(CASE STUDY)

I. PATIENT ASSESSMENT DATA BASE

A. GENERAL DATA
1. Patients Name: Initials only 2. Address: Generic not the complete address 3. Age: 4. Sex: 5. Birth Date: 6. Rank in the Family: 7. Nationality: 8. Civil Status: 9. Date of Admission: 10. Order of Admission: 11. Attending Physician:

B. CHIEF COMPLAINT: - problem, duration sign and symptom that prompted patient to seek health care

C. HISTORY OF PRESENT ILLNESS: - complete, clear, chronological account of problems prompting patient to seek care from onset of manifestations, interventions done, medications taken before date of admission

D. PAST HEALTH HISTORY/STATUS

Identify the clues that may aid in diagnosing the present illness 1. Childhood Illnesses: measles, mumps, common colds. If yes, how often, when did it occur? 2. Immunizations: Note if immunization is complete or incomplete, indicate how many doses are taken 3. Major Illnesses / Hospitalizations: operations, injuries (Date) 4. Current Medications: meds taken before confinement (6 mos) Prescribed: Non-prescribed: 5. Allergies Ingestants: Injectants: Inhalants: Contactants:

E. FAMILY ASSESSMENT
Name Relation Age Sex Occupation Educational Attainment

F. SYSTEMS REVIEW Gordons 11 Functional Health Patterns

Assessment (for pts. more than 3 y/o)

1.

HEALTH PERCEPTION HEALTH MAINTENANCE PATTERN

- Purpose: to determine how the client perceives and manages his or her health. Compliance with current and past nursing and medical recommendation is assessed. The clients ability to perceive the relationship between activities of daily living and health is also determined. - Subjective: Clients perception of health Clients perception of illness Health maintenance and habits Compliance with prescribed medication and treatment
* narrative form by paragraph

2. NUTRITIONAL METABOLIC PATTERN

- Purpose: to determine the clients dietary habits and metabolic needs. Subjective: Dietary and fluid intake > Appetite: food consumption, what triggers appetite (sight, smell, thoughts of food) > Usual daily menu - Food meat, vegetables - Water glasses per day - Beverages cola or other drinks

3. ELIMINATION PATTERN
Purpose: to determine the adequacy of function of the clients bowel and bladder elimination Subjective: > Bowel habits: note for any frequency of defecation, characteristic of stool - color - odor - consistency - laxative use if any

> Bladder: frequency of urination, characteristics of urine Color: Odor: Alterations if any:

4. ACTIVITY EXERCISE PATTERN

Purpose: To determine the clients activities of daily living, including routines of exercise, leisure and recreation. This includes activities necessary for personal hygiene, cooking, shopping, eating, maintaining the home and working.
Subjective: Self-care ability _____ feeding _____ bathing _____bed mobility _____ others

______dressing _____grooming ______toileting _____Cooking ______home maintenance

5. COGNITIVE PERCEPTUAL PATTERN

Purpose: to determine the functioning status of the 5 senses: vision, hearing, touch, taste and smell. Devices and methods used to assist the client with deficits in any of these five senses are assessed. Subjective: >Hearing: abnormalities and use of hearing aids > Vision: visual acuity and use of glasses or contact lenses >Sensory perception: ability to feel, taste and smell > Learning styles: learning abilities, level of understanding, strategies in decision making

6. SLEEP - REST PATTERN

Purpose: to determine the clients perception of the quality of his or her sleep, relaxation and energy levels. Methods used to promote relaxation and sleep are also assessed. Subjective: > sleep habits > special sleeping problems > hours of sleep > sleeping alterations > sleeping aids (reading, medications, relaxation techniques

7. SELF-PERCEPTION AND SELF CONCEPT PATTERN

Purpose: to determine the clients perception of his or her identity, body image and self-worth. The clients behaviour, attitude and emotional patterns are assessed. > feelings of current state > description of self > known capabilities and weaknesses > self worth

8. ROLE RELATIONSHIP PATTERN

Purpose: to determine the clients perception of responsibilities and roles in the family, at work and in social life.

9. SEXUALITY-REPRODUCTIVE PATTERN
Purpose: to determine the clients fulfillment of sexual needs and perceived level of satisfaction. The reproductive pattern and developmental level of the client are determined and perceived problems related to sexual activities, relationships or self-concept are elicited. For female client include: menstrual hx, age of onset of menarche, number of menstrual days, number of pads every menstruation, presence of dysmenorrheal and other menstrual problems, obstetric hx (GTPAL), operations For both sexes: contraception, sexual activities, special health reproductive problems, hx of sex abuse

10. COPING STRESS TOLERANCE PATTERN

Purpose: to determine the areas and amount of stress in a clients life and the effectiveness of coping methods used to deal with it. Availability and use of support system such as family, friends and religious beliefs are assessed. Subjective: >perceptions of stress and problems in life > coping methods and support systems used

11. VALUE BELIEF PATTERN

Purpose: to determine the clients life values and goals, philosophical beliefs and spiritual beliefs that influences his or her own choices and decisions. > values, goals and philosophical beliefs > religious and spiritual beliefs

G. HEREDO-FAMILIAL ILLNESS

Maternal Paternal

H. DEVELOPMENTAL HISTORY (according to

Erickson, Freud, Piaget, Kohlberg, Fowler)

Theorist Age Sex

Patient Description (how the nurse sees the patient based on the different developmental task)

I. PHYSICAL ASSESSMENT
A. GENERAL SURVEY 1. overall appearance and grooming 2. actual height and weight vs. ideal body weight 3. symptoms of distress 4. posture, gait 5. affect, mood 6. relevance and organization of thought * for pedia (0-3 y/o) include anthropometric measurements B. VITAL SIGNS on the day of P.E.

C. REGIONAL EXAM utilize IPPA technique 1. hair, head and face Inspection: Palpation: Percussion: Auscultation: 2. Eyes 3. Nose 4. Ears 5. Mouth and throat 6. Neck and lymph nodes 7. Skin 8. Nails 9.Thorax and lungs 10. Cardiovascular 11. Breast and axilla 12. Abdomen IAPePa 13. Extremities 14. Genitals 15.Rectum and Anus 16. Neurological / Cranial nerves * Note: breast, genitals, rectum and anus are strictly assessed only with CI. ASK PARENTAL / PATIENT CONSENT * NO IE FOR PREGNANT WOMEN

II. PERSONAL / SOCIAL HISTORY

A. HABITS / VICES a. caffeine cups/day b. smoking sticks/ packs/day c. alcohol brand; bottles / day d. Tea cups / day e. drugs marijuana, etc. , OTC drugs B. LIFESTYLE

C. SOCIAL AFFILIATION D. RANK IN THE FAMILY E. TRAVEL (WITHIN 6 MOS) F. EDUCATIONAL ATTAINMENT

III. ENVIRONMETAL HISTORY (LIVING / NEIGHBORHOOD / CIRCUMSTANCES)

IV. PEDIATRIC HISTORY (for neonates / infants and mothers)

a. Maternal and birth history > date of birth, birth wt., type of delivery, condition after birth, hospital b. Mother > complications of delivery, anesthesia, exposure to teratogens c. Neonates > neonatal history, feeding history, type of feeding

V. INTRODUCTION (RELATED TO THE DISEASE/ CASE OF THE PATIENT)

VI. ANATOMY AND PHYSIOLOGY

- Discuss the related system with regards to the disease

VII. PATHOPHYSIOLOGY (IN DIAGRAM)

VIII. LABORATORY AND DIAGNOSTIC EXAMINATIONS

Date: Type of Examination:

Results

Normal Value

Significance

IX. DRUG STUDY

Generic Name: Brand Name: Drug Classification: Dosage: Indication: Mechanism of action Side Effects Contraindication Adverse reaction Nursing Consideration

X. LIST OF IDENTIFIED PROBLEMS ACCORDING TO PRIORITY (P + E format)

XI. NURSING CARE PLAN

Assessment Nursing Diagnosis Scientific Background Goals Interventions Rationale Evaluation

Cues: S>

O>

SMART Subjective + verb + Modifiers + Criterion of Desired performan ce

Independent/ Collaborative/ Dependent

With references

XII. ONGOING APPRAISAL

- Summary of the patients health status, day to day appraisal

XIII. DISCHARGE PLAN (HEALTH TEACHINGS)

Medications Exercise Treatment Clinic follow-up Diet Danger signs