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EMILIO AGUINALDO COLLEGE

SCHOOL OF NURSING AND MIDWIFERY CASE STUDY FORMAT


INTRODUCTION PATIENT PROFILE PATIENT HISTORY/ NURSING HISTORY GORDONS LEVEL OF HEALTH FUNCTIONING PHYSICAL ASSESSMENT ANATOMY AND PHYSIOLOGY RELATED LITERATURE PATHOPHYSIOLOGY LABORATORY RESULTS/ DIAGNOSTIC PROCEDURES COURSE IN THE WARD NCP DISCHARGE PLANNING DRUG STUDY

I. INTRODUCTION Objectives of the study (Reasons why you chose the case) General picture/ explanation of the disease - What is the disease; Brief pathophysiology - The people at risk of acquiring the disease - predisposing factors and precipitating factors Morbidity rate (Philippine Setting) Mortality rate (Philippine Setting) II. PATIENT PROFILE

Ward Date of Admission Pt. Name (Initials only) Address (Complete address need not to be included) Age Gender Birth date Educational Status Religion Nationality Civil Status Occupation Health Care Financing Informant Reliability

Admission data 1. Chief Complaint 2. Initial Diagnosis 3. Final Diagnosis 4. Attending Physician

III. PATIENT HISTORY

CHIEF COMPLAINTS The chief reason for seeking medical treatment. State in patients own words the current problem HISTORY OF PRESENT ILLNESS o Chronological onset of symptoms: Onset/duration/frequency Associated signs and symptoms, manifestations, related history Previous treatment for the problem PAST MEDICAL HISTORY o Current medications, allergies,surgeries,hospitalizations o Childhood Illness (rheumatic fever,polio,chicken polio,chicken pox,measles,mumps Adult Illness (HPN/stroke/renal/pulmonary , etc) o Routine Health Maintenance Pap Smear/mammogram/breast exam/colonoscope/immunization (e.g pneumococcal and flu vaccine) FAMILY HISTORY with Genogram o Medical problems for any blood relatives cancer/TB/asthma/MI/HPN/thyroid disease/kidney disease/DM/bleeding disorders PERSONAL/SOCIAL HISTORY o Substance Abuse : alcohol/tobacco (pack years)/prohibited drugs o Employment History : Chemical exposure (exposure to environmental agents)

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Sexual History: gender preference (women, men, both)/active?/protection Lifestyle: activity/hobbies/exercise/diet

FOR PEDIATRIC CLIENT INCLUDE THE FOLLOWING AS WELL: ANTENATAL HISTORY: Mothers health, drug use or abuse, gravida and para PERINATAL HISTORY : APGAR Score, birth weight, problems at birth POST NATAL HISTORY : type, amount and duration of various feeding practices

FEEDING HISTORY: ask questions regarding nutrition that are appropriate for the childs age, note if the child was breast fed or bottle fed and how well the baby took the first feeding o BREAST or FORMULA FEED type, amount, weaning difficulties o SUPPLEMENTS vitamins, iron, fluoride o SOLID FOODS when it was introduced, taken, types, dietary habits; appetite (likes and dislkes,allergies) DEVELOPMENTAL HISTORY : Record information regarding childs current developmental status with regard to each of the 4 following areas: gross motor, fine motor, social and language skills (utilizing the MMDST) o When children are of school age also include information regarding academics and physical activities such as sports IMMUNIZATION HISTORY : Indicate sources of information, dates when the immunization were given and which type of immunization was provided (BCG, DPT, MMR, Hep B, Polio, others) also include any TB testing that has been performed SOCIAL HISTORY : Living circumstances place and nature of dwelling, sleeping arrangements, daycare arrangements Economic Circumstances- parents occupations, household pets, potential exposures to toxins in home, for example: cigarette smoke exposure), water source (MWSS, deep well, others) FOR OB/ GYNE CLIENTS INCLUDE THE FOLLOWING AS WELL: HISTORY OF PRESENT ILLNESS - Gravidity, parity, EDD, LMP MENSTRUAL HISTORY menarche, cycle, subjective assessment of flow (number of pads use), dysmenorrheal and timing of pain OBSTETRIC HISTORY o Parity where, when and outcome o Gestation birth weight, sex, mode of delivery o Complications ante/intra/postpartum EXAMPLE: G1- 1990, LFT baby boy via NSD at UERM hospital, BW=6.7 lbs; no complications G2-1991, 8 mos old baby boy via CS at UERM hospital;BW= 5.5lbs; no complications GYNECOLOGICAL HISTORY : note previous surgical procedures, previous gyne problems (PID, endometriosis etc CONTRACEPTIVE HISTORY : details of contraceptive use; methods use; duration of use; acceptance and side effects

IV. GORDONS FUNCTIONAL HEALTH PATTERN Level Of Functioning Before Hospitalization During Hospitalization Analysis/Inference

Health Perception/ Health management Nutritional and metabolic Pattern Elimination Pattern Activity- exercise Pattern Sleep- Rest Pattern Cognitive Perceptual Pattern Self- perception and self- concept pattern Role- Relationship Pattern Sexuality/ Reproductive Pattern Coping Stress Tolerance Value Belief Pattern

NOTE : If the subject is conscious and coherent and able to express him/herself then use Gordons, otherwise use ROS (Review of Systems) please see attached format for the review of systems V. PHYSICAL ASSESSMENT

General Survey: Mood, stage of development, race and sex. Note if patient is in distress (cardiac/respiratory) or assuming an unusual position. Note if cooperative or non cooperative. State also if irritable, agitated or pleasant. Determine BMI Vital Signs o Temperature(Take note if its ORAL, AXILLARY, RECTAL, AURAL) o Respiration (observed if its normal or labored) o Pulse (Note whether the pulse is regular/irregular; note if volume is normal e.g. weak/thread o Blood Pressure (Note if taken while patient is lying, sitting or standing NORMAL FINDINGS ACTUAL FINDINGS ANALYSIS/INFERENCE

AREA TO BE ASSESSED HEENT NECK CHEST AND LUNGS HEART BREAST ABDOMEN GENITALS RECTUM EXTREMITIES SKIN/HAIR/NAILS

INCLUDE NEUROLOGIC EXAMINATION for patients with neurological impairment INCLUDE ASSESSMENT OF GESTATIONAL AGE (AOG) for newborn patients

VI. ANATOMY AND PHYSIOLOGY

VII.RELATED LITERATURE

VIII. PATHOPHYSIOLOGY

Drawing Physiology in diagram form

articles/journal from the internet or library journals

Patient Based Diagram Format Should show the different S/S

Sample: Pathophysiology
Modifiable risk factors Non- Modifiable risk factors

IX. DIAGNOSTIC / LABORATORY PROCEDURES Date (Chronological) Data Result Normal Values Interpretation/ Analysis (Patient Based) ACTUAL RESULT NORMAL VALUE Analysis/ Inference REFERENCE

LABORATORY/ DIAGNOSTIC TEST

X. COURSE IN THE WARD Doctors order (From admission to discharge or until the last day of exposure with the client) New meds New orders (Doctors) Reason of new meds and orders Response of patient to the new orders

XI. NURSING CARE PLAN Cues Nursing Diagnosis Inference/ Analysis/ Minipathophysiology Goal/ Plan Intervention/ Implementation Rationale Evaluation

Seven Columns 3 Actual problem 2 Potential problems

XII. DRUG STUDY Name of drug Generic Name Brand Name Drug Classification Dosage and Frequency ( patient based) Action Action (Specific to the case of the patient) Indication (specific to the case of the patient) Side Effects (patient centered) Adverse Effects (patient centered) Nursing Considerations & Responsibilities (patient centered) Indication (Patient Based) Side Effects and Adverse Effects Nursing Consideration and responsibilities

Generic Name (brand name) Drug Classification Dosage & Frequency

XIII. DISCHARGE PLANNING M- edication E- xercise T-reatment

H-ealth teachings O-ut patient follow up D-iet (Sample of a whole day meal) S-piritual and Sex

Prepared By: AILYN PINEDA, RN JULIE ANNE E. ALCALA, RN, RM, MSN Revised 7/31/2010