Case Study and

Nursing Care Plan

A RLE Concepts for Level II BSN Students

ROMAN J-LOU B. CORDOVILLA, RM, RN, MAN, EMT-B, PhD (c)

Assistant Professor II
The Interview
Nurse - Client Interaction Phase
A good health history assessment is
the gateway to a successful nurse-
patient relationship.
Active Listening

Nurses must do more than simply listen when conducting a health

history assessment—they must actively listen. Active listening involves
fully comprehending what a patient is communicating through both
verbal and nonverbal cues (such as body language), as well as the
patient’s emotional state. Complete concentration is essential during a
nursing assessment. Listen carefully, using verbal and nonverbal
prompts to encourage the patient to expand on his or her symptoms and
the circumstances surrounding them.
 Adaptive Questioning
Also referred to as guided questioning, adaptive questioning helps
you encourage a patient to fully communicate without interrupting the
flow of his or her narrative. Start with general questions, making them
more specific as you move through the interview. Health assessments in
nursing require questioning that elicits a graded response versus a yes or
no reply. A series of questions, asked one at a time, often helps patients
open up, as does offering multiple choices for answers. Request
additional information when necessary by asking the patient to clarify
their statements. Repeating his or her statements (a technique called
echoing) is also helpful, as is using verbal and nonverbal continuers,
such as nodding your head or saying things like “go on.”
Nonverbal Communication

Nursing assessments also require that you be in tune with a

patient’s nonverbal communication, such as posture, eye contact, facial
expression, and the like. Reading and understanding these nonverbal
cues help nurses understand patients more fully, and using nonverbal
communication of their own—such as mirroring a patient’s position or
using therapeutic physical contact (placing a hand on the patient’s arm,
for example)—can further augment the health history assessment.
Empathy, Validation, and Reassurance

Empathy is key in nursing health assessments, as it demonstrates

that you understand and care about what a patient is experiencing and
helps establish a trusting nurse–patient relationship. Empathic responses
during a health history assessment interview can be both verbal (“I
understand”) and nonverbal (such as offering a tissue if the patient is
crying). Beyond being empathic, be sure to validate patients’ feelings to
help reassure them that their emotions are natural and reasonable and
their problems are understood and will be fully addressed.
Partnering and Summarization

Another essential element of a nursing health assessment is

expressing to the patient that you are committed to forging a continuing
partnership dedicated to his or her wellness. Even if you’re still enrolled
in a nursing program —such as a Bachelor of Science in Nursing or RN
program—as a student, this support can make a tremendous difference
in a patient’s life. As you conduct your interview, summarizing what the
patient has said is also helpful, as it demonstrates that you’ve been
listening and can fill in holes in the patient’s story.
Transitions and Empowerment

Health problems can elicit feelings of anxiety in patients. One

way to put their fears at ease is to use transitions during their health
history assessment to let them know what they should expect next, such
as a change in subject matter or a physical examination. Patients also
feel vulnerable when they’re experiencing health problems, making it
essential to empower them with the idea that their participation in the
process and working closely with their medical team can make a
positive difference in their outcomes.
General Health Assessment

The Nursing Health Assessment is an incredibly valuable tool

nurses have in their arsenal of skills. A thorough and skilled assessment
allows you, the nurse, to obtain descriptions about your patient’s
symptoms, how the symptoms developed, and a process to discover
any associated physical findings that will aid in the development of
differential diagnoses. Assessment uses both subjective and objective
data. Subjective assessment factors are those that are reported by the
patient. Objective assessment data includes that which is observable
and measurable (Jarvis, 2008).
 During the assessment period, you are given an opportunity to
develop a rapport with your patient and their family. Remember the
adage “first impressions are lasting impressions?” That adage is also
very true in healthcare. You are often the first person your patient sees
when admitted to your unit, returns from testing, or at the beginning of
a new shift. Your interactions with your patient gives the patient and
family lasting impressions about you, other nurses, the facility you are
working in, and how care will be managed (Jarvis, 2008).
 All assessments
should consider the patient’s privacy and foster open,
honest patient communications.
Types of General Health Assessments
In general, there are four fundamental types of assessments that
nurses perform:
A comprehensive or complete health assessment
An interval or abbreviated assessment
A problem-focused assessment
An assessment for special populations
 Comprehensive or
Complete Health assessment
A comprehensive or complete health assessment usually begins
with obtaining a thorough health history and physical exam.

This type of assessment is usually performed in acute care

settings upon admission, once your patient is stable, or when a new
patient presents to an outpatient clinic.
 Interval or Abbreviated assessment
If the patient has been under your care for some time, a
complete health history is usually not indicated. Nurses perform an
interval or abbreviated assessment at this time.
These assessments are usually performed at subsequent visits in
an outpatient setting, at change of shift, when returning from tests, or
upon transfer to your unit from another in-house unit.
This type of assessment is not as detailed as the complete
assessment that occurs at admission. The advantage of an abbreviated
assessment is that it allows you to thoroughly assess your patient in a
shorter period of time (Jarvis, 2008).
 Problem-focused assessment
The problem-focused assessment is usually indicated after a
comprehensive assessment has identified a potential health problem.
The problem-focused assessment is also indicated when an interval or
abbreviated assessment shows a change in status from the most
current previous assessment or report you received, when a new
symptom emerges, or the patient develops any distress.
An advantage of the focused assessment is that it directs you to
ask about symptoms and move quickly to conducting a focused physical
exam (Jarvis, 2008; Scanlon, 2011).
 Assessment for Special Populations
The fourth type of assessment is the assessment for special
populations, including:
a. Pregnant patients b. Infants c. Children d. The elderly
If there is any indication to perform a problem-focused or special
population assessment during the comprehensive assessment, the
assessment should occur after obtaining a baseline comprehensive
assessment.
Based upon the results of the problem-focused or special
population assessment, you can decide how often to perform interval
assessments to monitor your patient’s identified problem (Jarvis, 2008;
Scanlon, 2011).
Health History
The purpose of obtaining a health history is to provide you with a description
of your patient’s symptoms and how they developed. A complete history will serve as a
guide to help identify potential or underlying illnesses or disease states.
In addition to obtaining data about the patient’s physical status, you will obtain
information about many other factors that impact your patient’s physical status
including spiritual needs, cultural idiosyncrasies, and functional living status.
The basic components of the complete health history (other than biographical
information) include: Chief complaint, Present health status, Past health history,
Current lifestyle, Psychosocial status, Family history, Review of systems.
Communication during the history and physical must be respectful and
performed in a culturally-sensitive manner. Privacy is vital, and the healthcare
professional needs to be aware of posture, body language, and tone of voice while
interviewing the patient (Jarvis, 2008; Caple, 2011).
Chief Complaint
In your patient’s own words, document the chief complaint. The chief
complaint may be elicited by asking one of the following questions:
-So, tell me why you have come here today?
-Tell me what your biggest complaint is right now?
-What is bothering you the most right now?
-If we could fix any of your health problems right now, what would it
be?
-What is giving you the most problems right now?
If your patient has more than one complaint, discuss which one is the most troublesome
for them and document the complaints in order of importance as determined by the patient (Jarvis,
2008; Baid, 2006).
Present Health Status
Obtaining information about a patient’s present health status allows the nurse to
investigate current complaints. The PQRST, utilizes a structured format for
information gathering, including evaluation of pain, and provides an efficient
methodology to communicate with other healthcare providers. Use PQRST to
assess each symptom and after any intervention to evaluate any changes or
responses to treatment (Jarvis, 2008):
Provocative or Palliative: What makes the symptom(s) better or worse? Quality: Describe
the symptom(s).
Region or Radiation: Where in the body does the symptom occur? Is there radiation or
extension of the symptom(s) to another area of the body?
Severity: On a scale of 1-10, (10 being the worst) how bad is the symptom(s)? Another visual
scale may be appropriate for patients that are unable to identify with this scale.
Timing: Does it occur in association with something else (i.e. eating, exertion, movement)?
Past Health History
It is important to ask questions about your patient’s past health history.
The past health history should elicit information about the patient’s
childhood illnesses and immunizations, accidents or traumatic injuries,
hospitalizations, surgeries, psychiatric or mental illnesses, allergies, and
chronic illnesses. For women, include history of menstrual cycle, how
many pregnancies and how many births (Jarvis, 2008).
Childhood Illnesses: Data related to childhood illnesses is more
pertinent to children than adults and the elderly. For adults, you want
to know if they have ever had rheumatic fever and if their tetanus and
hepatitis B vaccinations are current. For the elderly, you may want to
ask if they ever had polio, rheumatic fever, or chicken pox. Pertinent
vaccinations for the elderly would include tetanus, pneumonia and
 Accidents or Traumatic Injuries: When assessing this area of the
past health history, pay particular attention to patterns of injury,
especially in infants, children, women and the elderly (Jarvis, 2008).
Hospitalizations: Be sure to ask the reason for the hospitalization
and the nature of the treatments received while in the hospital such as
blood transfusions, surgeries and any follow-up treatments. Remember
to include hospitalizations for childbirth (Jarvis, 2008).
Surgeries: Many surgical procedures are performed on an
outpatient basis. Questions regarding surgeries should also be asked in
addition to hospitalizations, as patients may not discuss a surgery if
there was no associated hospital stay (Jarvis, 2008).
 Psychiatric or Mental Illnesses: If your patient has a past history
of psychiatric or mental illnesses, ask what triggered the illness, if
anything, and the course and the progression of the illness. This
includes depression and anxiety, as well as diagnosed mental illness
(Jarvis, 2008).
Allergies: Identify what your patient is allergic to (both food and
medication), as well as the reaction and response to treatment. It is
important to ask about any environmental allergies or sensitivities
(such as latex) also (Jarvis, 2008).
Family History
Family history is important in identifying your patient’s risk for certain
disease states.
Applicable generations with whom to explore health status
include grandparents, parents, and the children of your patient.
Chronic illnesses or known diseases with genetic components
should also be screened for. Chronic illness or disease can include
cancer, diabetes, autoimmune disorders, cholesterol, heart disease,
hypertension, renal disease, and mental illness, among others (Jarvis,
2008).
Current Health Status
Information collected should also include details about your
patient’s personal habits such as smoking or drinking, nutrition,
cholesterol, and if there is a history of heart disease or hypertension.

Medications:
Obtain a list of current medications, including dose and
frequency, as well as reason for taking them. Remember to ask the
patient about over the counter medications, vitamins, and herbal
supplements (Jarvis, 2008; Baid, 2006).
The Nursing Process
The Nursing Process
Is the common thread uniting different types of nurses
who work in varied areas is the nursing process—the essential
core of practice for the registered nurse to deliver holistic,
patient-focused care.
One definition of the nursing process…”an assertive,
problem solving approach to the identification and treatment
of patient problems. It provides an organizing framework for
the practice of nursing and the knowledge, judgments, and
actions that nurses bring to patient care.”
Assessment
An RN uses a systematic, dynamic, rather than static way to
collect and analyze data about a client, the first step in delivering
nursing care.
Assessment includes not only physiological data, but also
psychological, sociocultural, spiritual, economic, and life-style factors as
well.
For example, a nurse’s assessment of a hospitalized patient in
pain includes not only the physical causes and manifestations of pain,
but the patient’s response—an inability to get out of bed, refusal to eat,
withdrawal from family members, anger directed at hospital staff, fear,
or request for more pain medication.
DIAGNOSIS
The nursing diagnosis is the nurse’s clinical judgment about the
client’s response to actual or potential health conditions or needs.
The diagnosis reflects not only that the patient is in pain, but that
the pain has caused other problems such as anxiety, poor nutrition, and
conflict within the family, or has the potential to cause complications—
for example; respiratory infection is a potential hazard to an
immobilized patient. The diagnosis is the basis for the nurse’s care plan
Planning / Goal / Expected Outcome
Based on the assessment and diagnosis, the nurse sets
measurable and achievable short- and long-range goals for this patient
that might include moving from bed to chair at least three times per
day; maintaining adequate nutrition by eating smaller, more frequent
meals; resolving conflict through counseling, or managing pain through
adequate medication.
Assessment data, diagnosis, and goals are written in the patient’s
care plan so that nurses as well as other health professionals caring for
the patient have access to it.
Implementation
Nursing care is implemented according to the care plan, so
continuity of care for the patient during hospitalization and in
preparation for discharge needs to be assured.
Care is documented in the patient’s record
Evaluation
Both the patient’s status and the effectiveness of the nursing
care must be continuously evaluated, and the care plan modified as
needed.
The Case:
Mr. Ping is a 57-year-old businessman who was admitted to the surgical unit for treatment of a possible
strangulated inguinal hernia. Two days ago he had a partial bowel resection. Postoperative orders include NPO,
intravenous infusion of D51/2 NS at 125 cc/hr left arm, nasogastric tube to low intermittent suction. Mr. Ping is
in a dorsal recumbent (supine) position and is attempting to draw up his legs. He appears restless and is
complaining of abdominal pain (7 on a scale of 0–10).

Physical Examination Diagnostic Data

Height: 188 cm (6′ 3′′) Chest x-ray and urinalysis negative
Weight: 90.0 kg (200 lb) WBC 12,000
Temperature: 37°C (98.6°F)
Pulse: 90 BPM
Respirations: 24/minute
Blood pressure: 158/82 mmHg
Skin pale and moist, pupils dilated.
Midline abdominal incision, sutures dry and intact.
What is a Nursing Diagnosis?
A nursing diagnosis is a clinical judgment concerning
human response to health conditions/life processes, or a
vulnerability for that response, by an individual, family, group,
or community. A nursing diagnosis provides the basis for the
selection of nursing interventions to achieve outcomes for
which the nurse has accountability.
Nursing diagnoses are developed based on data
obtained during the nursing assessment and enable the nurse
to develop the care plan.
Purposes of Nursing Diagnosis
The purpose of the nursing diagnosis is as follows:
• Helps identify nursing priorities and help direct nursing
interventions based on identified priorities.
• Helps the formulation of expected outcomes for quality
assurance requirements of third-party payers.
• Nursing diagnoses help identify how a client or group
responds to actual or potential health and life processes and
knowing their available resources of strengths that can be
drawn upon to prevent or resolve problems.
• Provides a common language and forms a basis for
communication and understanding between nursing
professionals and the healthcare team.
• Provides a basis of evaluation to determine if nursing care
was beneficial to the client and cost-effective.
• For nursing students, nursing diagnoses are an effective
teaching tool to help sharpen their problem-solving and
critical thinking skills.
Discussions in this area:
https://www.youtube.com/watch?v=ReXuXy4M7oY
Therapeutic Mechanism of Action
Side Effect VS Adverse Effect
References for your perusal:
Berman, A., Snyder, S., & Frandsen, G. (2016). Kozier & Erb’s Fundamentals of Nursing: Concepts,
process and practice. Boston, MA: Pearson.
Ackley, B. J., & Ladwig, G. B. (2010). Nursing Diagnosis Handbook-E-Book: An Evidence-Based Guide to
Planning Care. Elsevier Health Sciences.
https://www.waldenu.edu/online-bachelors-programs/bachelor-of-science-in-nursing/resource/
effective-nursing-health-assessment-interview-techniques
https://www.mjc.edu/instruction/alliedhealth/adnprogram/nursingprocessoverview.pdf
https://nurseslabs.com/nursing-diagnosis/
https://i.pinimg.com/originals/a2/38/86/a23886116ccae7823441a4099168dd13.gif
https://www.pearson.com/uk/educators/higher-education-educators/program/Barrett-Care-
Planning-A-Guide-for-Nurses/PGM931268.html
https://rnspeak.com/what-is-ncp-nursing-care-plan/
Case Study:
Ms. Manilyn, a 27-year-old sales clerk, reports weakness, malaise, and flu-like symptoms for 3–4 days. Although
thirsty, she is unable to tolerate fluids because of nausea and vomiting, and she has liquid stools 2–4 times per
day.

Physical Examination Diagnostic Data

Height: 160 cm (5′3′′) Urine specific gravity: 1.035
Weight: 66.2 kg (146 lb) Serum sodium 155 mEq/L
Mild fever: 38.6°C (101.5°F) Serum potassium 3.2 mEq/L
Pulse: 86 BPM Chest x-ray negative
Respirations: 24/minute
Scant urine output
BP: 102/84 mmHg
Dry oral mucosa, furrowed
tongue, cracked lips