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STI COLLEGE SOUTHWOODS

Lot 2A Maduya, Carmona, Cavite


COLLEGE OF HEALTH CARE
CASE STUDY FORM
PATIENTS HISTORY
A. BIOGRAPHICAL DATA
Name: Jhondy Boy Desosa Bayan
Age: 10 years old

Gender: Male

Civil Status: Single

Address: Bancal,Carmona Cavite


Educational Attainment:
Occupation: N/A

Religion: Dating Daan

Dialect / Language spoken: Tagalog


Health Insurance: N/A
Chief Complaint:LBM & Fever
Admitting Diagnosis: Acute Gastroenteritis, Age malnutrition and Pulmonary Tuberculosis V
B. NURSING HISTORY

1.

History of Present Illness: 1-2 days PTA ---(+)LBM watery, yellowish(4x) foul smelling non bloody
(+) on and off fever
Fever virus PTA= (+) upward rolling of eyeballs, (+) stiffening of extremities,(-) DOB
(-) active bleeding, (+) GI abdominal pain, colicky bleeding, tenderness,(+) cough x few days
(+) loss of appetite

2. Family History of Illness: _____________________________________________________


_________________________________________________________________________
3. Childhood Illness: __________________________________________________________
_________________________________________________________________________
__________________________________________________________________________
4. Hospitalization history:
Date of
Hospitalization
July 10, 2009

Hospital

Diagnosis

Pagamutang

Mild

bayan ng

dehydration,severe

Carmona

malnutrition and

Treatment
rendered

Medication

pulmonary
tuberculosis 3

C. CURRENT HEALTH STATUS


Physiologic Mode
a.

ACTIVITY
Frequency and regularity of exercises: ____________________________________

Duration and length of exercises: ________________________________________


Limitations of activity: _________________________________________________
Any complaints/discomfort during activity: _________________________________
Complaint of Fatigue: __________________________________________________
Measures done to relieve the discomfort / complaint: _________________________
b.

REST
Usual no. of hours of sleep and rest at night: ____________at day time: ________
No. of hours of sleep and rest to feel rested: _______________________________
Change in sleep / rest pattern: __________________________________________
Discomfort or difficulty going to sleep: _____________________________________
Remedy done with the discomfort: _______________________________________
No. of pillows use when sleeping: ________________________________________

c.

NUTRITIONAL METABOLIC PATTERN


Food Preference:_________________

Food restrictions:______________________

Volume and type of fluid taken per day: ____________________________________


Source of drinking water supply: __________________________________________
Frequency of taking meals at home:________________ at restaurant:____________
Any change in diet: _________________Specify:_____________________________
Any change in appetite: ________________________ specify: __________________
Medication used (if any) : ________________________________________________
d.

ELIMINATION PATTERN
i.

Bladder
Frequency and amount of urination per day: _________________________
Color and odor of urine:__________________________________________
Any discomfort in urination:_______________________________________
Remedy and intervention done: ___________________________________

ii.

Bowel
Frequency of bowel elimination per day: ____________________________
Consistency and color of stools:___________________________________
Changes in bowel elimination:____________________________________
Discomfort in Bowel elimination:___________________________________
Intervention done: _____________________________________________

e.

FLUID AND ELECTROLYTES


Skin Turgor: _____________________________________________________
Condition of mucous membrane: _____________________________________
Edema: _________________________________________________________
K, Ca, Na, supplements: ____________________________________________

f. OXYGENATION AND CIRCULATION


Do you smoke: _______________ No. of Cigarettes per day: ______________
Presence of Cough:_______ Characteristics: __________________________
Usual BP: ______________________
History of asthma, PTB in the family: _________________________________
History of heart disease and HPN :___________________________________
Chest pain (location, frequency, duration, and type of pain ) : _____________
_______________________________________________________________
Medication taken / maintenance drugs : ______________________________
Shortness of breath / DOB: ________________________________________

g. SENSES
Any disturbance / difficulty in:
Sight: ________________________
Hearing: ______________________
Touch: _______________________
Taste: _______________________
Smell: _______________________
How long do you have the difficulty?____________________________
How do you manage it?______________________________________
How has this affected your lifestyle:____________________________
Device used?______________________________________________
h.

SKIN INTEGRITY
Pigmentation: ___________________________________________________
Temperature:___________________
Smooth ( )

Rough ( )

Soft ( )

Dry ( )

Perspiration and odor problem: ________________________________________


Use of any beauty aid: ______________________________________________
i.

ENDOCRINE FUNCTION
Age of menarche: _____________

Duration: ____________ Cycle:__________

Menstrual discomfort: _____________ Discomfort done: _____________________


Usual Blood sugar: _______________________
Supplement taken: _______________ Insulin schedule: ______________________
j.

NEUROLOGICAL FUNCTION
Level of consciousness;_________________________________________________
Orientation:_____________ gait:__________________ Posture:______________
Changes in facial, mouth and neck function:_________________________________
Deep tendon reflex:____________________________________________________
Sense of pain and light touch : ___________________________________________

Self Concept Mode


a. PERSONAL SELF
Describe yourself:_________________________________________________________
Describe your Moods:______________________________________________________
What do you like about yourself: ____________________________________________
What do you want to change in yourself:_______________________________________
Hindrances to your change:__________________________________________________
Changes you feel about yourself: _____________________________________________
Reaction to illness / hospitalization: ___________________________________________
b.

PHYSICAL SELF
Present weight: ___________ Lowest weight: ______________
How do you feel yourself and appearance:_______________________________________
Any physical changes in your body:____________________________________________
Has this changes affected your relationship with others?_____________________________

c.

PERSONAL VALUES
What do you consider as the most valuable / important in your life:____________________
_________________________________________________________________________
With what and who do you find a source of strength or meaning? ____________________
________________________________________________________________________

Does illness / hospitalization interfere with your religious practices : __________________


How? ___________________________________________________________________
Role Function Mode
Type of family structure:___________________________________________________
How many members in the family : ____________________________________
Who is the bread winner:_________________ Who is the decision Maker: ______________
How does the family feel about the illness: _______________________________________
Expectations to self: _________________________________________________________
Expectation from the attending physician: ________________________________________
Expectation from Nurses: _____________________________________________________
Interdependence Mode
Frequency of interaction with the family: _________________________________________
Duration of Interaction: ______________________________________________________
Frequency of interaction outside of family: ___________________________________
What social group do you belong to:___________________________________________
How do you make the decision: _____________________________________________
With whom: ____________________________________________________________
How does the family cope in time of crisis?: ______________________________________
Any big change in your life in the last year or two?:________________________________
What was the change: _____________________________________________

D.
PSYCHOSEXUAL
(Freud)

PSYCHOLOGICAL DEVELOPMENT

PSYCHOSOCIAL
(Erickson)

Latency

Industry vs

stage

inferiority

E.

(Piaget)

concrete

INTERPERSONAL

MORAL

(Sullivan)

(Kohlberg)

(Fowlers)

Preconventiona

Mythical and

l Morality

literal faith

No. of hospital Days: _________________________

Vital signs :

a.

Temperature: 39*C

b.

Pulse Rate:

c.

Respiratory Rate: 22

2.

Blood pressure:

3.

Regional Examination:

Regions of the body

58 bpm

Methods of Assessment (IPAP)

Results

a. Hair
b. Head
c. Face
d. Eyes
e. Nose
f. Mouth and pharynx
g. Neck
h. Chest wall ( Anterior)
i. Chest wall (Posterior)
j. Breast and Axilla
k. Heart

SPIRITUAL

complementarity

PHYSICAL EXAMINATION

Date performed: 9/18/09


1.

COGNITIVE

Sunken eyeballs

l. Abdomen
m. Skin and nails
n. Anus and Rectum
o. Extremities (lower) *include
ROM and muscle strength
p. Extremities (upper) *include
ROM and muscle strength
q. Urinary
r. Genitals
s. Musculoskeletal
t. Hematology
u. Gastrointestinal
v. Cranial Nerves (I-XII)
If applicable please include Neuromuscular Vital signs / assessment
F. LABORATORY EXAMINATIONS

Purpose of the

Date and

examination to

Type of
Examination

the patients

Nursing
Normal Values

Results of the
examination

Interpretation

case

responsibilities
(before,
during , after)

G. DIAGNOSTIC EXAMINATIONS

Purpose of the

Date and

examination to

Type of
Examination

the patients

Nursing
Normal Values

Results of the
examination

Interpretation

case

responsibilities
(before,
during , after)

H. MEDICAL PLAN OF CARE

Date of the order

I.

Doctors order

Responsibility of the nurse

Purpose of the given

with the order

order

ANATOMY AND PHYSIOLOGY

Include picture of system and brief explanation that relates to the patients.
J.

PATHOPHYSIOLOGY

A. Diagram
Include precipitating and predisposing factors.
B. Tabular
Definition of the diseases

Signs and Symptoms

Signs and Symptoms

found in the book

manifested by the patient

Evaluation or comparison

K. DRUG STUDY
Name of Drug, Classification,
Route, Frequency and

Drug Indication

Nursing Responsibility

Drug Action

(before, during , after)

Dosage

L.

NURSING CARE PLAN

Cues
(subjective/objective)

Nursing Diagnosis

Objectives

Nursing Intervention
and Rationale

Evaluation

M. PROGRESS NOTES
Day

Status of the Patient

N. DISCHARGE PLAN OF CARE

1.
2.
3.
4.

Key Area
Nutrition
Medication
Activity
Self Care / knowledge on

Plan of Care

treatments
5. Follow up check ups
O. HEALTH TEACHING PLAN
Topic

P.

Objective

Methods of Teaching

Visual aids

Evaluation

SUMMARY OF CLIENTS STATUS OR CONDITION AS OF LAST DAY OF CONTACT

Date:
Condition of the patient on his/her last day.