NURSING CASE STUDY

ADMISSION/FINAL DIAGNOSIS

I. HEALTH HISTORY
A. DEMOGRAPHIC (BIOGRAPHICAL DATA)
1. Client’s Name or Initial (optional)
2. Gender (sex)
3. Age, Birth date and Birthplace
4. Marital (Civil) Status
5. Race and Nationality
6. Religion
7. Address, Telephone Number, E-mail Address
8. Educational Background/Other Significant Framing
9. Occupation (usual and present)
10. Usual Source of Medical Care
B. SOURCE AND RELIABILITY OF INFORMATION
Sample Statements
Client himself who seems reliable
Client’s daughter, Rosalinda Paloma, who seems reliable
Mr. Picachu, interpreter for La-la who does not speak English
C. REASONS FOR SEEKING CARE OR CHIEF COMPLAINTS (top 3)
Example
“ Chest pain for 2 hours”
“Earache and restlessness all night” “Need
yearly physical for work”
“ Want to start jogging and need checkup”
D. HISTORY OF PRESENT ILLNESS/OR PRESENT HEALTH (Narrative form)
Well person General state of health
Ill person Chronological Story Record
Usual state of health
8 Critical Characteristic
1. Timing (Frequency/Onset/Duration)
2. Location
3. Quality (Character)
4. Quantity (Severity)
5. Setting
6. Associated phenomena/factors
7. Aggravating and Alleviating Factors
8. Client’s Perception
E. PAST MEDICAL HISTORY OR PAST HEALTH (Narrative form)
 Pediatric/Childhood/Adult Illnesses
 Injuries or accidents
 Hospitalization
 Operation
 Obstetric History (for female only)
 Immunization
 Allergies
 Medications (Prescribed and OTC drugs)
 Last Examination Date
 F. FAMILY HISTORY (Family tree or genogram/roster)
Include age, present condition, cause of death

Female Male Patient shaded-deceased

G. SOCIO-ECONOMIC
H. DEVELOPMENTAL HISTORY
Select 1 Developmental Theory
I. REVIEW OF SYSTEMS AND PHYSICAL EXAMINATION (refer to guide)
1. ROS AND PE
Date of Examination:

Systems ROS PE
(includes history of illness or (includes assessment via IPPA)
complaints) -all objective
-all subjective
a. General/Overall Health Status
b. Integument
c. Head
d. Eyes
e. Ears
f. Nose and Sinuses
g. Mouth and Throat
h. Neck
i. Breast and Axillary
j. Respiratory
k. Cardiovascular
l. Urinary
m. Genitalia
n. Musculoskeletal
o. Neurologic
p. Hematologic
q. Endocrine

2. LABORATORY STUDIES/DIAGNOSTICS
Procedure/Date Indication Normal Actual Nursing
Values/Findings Findings Responsibilities
/ Implications
(PRE, INTRA,
POST)

3. OTHER ASSESSMENT TOOLS (Scale, Sheet, Grade, Level, etc.)

Date(s) Comprehensive Actual Content/Legend Actual Result
Taken

J. FUNCTIONAL ASSESSMENT (including ADL) (refer to guide)

1. Health Perception/Health Management Pattern
2. Self-esteem, Self-concept/Self-perception Pattern
3. Activity/Exercise Pattern
4. Sleep/Rest Pattern
5. Nutrition/Elimination
6. Sexuality/Reproductive
7. Interpersonal Relationships/Resources
8. Coping and Stress management/Tolerance Pattern
9. Personal Habits
10. Environmental Hazards
 II. PROBLEM LIST
A. ACTUAL or Active
Problem No. Problem Date Identified Date Resolved/Remarks

B. HIGH RISK or Potential

Problem No. Problem Date Identified

III. NURSING CARE PLAN

CUES NURSING LONG SHORT INTERVENTION RATIONALE EVALUATION
DIAGNOSIS TERM TERM
“ S” ND: Prob + PDx (diagnosis)
“ O” Cause if refer behavior PRx (therapeutic) Be brief and Goal Met/Not
-PE known to criterion, - Independent concise Met/
Labs/ Dx (refer to Abdell performance Partially Met +
PEd (education/
NANDA) ah 21 condition supporting data
(head health
Problem teachings)
to toe) s (refer to
Atkinson’s)

IV.
 Main organ/ system involved
 Include diagram / illustration
 Synthesis

V. PATHOPHYSIOLOGY
 Paradigm and Narrative format
 Present (both textual and actual) signs and symptoms
 Use legends and
color coding
Example
Circle Diagnostics/Laboratory Results
Triangle Signs/Symptoms (clinical
manifestations) Square Precipitating
Factors
Rectangle Sequence of events
 Highlight color the S/S seen present in the patient)

VI. MEDICAL-SURGICAL MANAGEMENT (Curative)

1. Procedure (USN, Gavage, CPT, Surgery, etc.)
Procedure/Date Indication/Analysis Nursing Responsibilities
(PRE, INTRA, POST)

2. Pharmacotherapeutics/Medicines (IV Fluids, Drugs)

GN (BN) Indication (client-specific) Nursing Responsibilities/Implications
Classification Dosage and Frequency (PRE, INTRA, POST)
Stock

VII. PROGRESS NOTES (Narrative) – phase form

Day No. Existing Cues/Problems
Interventions Actually Done (Nursing and
Collaborative) Client’s Response
 VIII. DISCHARGE HEALTH TEACHING PLANS
Content Strategy
1. Compliance
Medication
Diet
Exercise
Activity/Lifestyle Changes
2. Follow up/Check up

IX. SUMMARY OF CLIENT’S STATUS OR CONDITION AS OF LAST DAY OF

CONTACT (Narrative Form)
Date:
Problems encountered (actual and resolved)
DHTP

_____________________________________
Signature over PRINTED NAME
 FUNCTIONAL ASSESSMENT
(Interview Guide)

A. Health Perception – Health Management Pattern

a. How has general health been?
b. Any colds in the past?
c. Most important things done to keep healthy? You think these things nurses or doctors
suggest?
d. In the past, has it been easy to find ways to follow things nurses or doctors suggest?
e. If appropriate, what do you think caused this illness? Actions taken when symptoms
were perceived? Results of actions?
f. If appropriate: Things important to you while you are here? How can we be most helpful?

B. Self-esteem, Self-concept/Self-perception Pattern

a. How do you describe yourself? Most of the time, do you feel good (not so bad)
about yourself?
b. Changes in the way you feel about yourself or your body? (Since illness started)
c. Did things frequently make you angry? Annoyed? Fearful? Anxious, depressed? What
helps?

C. Activity/Rest Pattern
a. Sufficient energy for completing desired/required activities?
b. Exercise pattern? Type? Regularity?
c. Spare time (leisure) activities? Child play activities?
d. Perceived ability for (refer to functional level
code) Feeding Grooming
Bathing Gen. Mobility
Toiling Cooking
Bed Mobility Home Maintenance
Dressing Shopping

Legend Functional Level Code

Level 0 Full Self Care
Level 1 Requires use of requirements or device
Level 2 Requires assistance or supervision from another person
Level 3 Requires assistance or supervision from another person or device
Level 4 Is dependent and does not participate

D. Sleep/Rest Pattern
a. How many hours of sleep? Rest?
b. Do you feel good upon waking up?
c. What makes you put to sleep?
d. Sleep patterns
e. Daytime naps
f. Any sleep aids used

E. Nutritional/Elimination
a. Typical daily food intake? (Describe) Supplements?
b. Weight loss/gain? (amount)
c. Appetite
d. Food or eating discomforts? Diet restrictions?
e. Food allergies/intolerance
f. Recall the diet by a recall of food/beverage taken over the last 24 hours
g. Heal well or poorly
h. Skin problems, lesions and dryness?
i. Dental problems
j. Bowel elimination pattern. (Describe) Frequency? Characteristics? Discomfort?
k. Urinary elimination pattern. (Describe) Frequency? Characteristics? Discomfort?
l. Excess perspiration? Odor problems?
F. Sexuality-Reproductive Pattern
a. If appropriate – Any change or problem in sexual relations?
b. If appropriate - Use of contraceptives? Problems?
c. Female_ When menstruation? LMP (Last Menstrual Period)? Menstrual problems? Para? Gravida?

G. Interpersonal Relationships/Resources
a. Social role
b. How would you describe your role in the family?
c. How do you say you get along with family and coworkers?
d. Ask about support systems and significant others
e. To whom could you go for support with a problem at work, with your health, or a personal
problem?
f. Include contact with spouse, siblings, parents, children, friends, organization and workplace
g. Is time spent alone pleasurable or relaxing or isolating?

H. Coping and Stress Management/Tolerance Pattern

a. Kinds of stress in life
b. Any change in lifestyle or any current stress
c. Method tried to relieve stress or if has been helpful
d. Tense a lot of the time? What helps? Use of any medicines, drugs and alcohol?
e. Who’s most helpful in taking things over? Use of any medicines, drugs and alcohol?
f. Any big change in your life in the last year or two?
g. When with big problems (any problems) in your life, how do you handle them?
h. Most of the time, is this (are these) way(s) successful?

I. Personal Habits
a. Tobacco
b. Alcohol
 Be alert to early signs of hazardous alcohol use
 Ask whether the person drinks alcohol. If the answer is yes, ask specific questions about the
amount and frequency of alcohol use
 When was your last drink of alcohol?
 How much did you drink at that time?
 Out of the last 30 days, about how many would you say that you drink alcohol?
 Have you had drinking problems?

c. Street Drugs
d. Do you smoke cigarettes?
e. How many years did you smoke? (Record the number of packs smoked per day (PPD) and
duration. Eg. PPD x 5 yrs

J. Environmental Hazards
a. Housing and neighborhood
b. Living alone?
c. Knowledge of neighbors
d. Safety of the area
e. Adequate head and utilities
f. Access for transportation
g. Involvement in community services
h. Environmental health, hazards in the workplace
i. Use of seatbelts
j. Geographical And occupational exposures
k. Travel or residence in other countries
l. Time spent abroad during military services (if applicable)
 REVIEW
OFSYSTEMS
(A guide)

Note: Some symptom(s) /finding may appear in more than one place, answers only need to be recorded
once

General: Present weight gain (gain, loss, period of time, by diet or other factors), fatigue, weakness or
malaise, fever, chill, sweats or night sweats

Integument
Skin: History of skin disease (eczema, psoriasis, hives, pigment or color change in mole, excessive
dryness or moisture pruritus, excessive bruising, rash or lesion)
Hair: recent loss, change in texture
Nails: change in shape, color or brittleness
 Amount of sun exposure, method of self-care for skin and hair?

Head: Any unusually frequent or severe headache, any head injury, dizziness, vertigo

Ear: Otorrhea, tinnitus, history of infections, vertigo, otalgia, hearing loss, hearing aid use, how
loss affects the daily life, any exposure to environmental noise and method of cleaning ears

Mouth and Throat: Mouth pain, frequent sore throat, bleeding gums, toothache lesion on tips/tongue
or mucosa, dysphagia, hoarseness or voice change, tonsillectomy, altered taste. Pattern of daily
dental care, use of prosthesis (dentures, bridge), and last dental check up

Neck: Pain, stiffness, limitation of motion, lumps or swelling, enlarged or tender lymphnodes, goiter

Breast and Axillae: Pain, lump, nipple discharge, rash, history of breast disease, any surgery of
the breast, Performs BSE including its frequency and method used

Respiratory: History of lung diseases (emphysema, pneumonia, asthma, bronchitis, TB) chest pain
with breathing, wheezing, noisy breathing, cough, sputum (color, amount), hemoptysis, toxin or
pollution exposure. Last Chest X-ray study

Cardiovascular
Central: Precordial or retrosternal pain, palpitation, cyanosis, dyspnea on exertion (specify amount
of exertion, eg. Walking one flight of stairs, walking from chair to bath or just talking), orthopnea,
PND, nocturia, edema, history of heart murmur, HTN, CAD, anemia. Date of last ECG or other heart
tests.
Peripheral Vascular: coldness, numbness and tingling, swelling of legs (time of day, activity),
discoloration in hands or feet (bluish red, pallor, mottling, associated with position, especially around feet
and ankles), varicose veins or complications, intermittent claudicating, thrombophlebitis, ulcers.
Does work involve long term sitting or standing? Avoids crossing legs at the knees? Wear support
hose?

Gastrointestinal: Appetite, food intolerance, dysphagia, indigestion, other abdominal pain, pyrosis,
nausea and vomiting (character), hematemesis, history of abdominal disease (ulcer, liver, gall
bladder, jaundice, appendicitis, colitis, flatulence, frequency of bowel movement, any present change,
stool characteristics, constipation, or diarrhea, black stools, rectal bleeding, rectal conditions
(hemorrhoids, fistula). Use of antacids or laxatives (alternatively, diet history and substance habits can
be placed here).

Urinary: Frequency, urgency, nocturia, dysuria, polyuria or oliguria, hesitancy or straining, narrowed
stream, urine color (cloudy or presence of hematuria), incontinence, history of urinary disease
(kidney disease, kidney stones, UTI, prostate), pain in flank, groin, suprapubic region or lower back.
Exercise after childbirth.
 Genitalia
Male: Penis or testicular exam, pain, sore or lesions, penile discharge, lumps, hernias
Female: menstrual history (age at menarche, LMP, cycle and duration, any amenorrhea or
menorrhagia, premenstrual pain or dysmennorrhea, intermenstrual spotting), vaginal itching,
discharge and its characteristics, age at menopause, menopausal signs and symptoms, post-
menopausal bleeding. Last gynecological checkup and last Papanicolau smear.

Musculoskeletal: History of arthritis

Joints: pain, stiffness, swelling (location, migratory nature), deformity, limitation of motion,
noise with joint motion?
Muscles: Pain, cramps, weakness, gait problems or problems with coordinated activities?
Back: Pain (location and radiation to extremities) Stiffness, limitation of motion, or history of
back pain or disease
Neurologic: History of seizure disorder, stroke, fainting and block-outs Motor
function: tic or tremor, paresis, fainting and block-outs Sensory
function: memory disorders (recent or distant, disorientation)
Mental Status: any nervousness, mood change, depression, or any history of mental
dysfunction or hallucinations
Hematologic: Bleeding tendency of skin or mucous membranes, excessive bruising, lymph node
swelling, exposure to toxic agents or radiation, blood transfusions and reactions

Endocrine: History of diabetic symptoms (polydipsia, polyphagia, polyuria), history of thyroid disease,
intolerance to heat and cold, change in skin pigmentation or texture, excessive sweating,
relationships between appetite, abnormal hair distribution, nervousness, tremors and need for hormone
therapy