SILANG SPECIALISTS MEDICAL CENTER

San Vicente 2 Emilio Aguinaldo Hi-way

Silang, Cavite, Philippines

In Partial Fulfilment of the Requirements

In
Nursing Skills Enhancement Program
\

A CASE STUDY of a Client with

ANEMIA WITH TO CONSIDER CHRONIC KIDNEY DISEASE

Submitted by:
Bago,Lyn Karen M.
Balasa, Richard B.
Castro,John Ray
Certeza,Camille
Mardo, Nicole Arrianne G.
Muhi,Rizaldy G.
John Vincent Orleans C.
Obis,Sarah C.
Perea, Clarrisse L.
Ragasa, Jeralyn F.
Sudario,Camella DawnB.
Siazon,Sheen C.
Submitted to NSO Deparment Heads:
Dulce Angeles ,RN,MAN
Prof. Jonahlyn G. Corpuz, RN, MAN
Jonnah S. Magnaye RN, MAN
April Del Rosario

Clinical Areas
Gentri Doctors Medical Center
Inclusive RLE duty dates:
April 25-May 27,2016

Case Abstract

II. Nursing Health History

A. Biographic data
Patients initial:

Gender:

Age:

Date of birth:

Educational
Attainment:

Occupation:

Monthly Income:
(optional)

Place of Birth

Date of Admission:

No. of days in
hospital:

Order of admission

Source of Information:

B. Chief Complaint:
C. History of Present Illness : (6 months PTA)
D. History of Past Illness
E. Childhood Illness
Childhood Illness(es)
Childhood/adult Immunization(s)
Accidents and Injuries
Previous hospitalization/surgery
Medication prior to confinement
F. Family History
General family Information
NAME

RELATION

AG
E

GENDER

OCCUPATION

EDUCATIONAL
ATTAINMENT

DISEASE/
DISORDER

G. Genogram
H. Developmental History
Theory
Sigmund Freud

Age

Developmental Task
Genital Stage

Client Description

Interpretation

Erik Erickson
Jean Piaget
Lawrence
Kohlberg
James Fowler
References: (with pages)
I.

Environmental History:

III. Gordons Typology of 11 Functional Health Pattern

A. HEALTH PERCEPTION AND HEALTH MANAGEMENT PATTER

Prior to confinement
During confinement,
Analysis:
Reference:
Interpretation:
B. NUTRITIONAL AND METABOLIC PATTERN
Prior to confinement
3 day diet recall prior to confinement
August 12, 2013
Breakfast:
Lunch:
Dinner:

August 13, 2013

Breakfast:
Lunch:
Dinner:

August 14, 2013

Breakfast:
Lunch:
Dinner:

August 12, 2013

Breakfast:

August 13, 2013

Breakfast

August 14, 2013

Breakfast:

Lunch:
Dinner:

Lunch:
Dinner:

Lunch:
Dinner:

During confinement,
3 day diet recall during confinement

Analysis:
Reference:
Interpretation:
C. ELIMINATION PATTERN
Prior to confinement
During confinement,
Analysis:
Reference:
Interpretation:
D. ACTIVITY-EXERCISE PATTERN
Prior to confinement
During confinement,
Analysis:
Reference:
Interpretation:
E. SLEEP-REST PATTERN
Prior to confinement
During confinement,
Analysis:
Reference:
Interpretation:
F. COGNITIVE PERCEPTUAL PATTERN
Prior to confinement
During confinement,
Analysis:
Reference:
Interpretation:
G. SELF-PERCEPTION AND SELF-CONCEPT PATTERN
Prior to confinement
During confinement,
Analysis:
Reference:
Interpretation:

H. ROLE RELATIONSHIP PATTERN

Prior to confinement
During confinement,
Analysis:
Reference:
Interpretation:
i.

SEXUALITY- REPRODUTIVE PATTERN

Prior to confinement

During confinement,
Analysis:
Reference:
Interpretation:
J. COPING- STRESS PATTERN
Prior to confinement
During confinement,
Analysis:
Reference:
Interpretation:
K. VALUE BELIEF PATTERN
Prior to confinement
During confinement,
Analysis:
Reference:
Interpretation:
IV. Physical Assessment (August 14, 2013 12:30pm)
a. General Survey
Body Built:

Grooming/Hygiene

Posture & Gait:

Body odor & Breath

Signs of Distress:

Obvious Signs of Illness(es)

Orientation:

Level of

Affect:

Mood:

Consciousness

Time:

:
.

Person:
Place:
Note:
Quantity & Quality of Speech:

Organization of thoughts:

b. Anthropometric Measurement
Weight:

Height:

IBW/BMI:

c. Vital Signs
Temperature:

d. Physical Examination
Body Part

Pulse Rate:

Normal Findings

Respiratory Rate:

Actual Findings

Blood Pressure:

Analysis & Interpretation

Skin
Hair

Nails
Head & face
Eyes
Ears

Nose
Mouth & pharynx

.
.

Neck
Spine
Thorax/lungs
Cardiovascular/hear
t
Breast &
Axilla(optional)
Abdomen
Musculoskeletal
Genitals(optional)
Rectum & anus
(optional)

a. Neurologic Status

Cranial Nerves
I. Olfactory
II. Optic
III, IV, VI. Oculomotor, Trochlear, and Abducens
V. Trigeminal
VII. Facial
VIII. Acoustic
IX and X. Glossopharyngeal and Vagus
XI. Accessory
XII. Hypoglossal
Reflexes
Biceps Reflex
Triceps Reflex
Brachioradialis Reflex
Patellar Reflex
Achilles Reflex
Plantar/ Babinski Reflex
Deep Tendon Reflexes are graded as follows:
0 = no response; always abnormal
1+ = a slight but definitely present response; may or may not be normal
2+ = a brisk response; normal
3+ = a very brisk response; may or may not be normal
4+ = a tap elicits a repeating reflex (clonus); always abnormal

Sensory Function
Touch
Pain
Temperature
Tactile Discrimination
Muscle Strength

Left arm
Left leg
Right arm
Right leg
Muscle grading strength conducted with resistance
1- Negative movement
2- No contractions felt
3- very weak contractions felt
4- Contractions felt, with gravity as hindrance
5- Able to move weakly but not completely against gravity
6- Able to move against gravity and resistance
Glasgow Coma Scale

Interpretation

Eye Opening
Best Verbal Response
Best Motor Response
Total Score

V. Anatomy and Physiology

VI. Pathophysiology
VII. Laboratory Study
Laboratory and Date
Name of laboratory
exam
Date/day/time

Normal Values

Result

Analysis and Interpretation

VIII. DRUG STUDY

Drug(s)

Indication

Action

Side Effect(s) and

Adverse Effect(s)

Nursing
Consideration(s)/
Health Teaching(s)

Brand Name:
Generic Name:
Classification:
Dose:
Route:
Frequency:
Date Ordered:

References :
X. LIST OF PRIORITY PROBLEM
NURSING DIAGNOSIS

RANK

JUSTIFICATION
.

IX. Nursing Care Plan

Subjective/
Objectives

Nursing
Diagnosis

Planning

Intervention

Rationale

Evaluation

XI. Evidenced based

Nursing practice

Evidenced-Based Nursing

Recommendations to Present
Practice

References:
XII. On- going Appraisal
Date

Progress Notes

Laboratory

Medication

XII. Health Teaching Plan

Topic:
Goal:
Time allotment:
Learning Objectives

Learning Content

Methodology

Resources

Method of
Evaluation

XIII. Discharge Plan

Medications
Exercise
Treatment
Health Teachings
Out Patient/Follow Up
Diet
Spiritual

BRING ON SATURDAY
BOOK- Brunner/fundamental ,drug hand book,
fundamental (kozier) NCP
lap tap
internet
7