Fundamentals of Nursing Major Output

LECTURE REQUIREMENT:

Instruction: Read the case of Amanda Aquilini. Based on the data, Fill up the Focused Assessment forms
found on the Health Assessment Checklist, specifically:

I. BIOGRAPHIC DATA
II. HEALTH HISTORY
III. PSYCHOSOCIAL PROFILE
IV. ANATOMY AND PHYSIOLOGY
V. DRUG STUDY (you may search this in the internet or any drug book)
VI. HEALTH TEACHINGS
VII. NURSING CARE PLAN (2 NCP)

A guide on how to fill up the form is provided on the HA checklist (Page 60 and onwards). Write your
answers in a yellow paper.

CASE STUDY: AMANDA AQUILINI

Amanda Aquilini, a 28-year-old married attorney, 158 cm (5 ft. 2 in.) tall and weighs 56 kg
(125lb). She is admitted to the hospital with an elevated temperature, a productive cough in small
amounts of pale pink sputum, and rapid, labored respirations. In taking a nursing history, Nurse Mary
Medina, RN, finds that Amanda has had a “chest cold” for two weeks, and has been experiencing
shortness of breath upon exertion. Yesterday she developed an elevated temperature and began to
experience “pain” in her “lungs”.

Nurse Medina’s physical assessment reveals that Amanda’s vital signs are: Temperature, 39.4 o C
(103 o F) ; Pulse, 92; Respirations, 28; and blood pressure, 122/80 mm Hg. Nurse Medina observes that
Amanda’s skin is dry, her cheeks are flushed, and she is experiencing chills. She also has a decreased skin
turgor, dry and pale mucous membrane, shallow respiration with chest expansion of <3cm. Auscultation
reveals inspiratory crackles with diminished breath sounds in the right lung. Abdomen soft and not
distended. She claimed that she had difficulty in sleeping because of cough. She stated that she can’t
breathe lying down. She also states that she feels weak. She also claims to be short of breath on
exertion albeit she exercises daily.

Upon further assessment she has no sensory deficits. Her pupils 3 mm, equal with brisk reaction.
She’s oriented to time, place, and person. She’s responsive but fatigued. She responds appropriately to
verbal and physical stimuli. Her recent and remote memories are intact. She also doesn’t have any
musculoskeletal impairment.

In addition to her previous assessments, Amanda said that she has the usual eating pattern of
having 3 meals a day but recently she doesn’t have any appetite due to her cold. She hasn’t eaten today
and she had taken her last fluids this noon. Amanda doesn’t usually have any problems in eliminating.
But recently she’s exhibiting decreased urinary frequency and amount × 2 days. Her last bowel
movement was yesterday, it was formed and she said it was normal.

Amanda provided Nurse Mary a thorough history of illnesses and surgeries. Amanda said she
had a history of appendectomy and partial thyroidectomy. She complies with Synthroid regimen having
Synthroid 0.1 mg per day and she relates the progression of the illness in detail. Amanda expects to have
antibiotic therapy and she also expects to go home in a day or two.

Upon interview, Amanda said she lives with her husband and her 3-year-old daughter. Her
husband is currently out of town and will be back tomorrow afternoon. Her daughter is with their
neighbor until her husband returns. She states that she has a good relationship between her friends and
co-workers. Amanda expresses her concern and worry regarding leaving her daughter under the care of
their neighbors until her husband returns. She also expresses her concerns regarding her work she said
“I’ll never get caught up”. Amanda seems to be anxious, she said can’t breathe. Her facial muscles are
tense; trembling. She said she is usually well groomed but today she is just too tired to put on makeup.
Amanda is a Catholic but she doesn’t wish to see a chaplain or a priest as of the moment. She believes
the priest has no special practices except anointing of the sick.

RLE REQUIREMENT

Search for a Case with problems on sleep, Nutrition, mobility, pain, fluid and electrolyte. Based on the
data from the case you had selected, Fill up the Focused Assessment forms found on the Health
Assessment Checklist, specifically:

I. BIOGRAPHIC DATA
II. HEALTH HISTORY
III. PSYCHOSOCIAL PROFILE
IV. ANATOMY AND PHYSIOLOGY
V. DRUG STUDY (you may search this in the internet or any drug book)
VI. HEALTH TEACHINGS
VII. NURSING CARE PLAN (2 NCP)
VIII. BIBLIOGRAPHY