IV patency & insertion site None

Mobility & gait (any aids used): High fatigue levels

Upper muscle strength: R moderate L Moderate

Lower muscle strength: R Moderate L Moderate

Reflexes: ________________________________Normal___________________

Fall Risk scale (MORSE): ______25-44(medium risk) ______________ (fall precautions if

indicated) ___________Enforce medium fall prevention such as using walking
sticks

Abdominal assessment: _________________Normal_________________________________

Abdomen
Urinary/Gastrointestinal Bowel sounds (four quadrants): __________Normal__________________________________

Last Bowel Movement: Normal________________________________________

Stool (color, consistency, frequency): Pale yellow

Nutrition/Diet/Toleration: Mediterranean diet with medium tolerance

(Aspiration precautions if indicated) ____None__________________________________________

Voiding freely Assess for incontinence or retention ______________________________

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NSG120 Patient Case Study I Care Plan & Client Concept Map Packet

Urine color, clarity, quantity Clear Urinary catheter: None

Psychosocial, Safety,
Support at home: Walking support due to fatigue
Care & Comfort
Safety interventions: Walking in presence of a care giver or using a stick

Self-care needs: Low fat diet

Risk for Depression/suicide___Low _ due to adequate family support_

Teaching & learning needs: Anticipatory guidelines on home care pain

theraphies

Psychosocial & Spiritual concerns: None__________________________________________________

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NSG120 Patient Case Study I Care Plan & Client Concept Map Packet

Part II: Medication Reconciliation and New medications

for disease process
List all medications, dosages, classifications and the rational for the medications you feel would be prescribed for this patient include major considerations
for administration and the possible negative outcomes associated with this medication.

ALLERGIES:
Medication Classification Dosage Purpose/Mechanism of Action

Primary /preventive 300mg in every helps thin the blood and prevent blood clots
Aspirin 8hours Reduces chances of heart attack /stroke

Primary /preventive 80mg/day Reduces severe effects of coronary heart disease

Angiotensin-
converting enzyme
(ACE) inhibitors and
angiotensin II
receptor blockers
(ARBs)
Ranolazine. Pain killers 8mg/day Relieves pians

Newly prescribed (or dosage changes) medications

Beta blockers Primary /preventative 80mg/day To be used as replacement of aspirin due to allergies noted

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NSG120 Patient Case Study I Care Plan & Client Concept Map Packet

Part III: DIAGNOSTIC STUDIES AND INTERPRETETION

LAB Normal Initial Most current How is this related Pertinent nursing What expected assessment findings
values results results to the disease interventions, if applicable correlate with this result?
process?
HEMATOLOGY
WBC 4500- - 12000mm3 High level of Consider clinical High blood cells correlate to
11,000/mm3 WBC- Immunity treatments pulmonary inflammation
response
RBC 4.3-5.9 - 2.3million/ Low levels of Use treadmill test Low level of RBC is associated
million/mm3 mm3 RBC associated with fatigue
with fatigue
HGB 13.5-17.5 - 12.5g/dL Inflammation can Low HB links to low oxygen
g/dL be associated with saturation than normal values
reduced
hemoglobin
HCT 41%-53% - 53%
PLATLETS 150,000- - 400,000/
400,000/mm3 mm3
WBC
Differential
Lymphocytes 1000-4000 4200 per
per mm3 mm3
Monocytes 100-700 per 800 per mm3
mm3

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NSG120 Patient Case Study I Care Plan & Client Concept Map Packet

Eosinophils 50-500 per 550 per mm3

mm3
COAGULATION
PT 60-70s 60.4s Measure blood Measure blood health
clotting ability
INR 0.8-1.1 0.9
aPTT or PTT 30-40s 37.8s
Arterial Blood
Gases (ABG)
PH 7.35-7.45. 8
PACO2 35 - 45 36-39mmHg
mmHg.
HCO3 22-26mmEq/l 24mmHg
PO2 80-100mmHg 70mmHg
PULSE OX: 80mmHg 60mmHg

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NSG120 Patient Case Study I Care Plan & Client
Concept Map Packet
Normal Initia Most current How is this related to the Pertinent nursing What expected assessment findings
values l results disease process? interventions, if correlate with this result?
result applicable
s
URINALYSIS
pH 4.5-8 6.2
Protein 50-80mg 70mg
Glucose 50-300mg 120mg
Ketones None none
Bilirubin None None
WBC <4cells/HPF 5cells/HPF Shows extent of dead Immunology of the patient
cells in blood
RBC <3cells/HPF 2cells/HPF
CHEMISTRY
Glucose 90-120mg/ 165mg/dl
dl
BUN 7-24mg/dl 22mg/dl
Creatinine 0.7-1.4mg/ 0.9mg/dl
dl
GFR >90 85 Extent of kidney
health
Potassium 3.5-4.5 4.6mEq/l
mEq/l
Calcium 8.5-10.5 11mEq/l
mg/dl
Sodium 134-143 139mEq/l
mEq/l
Phosphorus 95-108 98.6mEq/l
mEq/l
Amylase 30-120U/l 66U/l

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NSG120 Patient Case Study I Care Plan & Client
ConceptLipase 10-150U/l
Map Packet 12U/l
Albumin 35-50U/l
Ammonium
Cholesterol
Triglycerides <200mg/dl 220mg/dl Cholesterol level Reducing high It provides insight on
indicate level of cholesterol foods substantial cause of fatigue due
coronary blockage to pulmonary blockages
HDL 100mg/dl 120mg/dl Cholesterol level Reducing high
indicate level of cholesterol foods
coronary blockage
LDL 50mg/dl or 60mg/dl Cholesterol level Reducing high
higher indicate level of cholesterol foods
coronary blockage

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NSG120 Patient Case Study I Care Plan & Client
Concept Map Packet
Normal Initial Most current How is this related to the Pertinent nursing What expected assessment findings
values results results disease process? interventions, if applicable correlate with this result?
Radiology
EKG 60-100 60 beats 62 beats Links to coronary None Establishing heart health.
beats/minu blockages and cause
tes of fatigue

CT N/A N/A Blockage in Images shows vein None Establish blood movements
right /arteries profiles to and possible deposition in
ventricle of detect any blockage heart blood vessels
heart noted /swelling

MRI

Ultrasound

Endoscopy

X-Ray

Additional Labs, Tests, or Special Procedures

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NSG120 Patient Case Study I Care Plan & Client
Concept Map Packet

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NSG120 Patient Case Study I Care Plan & Client
Concept Map Packet

Part IV. Nurses note

Patient Name: Alverez Fernadez
1. Summary of pertinent Health History and Review of Symptoms
2. Positive & Negative Physical Exam Findings
3. Diagnostic Findings

Summary of patient History and review of symptoms

The patients have history of smoking and alcohol use. He reported pulmonary
surgeries in 2020 and has family history of heart attack and pulmonary related
disease. The patients reported sharp pains in the chest, neck, back which has been
repeatedly over the last one year. In some case, fatigue, shortness of breath and
body weakness has been recorded.

Physical Examination finding

The patient’s severe fatigue and need support while walking. He exhibits
moderate fall risk and uses a walking stick as an intervention. His heart sound is
pathologic and suffers some breath shortness. The eyesight is normal and has no
indication of stress or depression.

Diagnostic review

It is noted that the patient experience considerable high levels of WBC and low
hemoglobin level. Cholesterol levels are high while CT scan show blockages in
the right ventricle of the heart. Equally, the recorded heart /pulse rate by EKG
scan is 60-62 per minutes which is quite low. This is a strong indication of a
coronary artery disease (CAD).
NSG120 Patient Case Study I Care Plan & Client
Concept Map Packet
NSG120 Patient Case Study I Care Plan & Client
Concept Map Packet

CLIENT CONCEPT MAP- PART V a. – ASSESSMENT / RECOGNIZE CUES

Identify relevant and important objective & subjective information from different sources (e.g. medical history, vital signs)
You do not need to fill out each box. Only complete what is relevant to the patient’s diagnosis and assessment findings.

PRIMARY ADMITTING DIAGNOSIS AND NERVOUS SYSTEM/ COGNITION: RESPIRATORY SYSTEM:

PATHOPHYSIOLOGY:
SUBJECTIVE SUBJECTIVE
Cardiac artery disease - affects pulmonary
in the right ventricle Pathologic heart sound(S4) is a sign of difficult in
cardiac function
OBJECTIVE
OBJECTIVE

CARDIOVASCULAR SYSTEM: MUSCULSKELETAL AND MOBILITY: INTEGUMENTARY SYSTEM:

SUBJECTIVE SUBJECTIVE
Smoking and alcohol use are risk factor to SUBJECTIVE
cardiac related illnesses.
OBJECTIVE
OBJECTIVE OBJECTIVE

Low pulse rate translates to cardiac related

diseases

High WBC raise concerns of secondary

infections

Low HBC is relating to low oxygen saturation in

the patients

GASTROINTESTINAL SYSTEM: URINARY SYSTEM: BLOOD, LYMPH, and/or ENDOCRINE SYSTEM:

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NSG120 Patient Case Study I Care Plan & Client
Concept Map Packet
SUBJECTIVE SUBJECTIVE SUBJECTIVE

OBJECTIVE OBJECTIVE OBJECTIVE

High cholesterol is a risk factor to cardiac

disease

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NSG120 Patient Case Study I Care Plan & Client
Concept Map Packet
PLANNING RESOURCE CLIENT CONCEPT MAP- PART V b.-PRIORITY PATIENT PROBLEM PLAN OF CARE: use the information from
PATIENT PROBLEM part one toGOAL
determine
& your priority PATIENT PROBLEM. You must use yourRATIONALES
INTERVENTIONS Textbook All-in-ONE NURSING
EDUCATION
(NURSING DIAGNOSIS) CARE for these sections.
OUTCOME CRITERIA (Please delete red words)
(DO/IMPLEMENT) (Expected Outcomes)
PLANNING

Carry out a CT scan and EKG To determine the cardiac
health
To determine the Home based care for
Determine the heart rate, pulse and possible cause of chest managing chest pain
detect any blockage pains and fatigue How to quite smoking as risk
ASSESS/MONITOR: factor to cardiac infections
1. Heart beats/Pulse rate
How to make a balanced diet

2.Veins profiles
Problem Statement:

3.Oxgen saturation
List 3 OUTCOMES:
1. The oxygen saturation
level was between 60-
65mmHg DO (INTERVENTIONS):
2. CT scan detected
1. Administer beta blockers
blockage
/inflammation in right
ventricle
3. The pulse rate was low 2. Quit smoking

3. Pulmonary surgery

To establish heart condition (pulse rate,

blockages and saturation levels)

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NSG120 Patient Case Study I Care Plan & Client
Concept Map Packet

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 NSG120 Patient Case Study I Care Plan & Client Concept Map Packet

Part VI. Interdisciplinary Plan of Care

Therapies (speech, physical, occupational) and rationales
(If not applicable state why.)

The patients should undergo subjected to treadmill constantly as measure of eliminating

excessive cholesterol. This burns out excessive cholesterols and improve the cardiac
function. Due to allergies, he should avoid working in poorly ventilated rooms

Pharmacology (medications, dosages, routes, duration) and rationales

The patients should take pain killers at prescribed levels and beta
blockers. Pain killers reduces chest and back pains while beta blockers
reduce chances of heart attacks by reducing cholesterol build up in
vessel.

Referrals to Specialists and rationales

Next inspection set to meet cardiologist for proper cardiac profile
analysis

Referrals to Community resources or agencies and rationales

American Heart Association: It contains valuable community

guidelines on cardiac health.

Alternative Therapies and rationales (if applicable)

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 NSG120 Patient Case Study I Care Plan & Client Concept Map Packet

CLIENT EDUCATIONAL HANDOUT- PART VII

Create an appropriate educational handout for your patient based on their current disease process and diagnosis.
Include the necessary interventions the patient should be doing at home, resources they should be using,
medication information, and possible complications they may experience. You do not utilize the table below; you
MUST create a hand out to give to the patient. It is there as a reminder to complete the education handout.
 How to quite alcoholism and smoking
- Smoke less in day one
- Use alternatives
- Engage in other activities to reduce addiction
- Visit rehabilitation centers
 Anticipatory guideline on home-based pain managements
 -Use of low effect pain killers

 Diet change and managements

Case Study/Clinical Report Grading Rubric & Check-Off Sheet

Category Value

I. History & Physical 31 points

a. Patient data base
 Demographics appropriate for patient condition 3
 Chief complaint given in detail (PQRSTU) 4

b. Complete patient history

 Patient’s medical history noted and appropriate 2
 Family medical history noted and appropriate 2
 Social history noted and appropriate 2

c. Physical Assessment
 Vital signs present and appropriate for condition 4
 General Physical exam form complete and accurate 14

II. Medications 14 points

 Preadmission medications 7
 New medications based on disease process 7

III. Diagnostic test 9 Points

 Normal results listed 3
 Patient results listed and appropriate for condition 3
 All appropriate diagnostic testing listed in chart form 3

IV. Nurses note 12 points

 Health History and Review of Symptoms 4
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 NSG120 Patient Case Study I Care Plan & Client Concept Map Packet
 Positive & Negative Physical Exam Findings 4
 Diagnostic Findings 4

V. Client Concept map 12 points

 Part I: Assessment/Recognize Cues 6
 Part II: Patient Problem & Plan 6

VI. Interdisciplinary Plan of Care 12 points

 Therapies (speech, physical, occupational) and rationales 3
 Referrals to Specialists and rationales 3
 Referrals to Community resources or agencies and rationales 3
 Alternative Therapies and rationales (if applicable) 3

VII. Education & Instructions Handout 10 points

Participation 10 points

APA, grammar, and spelling 10 points

Clinical Team Presenting Case:

________________________________________________________________________________________
______________________________________________________________________________________

Diagnosis:

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