CALAMBA DOCTORS’ COLLEGE
Virborough Subdivision, Parian, Calamba City, Laguna
MCN 109 - Laboratory
BSN 2
Case study 1
Direction: Summarize the case study using the nursing health history format and
provide nursing care plan
1. Biographic Data:
2. Reason for Seeking Health Care
A. COLDSPA application
 Characteristic
 Onset
 Location
 Duration
 Severity
 Pattern
 Associated factor
3. History of Present Health Concern
4. Past Health History
5. Family History
6. Lifestyle and Health Practices
7. 3 NCPs
 Physical Assessment
 Nursing Diagnoses
 Nursing Plan/Goal
 Nursing Intervention
 Possible Evaluation
8. Drug study if applicable
9. Laboratory study
Case Study
Mary Farrow is a 29-year-old, married, living with husband and two sons, who
presents to the clinic today for her initial prenatal examination. She states that her
last menstrual period (LMP) was on September 15, approximately 12 weeks ago.
Because she was so sick and unable to get transportation to the clinic, she did not
come in for prenatal care earlier in this pregnancy. She reports that she has had
severe nausea with vomiting (about 2 times daily) for the past 8 weeks of this
pregnancy. Client reports feeling of exhaustion.
Her husband always brings home free fast food, so nutrition not as she would
like. Client states if she is able to stay in bed and eat something before getting up.
The nausea and vomiting is reduced slightly. Client reports that certain smells and
being extra tired make the nausea and vomiting worse.
Two past deliveries of healthy babies weighing 6 lb 2 oz and 7 lb 6 oz, but first
pregnancy complicated with mild hyperemesis gravidarum throughout the
pregnancy. She gained 20 lb with her first pregnancy and 30 lb with her second
pregnancy. She gained 30 lb during the second pregnancy and was diagnosed with
pregnancy-induced hypertension and mild gestational diabetes; labor was induced at
38 weeks’ gestation. MF is not on any prescribed medications. She is taking some
prenatal vitamin capsules that she got from her local pharmacy. She occasionally
takes allergy tabs for symptoms of hay fever. She denies medication, food, insect, or
other allergies except for occasional hay fever. She denies use of herbal medicines or
alternative therapies. No other health issues described
Parents both alive and well, but live in another state. Mother was very sick
during pregnancy with MF and one other of three siblings. Father has mild
hypertension and mild obesity. No other health problems described in family.
States she knows good nutrition and hydration and exercise criteria, but does
not follow them due to being so sick with this pregnancy, two small children at
home, financial limitations, and husband bringing home free fast food. Knows she
should have come to prenatal visit much earlier, but physical, transportation, and
financial issues made it difficult. Sleeps only 6–7 hours per night, but tries to get 7–8
hours per night. Exercise is keeping up with her two boys each day and housework.
When feeling able, she walks her boys to a park 4 blocks from residence. 24-hour
diet recall: Breakfast—a roll with black tea; lunch—a few crackers and cheese;
dinner—a burger and fries.
Mrs. Farrow’s physical assessment reveals a blood pressure of 100/60 right arm,
sitting: pulse rate 86, regular and strong; respirations 18, regular and moderately
shallow; temperature 36.7°C. Her apical beat is also 86 and strong; heart sounds: S1
and S2 with no murmurs or clicks. Skin is warm and dry, slightly pale with light pink
nail beds, pale palpebral conjunctiva and oral mucous membranes. Abdomen
moderately rounded with striae; fundal height 20 cm; fetal heart rate 158 per
Doppler, right lower quadrant. Current weight 136 lb at 5 feet 9 inches tall, 4 lb less
than her stated usual weight, Lab values show hemoglobin (Hgb) 10.2 g/dl;
haematocrit (Hct) 29.9%; red blood cell (RBC) count 3.20 × 10–6/μl. Her sodium (Na)
level is 129 and her potassium (K) level is 3.1. The remainder of the blood values are
within normal limits. Urinalysis results are negative for protein and glucose
CALAMBA DOCTORS’ COLLEGE
Virborough Subdivision, Parian, Calamba City, Laguna
MCN 109 - Laboratory
BSN 2
Case study 2
Direction: Summarize the case study using the nursing health history format and
provide nursing care plan
1. Biographic Data:
2. Reason for Seeking Health Care
A. COLDSPA application
 Characteristic
 Onset
 Location
 Duration
 Severity
 Pattern
 Associated factor
3. History of Present Health Concern
4. Past Health History
5. Family History
6. Lifestyle and Health Practices
7. 3 NCPs
 Physical Assessment
 Nursing Diagnoses
 Nursing Plan/Goal
 Nursing Intervention
 Possible Evaluation
Case Study 2
Melinda is a 22-year-old college student who comes into the clinic. She complains, “I
feel like I have the flu—no energy, a headache, and fever.” She reports a recent outbreak of
genital lesions after a sexual encounter 10 days ago (“first and only”) with a fellow student
she only recently met. She denies the use of any protection or birth control, stating, “He
refused to use anything and I didn’t insist.” She took her temperature at home, and states it
was 100.6°F. When questioned, she confirms that she has a great deal of itching and pain in
the vaginal area and that “urinating and having a bowel movement hurts a lot.”
After investigating Melinda’s complaint of recent outbreak of genital lesions and
burning upon urination and defecation, the nurse continues with the health history
Client states that her menstrual cycle is regular occurring every 28 days. Last
menstrual period was 2 weeks ago, beginning on the 10th and ending on the 13th. She is
experiences bloating and mild cramping with period. She denies abdominal discomfort and
had a good appetite. Has one bowel movement daily that is brown, soft, and formed and
denies constipation, no history of hemorrhoids.
She denies vaginal discharge, lumps, swelling, or masses. She reports pain and
itching in genitalia and anus. No loss of bowel or bladder control. However, she states that
urine seems to burn her genital and anal area. She denies any prior gynecologic or rectal
abnormalities. no family history of reproductive, gynecologic, or rectal cancer.
She reports that she drinks 1–2 alcoholic beverages on the weekends only, but does
not drink and drive. She denies cigarette smoking or use of illicit drugs and states that her
immunizations are up to date, including vaccination for HPV. Has had one sexual encounter;
reports attempt at anal intercourse that was not successful.
Denies condom use or any form of birth control, and states, “I have always been
healthy—I don’t know why I behaved so stupidly and put my health at risk.” She dont
performance of monthly vulvar self-examination. Reports awareness of toxic shock
syndrome and wears tampons only during heavy flow days, changing them every few hours.
States has never had a Pap test.
Visual inspection discloses normal hair distribution of the mons pubis, with lesions
present as vesicles. Ulcerations noted as well. The labia majora is with in mild erythema and
vesicular lesions along with mild excoriation and labia minora dark pink, moist, and free of
lesions or excoriation. Vesicles and ulcerations extend into the perianal area. Visual
inspection of the anus reveals multiple vesicular lesions noted around the anal opening.
Upon palpation of the inguinal area and external genitalia, no masses or edema were noted
to the inguinal lymph nodes bilaterally. Mild edema noted to the labia majora. Labia minora
free from edema and discharge. Bartholin’s glands are soft, nontender, and free from
discharge.
No bulging at vaginal orifice. No discharge from urethral opening. Routine Pap smear
performed. The vaginal walls is smooth and pink. Cervix slightly anterior, pink, smooth in
appearance, slit-like os, without lesions or discharge present. Bimanual examination
indicates cervix mobile, nontender, and firm, with no masses or nodules detected. Firm
fundus located anteriorly at level of symphysis pubis, without tenderness, lesions, or
nodules. Smooth, firm, almond-shaped, mobile ovaries approximately 3 cm in size palpated
bilaterally, no excessive tenderness or masses noted. No malodorous, colored vaginal
discharge on gloved fingers. Firm, smooth, nontender, movable posterior uterine wall and
firm, smooth, thin, movable rectovaginal septum palpated during rectovaginal examination.
Good sphincter tone noted with the anus, noted to be smooth, nontender, and free of
nodules and hardness. Fecal matter on gloved finger reveals semi-soft, brown stool.
A. COLDSPA application
Character
“I feel like I have the flu—no energy, a headache, and fever.”
Onset
sexual encounter 10 days ago
Location
she has a great deal of itching and pain in the vaginal area and that
“urinating and having a bowel movement hurts a lot.”
Duration
She reports pain and itching in genitalia and anus.
Severity
Pattern
Associated factor