Republic of the Philippines

CAMARINES SUR POLYTECHNIC COLLEGES

Nabua, Camarines Sur

COLLEGE OF HEALTH SCIENCES

DOCUMENTATION AND REPORTING

FUNDAMENTALS OF NURSING PRACTICE
Second Semester, 2023 – 2024

INSTRUCTION: Make your own Focus Charting. Use the format given

CASE SCENARIO 1

A 24-year-old woman presented to the hospital with a 2-day history of watery diarrhea and fever.
Rehydration and electrolytic balance were restored with intravenous fluid therapy followed by oral rehydration
solution. Still, diarrhea did not improve by the fourth day of hospitalization despite treatment with a probiotic. Aliah,
the patient was next treated with gelatin tannate, a medical device recently marketed in Europe to control and reduce
the symptoms of diarrhea in infants, children, and adults. Aliah’s diarrhea improved considerably within the first
twelve hours and resolved completely within three days.

CASE SCENARIO 2

A 20-year-old patient, Christian was admitted with fever, nausea, headache and myalgia for 4 days. He
traveled to Metro Manila with his parents from March 21, 2023, to March 25, 2021, to visit his relatives living in a
squatters area. He was presented with a fever after 5 days of his return. The symptoms lasted 4 days, and then he
was referred to our hospital for evaluation. He had a history of pneumonia and allergic asthma. His tympanic
temperature was 37.0 °C, pulse rate 92 beats/min, respiratory rate 22 cycles/min and throat infection was found on
physical examination. Urine microscopy, chest X-ray and abdomen X-ray were normal. Intravenous hydration was
conducted on admission. Myalgia and headache subsided on the second day of hospitalization and the fever subsided
on hospital day 4. The rash did not appear during the illness.

CASE SCENARIO 3

Patient Joyce with a grimaced face accompanied by her relatives was admitted to a private hospital with a
chief complaint of labor pains and watery vaginal discharge for 2 hours. She lived in an urban area where pollution
is very common. They lived in a concrete house with 10 occupants. Patient Joyce described her habits by watching
TV all the time and using her smartphone for social medias. She was very lazy all the time as she stated. She didn't
even try to engaged herself to pre-natal exercises but she clearly states that she had a regular check-up. "Lagi lang
ako sa bahay, nakahiga nanunuod, cellphone, ganun", as verbalized. The client mentioned that she does not want to
breastfeed the baby. Initial V/S: T- 36.3° C; R - 20; BP - 110/70 mmHg; PR - 85 bpm

CASE SCENARIO 4

A 23-year old woman went to the emergency department complaining of vaginal bleeding. She noticed
that there was a blood on the toilet paper 2 days ago, and following this she has had bright red spotting
intermittently. She has no pain and there are no urinary or bowel symptoms.
She had a positive home urine pregnancy test 3 weeks ago after she realized she had a missed period
and was feeling very tired. This is her first pregnancy. She had been using condoms but with poor
compliance, so the pregnancy was unplanned but she is now happy about it.
She takes no medications and does not smoke. She claims on drinking minimal alcohol. Also, she denies
of using recreational drugs.
Upon assessing the patient, she verbalizes, <may lumalabas na dugo sa pwerta ko=. Initial vital signs as
follows: Temperature: 37.0 degrees Celsius, BP: 120/68 mmhG, Pulse rate: 82 bpm, RR: 20 cpm. The
abdomen is soft and non-tender with no palpable uterus or masses. Chest and cardiac examination are
normal. No uterine contractions noted. Bimanual examination reveals no adnexal mass tenderness or
cervical excitation and no obvious adnexal masses.
Queency is a 19-year-old girl who comes into the emergency department with her mother complaining of troubled
breathing. Her primary symptoms are that of fever and shortness of breath, but during physical assessment the nurse
also find she’s been experiencing cough and fatigue. The attending physician ordered Oxygen Therapy at 3 LPM and
salbutamol nebule. Initial Vital Signs: T- 37.1 ° C; R – 16 cpm; BP - 100/70 mmHg; PR - 95 bpm and O2 Sat: 94%.