ILIGAN MEDICAL CENTER COLLEGE

San Miguel Village, Pala-o, Iligan City

COLLEGE OF NURSING, MIDWIFERY & HEALTH AIDE

NCP BOOKLET
CASE METHOD APPROACH
GUIDE TO PATIENT CARE ANANLYSIS

STUDENT: _________________________________________________ YEAR LEVEL: ___________________ GROUP NO:

______________

HOSPITAL/ WARD: __________________________________________ INCLUSIVE DATE OF EXPOSURE:

__________________________________

CLINICAL INSTRUCTOR: _____________________________________ RATING:

________________________________________________________
PATIENT ASSESSMENT DATABASE

HEALTH HISTORY

Name : _________________________________________________ Address :________________________________________________

Age : _________________________________________________ Inclusive Date of Confinement : ______________________________

Sex : _________________________________________________ Admission Date & Time : ___________________________________

Nationality : _________________________________________________ Discharge Date & Time : ____________________________________

Civil Status : _________________________________________________ Attending Physician : ______________________________________

Religion : _________________________________________________ Initial Diagnosis : __________________________________________

Highest Educational Attainment :____________________________________ Final Diagnosis : __________________________________________

Occupation : ________________________________________________ Source of History : _________________________________________

Source of Income : _______________________________________________ Reliability of Historian : _____________________________________

Rank in the Family : ______________________________________________ Chief Complaint : __________________________________________

I. HEALTH PERCEPTION/ HEALTH MANAGEMENT PATTERN

A. Present Health Status

B. Past Health Status

b.1 General Health

_____________________________________________________________________________________________________________________

b.2 Prophylactic Medical/ Dental Care

_____________________________________________________________________________________________________________________

b.3 Childhood Illness

_____________________________________________________________________________________________________________________

b.4 Immunizations

____________________________________________________________________________________________________________________

b.5 Major Illness/ Hospitalizations

____________________________________________________________________________________________________________________

b.6 Current Medications

Prescribed

Non – Prescribed

____________________________________________________________________________________________________________________

b.7 Allergies

Ingestants ______________ Injectants_________________ Inhalants_____________________ Contactants ___________________

b.8 Habits

Alcohol________________ Caffeine __________________ Drugs _______________________ Tobacco ______________________

b.9 Family Health History (Genogram)

Legend:

X - male CA - cancer (specify)

Y - female DM - diabetes mellitus

+ - deceased PTB - pulmonary tuberculosis

AW - alive & well HPN - hypertension

* - patient MI - myocardial infarction

F - father SUI - suicide

M - mother RF - renal failure

B - brother CVA - cerebrovascular accident

S - sister ? - unknown

C - children Additional – if applicable

II. NUTRITION – METABOLIC PATTERN

A. Appetite

B. Usual Daily Menu

Breakfast _____________________________________________ Dinner _____________________________________________

Lunch ________________________________________________ Snacks _____________________________________________

C. Dentition _________________________________________________________________________________________________________

D. Metabolic ( wt. gain/ loss) ___________________________________________________________________________________________

III. ELIMINATION PATTERN

A. Bowel _____________________________________________________________________________________________________________

B. Bladder ____________________________________________________________________________________________________________
IV. ACTIVITY – EXERCISE PATTERN

A. Self – Care Ability

_________ Feeding __________ Toileting ____________ Dressing ___________ Home Maintenance ___________ Shopping

_________ Bathing __________ Bed Mobility __________ Grooming __________ Cooking ______________ General Mobility

Legend: Function eve’s Code

O - Full Self Care

I - Requires use equipment of device

II - Requires assistance or supervision

III - Requires assistance or supervision from another personal equipment device

IV - Is dependent and does not participate

B. Oxygenation/ Perfusion

b.1 Chest X – Ray ( If any )

b.2 Cardiac Risk Factors ( If applicable )

Positive Negative Not Known

1. Sedimentary life style _______ _______ ________

2. Hypertension _______ _______ ________

3. Obesity _______ _______ ________

4. Hyper-vigilant personality _______ _______ ________

5. Hyper-lipidemia _______ _______ ________

6. Family history of heart disease _______ _______ ________

7. Diabetes _______ _______ ________

8. Cigarette smoking _______ _______ ________

V. SLEEP & REST PATTERN

VI. COGNITIVE – PERCEPTUAL PATTERN

A. Hearing __________________________________________________________________________________________________________

B. Vision ___________________________________________________________________________________________________________

C. Sensory Perception ________________________________________________________________________________________________

D. Learning Style ____________________________________________________________________________________________________

VII. SELF – PERCEPTION/ SELF-CONCEPT PATTERN

VIII. ROLE – RELATIONSHIP PATTERN

IX. SEXUALLY – REPRODUCTIVE PATTERN

X. COPING-STRESS TOLERANCE PATTERN

XI. VALUE – CENTER PATTERN

 PHYSICAL EXAMINATION

I. GENERAL SURVEY

II. VITAL SIGNS DAY 1 DAY 2 DAY 3 DAY 4 DAY 5

Temperature _____ _____ _____ _____ _____

Pulse Rate/ Cardiac Rate _____ _____ _____ _____ _____

Respiratory rate _____ _____ _____ _____ _____

Blood Pressure _____ _____ _____ _____ _____

III. INTEGUMENTARY

A. Skin : Color __________________ Abnormalities ______________________________

B. Mucous membrane : _______________________

C. Nails : _______________________

D. Hair : Distribution ___________________ Appearance _______________ Hygiene ____________________

IV. HEENT

Head : Size _____________ Shape ____________________

Eyes : Color ( optic disk & conjunctive ) ________ Visual acuity _______ Pupil Response _________ Accomodation _______________

Ears : Symmetry ________________ Discharge/ Growth ______________ Hearing Ability __________________________________

Nose : Mucosal condition __________________________________ Discharge Growth ______________________________________

Mouth/ Throat/ Pharynx/ Teeth: ( Color/ Lesions/ Smoothness/ Presence of Cavity ) _________________________________________________

Face : Symmetry _____________________________________________ Facial Musculature ________________________________

V. Neck / Lymph Nodes

Symmetry : _________________________________ Growth : ___________________________________________

VI. Pulmonary ( Breath & Sounds )

Normal : _________________________________ Abnormal (please specify) _________________________________

VII. Breast and Axillary areas :

Symmetry _________________________ Growth _____________________ Retraction _________________________

Discharge _________________________ Lymph Nodes ________________

VIII. Cardiovascular

Normal : ________________________________ Abnormal : ____________________________________

(S1 S2 ) (extra sounds) : Murmurs

Rhythm _________________________________ Rate ___________________________________________

IX. Peripheral / vascular

Peripheral Pulse ( state if equal – bilaterally )

Grade ____________ Temporal ____________________ Legend : Peripheral Pulse Scales

Grade ____________ Carotid ______________________ 0 – Absent

Grade ____________ Bronchial ____________________ 1 – markedly diminished

Grade ____________ Radial _____________________ 2 – moderately diminished

Grade ____________ Femoral _____________________ 3 – slightly diminished

Grade ____________ Popliteal _____________________ 4 – normal

Grade ____________ Posterior Tibialis ______________

Grade ____________ Dorsalis Pedis _________________

X. Abdomen

General contour_________________________________ Tenderness _______________________________

Bowel Sounds _________________________________ Abdominal Sounds ____________________________

 LABORATORY DATA / DIAGNOSTIC STUDIES

NORMAL
A. LABORATORY EXAMINATIONS RESULTS SIGNIFICANCE
VALUES
 NORMAL
A. DIAGNOSTIC EXAMINATIONS RESULTS SIGNIFICANCE
FINDINGS
 COLLABORATIVE PLAN OF CARE

Medications

Standing Orders

Brand Name/ Generic Date/ Dosage/ Action/ Mechanism of

Indications Side Effects Nursing Precautions
Name Frequency Action
NURSING DIAGNOSIS DEVELOPED IN CARE PLAN

INTERVENTION
PATHOPHYSIOLOGIC NURSING
CUES PLAN/ OBJECTIVE RATIONALE EVALUATION
(Independent/ Dependent/
BASIS DIAGNOSIS
Interdependent)