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VISION Republic of the Philippines MISSION

A premier university in historic Cavite State University shall provide


CAVITE STATE UNIVERSITY excellent, equitable and relevant
Cavite recognized for
excellence in the development Don Severino Delas Alas Campus educational opportunities in the arts,
of morally upright and globally Indang, Cavite science and technology through
competitive individuals. quality instruction and relevant
research and development activities.
It shall produce professional, skilled
and morally upright individuals for
global competitiveness.
College of Nursing

Case Study of BBCC

Presented by:

Isabella Louise M. Samson

BSN 2-3
Group 2

Presented to:

Prof. Rhodeva Joy Braga. RN,USRN

Clinical Instructors, Level II or III

Date:

October 17,2019

In Partial Fulfillment of the Requirement in NURS 50/55 or NURS 60/65 for the Degree Bachelor of
Science in Nursing
TABLE OF CONTENTS

I. Demographic Data………………………………………………………………………………….1

II. Reason for Seeking Health Care…………………………………………………………………1

III. History of Present Illness…………………………………………………………………………..1

IV. Past Medical

History………………………………………………………………………………...1

V. OB-Gynecological History………………………………………………………………………….1

VI. Heredo-familial History…………………………………………………………………………...1-2

VII. Developmental History……………………………………………………………………………...2

VIII.Gordon’s Functional Health Patterns…………………………………………………………..2-5

IX. Physical Examination…………………………………………………………………………….5-12

X. Diagnostic Test…………………………………………………………………………………..12-13

XI. Review of System……………………………………………………………………………………13

XII. Concept Maps………………………………………………………………………………………..13

XIII.Case Management…………………………………………………………………………………..14

A. Medical……………………………………………………………………………………………14

B. Surgical……………………………………………………………………………………………14

C. Nursing…………………………………………………………………………………………15-16

XIV. Ongoing Appraisal………………………………………………………………………………….16


I. DEMOGRAPHIC DATA
A. Initials of Clients’ Name- BBC Date of Admission:
B. Address-Bancod,Indang Cavite Time of Admission:
C. Age- 3yearsold
D. Birth Date- April 4 2016 Date of Interview:
E. Birth Place- ERS TRECE Primary Informant:
F. Gender- Male Secondary Informant:
G. Civil Status- Single Other Data Sources:
H. Religion- Christian
I. Highest Educational Attainment
J. Occupation
K. Monthly Income / Budget
II. REASON FOR SEEKING HEALTH CARE

III. HISTORY OF PRESENT ILLNESS


The client doesn’t have any present illness.
IV. PAST MEDICAL HISTORY
A. Childhood / Adult Diseases- G6Pd
B. Injuries / Accidents- The client have no history accident or injuries.
C. Hospitalization- The client haven’t been hospitalized.
D. Operation- The client have no history of operation.
E. Allergies- The client have allergy to powder and perfume.
F. Medication- The client doesn’t take any medication.
G. Immunization- The client is complete in immunization.
H. Last Examination
V. OBSTETRIC-GYNECOLOGICAL HISTORY (if applicable)
A. Menarche
B. Menstruation
- LMP
- Usual amount
- Usual Duration
- Cycle
- Associated discomforts and relief measures
C. EDC, AOG, GP-TPALM
VI. HEREDO-FAMILIAL HISTORY
A. Genogram
Paternal Side Maternal Side
CT DU DM MR

64 y/o 65 y/o 59 y/o 55 y/o

A&W CVA CA A&W


JT LB
unknown LEGENDS: will depend on what is used.
25 y/o 36 y/o
A&W PIH COPD

NDT ET GB

5 y/o 3 y/o 8 y/o

A&W A&W A&W


VIII. GORDON’S 11 FUNCTIONAL HEALTH PATTERNS
A. Health Perception – Health Management

The client doesn’t yet think how to manage his own health. It is still depend on his parents on
how his health be manage.

B. Nutritional – Metabolic

*3-day Diet Recall


MEALS Date & Day Date & Day Date & Day
Breakfast (time) MILK AND BREAD
Snacks (if any)
Lunch (time) MILK AND FEW ISCOOP OF RICE
Snacks (if any)
Dinner (time) MILK
Snacks (if any)
Total Fluid Intake ___mL ___mL ___mL

C. Elimination
The client eliminate every other day and the amount of it is minimal.

D. Activity – Exercise
The client wakes up at 7am then after he will play and uses phone. After he play the mother
of the client will bath the client.
*7-Day Activity Table
Time Days of the Week & Date
Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7
1 am
2 am
3 am
4 am
5 am
6 am
7 am
8 am PLAY AND PHONE
9 am TAKES A BATH
10 am
11 am
12 nn
1 pm SLEEP
2 pm
3 pm
4 pm
5 pm
6 pm
7 pm
8 pm
9 pm SLEEP
10 pm
11 pm
12 mn

*Katz Index of Independence in Activities of Daily Living


Activities Independence = 1 point Dependence = 0 point
Points (1 or 0) No supervision, direction or personal With supervision, direction or
assistance needed personal assistance or total care
Bathing
Dressing
Toileting
Transferring
Continence
Feeding
TOTAL POINTS:

E. Sleep – Rest
The client sleeps in the afternoon around 1pm to 3pm and in the evening is 9pm. The client
doesn’t have any problem in sleeping.

Constructs Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7


Hours of Sleep
Sleeping Time
Waking Time 7am
Bedtime Rituals
Feeling upon
waking up
Problem
Encountered

F. Cognitive – Perceptual
The client doesn’t know it yet.
G. Self-Perception – Self-Concept
The client self perception is not yet known because he is still a child. The client only know is to
play.
H. Role-Relationship
The client role is to give happiness to his parents. The client is close to his parents.
*Ecomap

I. Sexuality - Reproductive
The client doesn’t sexually active yet.
J. Coping-Stress
The client doesn’t feel any stress yet because he only know is to play and have fun.

K. Value-Belief
The client doesn’t yet think about any value or belief.

IX. COMPREHENSIVE PHYSICAL EXAMINATION


A. Vital Signs Date / Time of Exam: ____________
T = _36_OC
PR = 110 bpm
RR = 80 cpm
BP = __/__ mmHg
B. Anthropometric Data (only those applicable)
Height = __ cm
Weight = __ Kg
Head Circumference = __ cm
Chest Circumference = __ cm
Abdominal Circumference = cm

Prepared by: Noted by:


Leah Ann Beltran, RN, MAN Nenita B. Panaligan, RN, MAN
Over-all Clinical Coordinator

Kriegel P.Bihasa, RM, RN

Reyner Joseph L. Catle, BSBio, RN Approved by:

Sunny Rose M. Ferrera, RN, MAN Lenila A. De Vera, RN, MPH, MAN

Karen Louela Rint, RN, MAN