VISION
A premier university in historic
Cavite recognized for
excellence in the development
of morally upright and globally
competitive individuals.
Republic of the Philippines
CAVITE STATE UNIVERSITY
Don Severino Delas Alas Campus
Indang, Cavite
College of Nursing
MISSION
Cavite State University shall provide
excellent, equitable and relevant
educational opportunities in the arts,
science and technology through
quality instruction and relevant
research and development activities.
It shall produce professional, skilled
and morally upright individuals for
global competitiveness.
TITLE OF THE CASE
Presented by:
YEAR LEVEL / SECTION / GROUP #:
Members
Presented to:
Prof. _________________ , RN, MAN
Prof. _________________ , RN, MAN
Prof. _________________ , RN, MAN
Prof. _________________ , RN, MAN
Clinical Instructors, Level II or III
Date:
Month xx, year
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
B. Address
C. Age
D. Birth Date
E. Birth Place
F. Sex
G. Civil Status
H. Religion
I. Highest Educational Attainment
J. Occupation
K. Monthly Income / Budget
Date of Admission:
Time of Admission:
Date of Interview:
Primary Informant:
Secondary Informant:
Other Data Sources:
II. REASON FOR SEEKING HEALTH CARE
III. HISTORY OF PRESENT ILLNESS
(Critical characteristics: setting, timing, location, quality, quantity, associated factors: aggravating /
alleviating; client’s perception)
IV. PAST MEDICAL HISTORY
A. Childhood / Adult Diseases
B. Injuries / Accidents
C. Hospitalization
D. Operation
E. Allergies
F. Medication
G. Immunization (to be tabulated for Pedia clients to keep track of time interval and dose, but for
Adult clients state if they have been fully immunized or not)
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
JT
CA
A&W
DM
26 y/o
25 y/o
A&W
36 y/o
PIH
NDT
5 y/o
A&W
ET
LB
COPD
GB
3 y/o
8 y/o
A&W
A&W
unknown
LEGENDS: will depend on what is used.
B. Family APGAR
Constructs
Adaptation
Partnership
Growth
Affection
Resolve
Questions
Almost
Always
(2)
Some of
the Time
(1)
Hardy
Ever
(0)
I am satisfied with the help that I receive
from my family when something is
troubling me.
I am satisfied with the way my family
discusses items of common interest and
shares problem-solving with me
I find that my family accepts my wishes
to take on new activities or make
changes in my lifestyle.
I am satisfied with the way my family
expresses affection and responds to my
feelings such as anger, sorrow and love.
I am satisfied with the way my family and
I spend time together.
TOTAL
VII. DEVELOPMENTAL HISTORY (Determine the exact stage based on client’s age and his
milestone and provide some justifications that would be most applicable to the specified
developmental stage)
A. J. Piaget’s Cognitive Development
Stage Specific Task(s)
Evidences of Milestone Achievement
B. E. Erikson’s Psychosocial Development
Stage Specific Task(s)
Evidences of Milestone Achievement
C. S. Freud’s Psychosexual Development
Stage Specific Task(s)
Evidences of Milestone Achievement
D. J. Fowler’s Spiritual Development
Stage Specific Task(s)
Evidences of Milestone Achievement
E. L. Kholberg’s Moral Development
Stage Specific Task(s)
Evidences of Milestone Achievement
F. R. Havighurst’s Developmental Task
Stage Specific Task(s)
Evidences of Milestone Achievement
G. Williams’ Metro Manila Developmental Screening Test (MMDST)
Personal-Social
1. Task for a particular month
2.
3.
Score
Passed /
Failed /
Refused /
No Opportunity
Justification
Fine-Motor Adaptive
1. Task for a particular month
2.
3.
Score
Passed /
Failed /
Refused /
No Opportunity
Justification
Language
1. Task for a particular month
2.
3.
Score
Passed /
Failed /
Refused /
No Opportunity
Justification
Gross-Motor Behavior
1. Task for a particular month
2.
3.
Score
Passed /
Failed /
Refused /
No Opportunity
Justification
VIII. GORDON’S 11 FUNCTIONAL HEALTH PATTERNS
A. Health Perception – Health Management
 Interaction
 Observation
 Measurement
B. Nutritional – Metabolic
 Interaction
 Observation
 Measurement
*3-day Diet Recall
MEALS
Date & Day
Breakfast (time)
- amount per serving
Snacks (if any)
- amount per serving
Lunch (time)
- amount per serving
Snacks (if any)
- amount per serving
Dinner (time)
- amount per serving
Date & Day
- amount per serving
- amount per serving
- amount per serving
- amount per serving
- amount per serving
Date & Day
- amount per serving
- amount per serving
- amount per serving
- amount per serving
- amount per serving
Snacks (if any)
Total Fluid Intake
C. Elimination
 Interaction
 Observation
 Measurement
- amount per serving
___mL
D. Activity – Exercise
 Interaction
 Observation
 Measurement
*7-Day Activity Table
Time
Day 1
Day 2
1 am
2 am
3 am
4 am
5 am
6 am
7 am
8 am
9 am
10 am
11 am
12 nn
1 pm
2 pm
3 pm
4 pm
5 pm
6 pm
7 pm
8 pm
9 pm
10 pm
11 pm
12 mn
- amount per serving
___mL
Days of the Week & Date
Day 3
Day 4
Day 5
- amount per serving
___mL
Day 6
Day 7
*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
 Interaction
 Observation
 Measurement
*7-Day Sleep Diary
Constructs
Hours of Sleep
Sleeping Time
Waking Time
Bedtime Rituals
Feeling upon
waking up
Problem
Encountered
Day 1
F. Cognitive – Perceptual
 Interaction
 Observation
 Measurement
G. Self-Perception – Self-Concept
 Interaction
 Observation
 Measurement
H. Role-Relationship
 Interaction
 Observation
 Measurement
*Ecomap
I. Sexuality - Reproductive
 Interaction
 Observation
 Measurement
J. Coping-Stress
 Interaction
 Observation
Day 2
Day 3
Day 4
Day 5
Day 6
Day 7
 Measurement
K. Value-Belief
 Interaction
 Observation
 Measurement
IX. COMPREHENSIVE PHYSICAL EXAMINATION
A. Vital Signs
Date / Time of Exam: ____________
O
T
= __ C
PR = __ bpm
RR = __ cpm
BP = __/__ mmHg
Pain (if any…since this is the 5th vital sign, using the PQRST method)
Provoking factor
Quality
Region/radiation
Severity (using pain or face pain scale)
Time
B. Anthropometric Data (only those applicable)
Height = __ cm (for both adult & pedia)
BMI = __ (for adult)
Weight = __ Kg (for both adult & pedia)
IBW = __ (for adult & pedia)
Head Circumference = __ cm (for pedia)
Chest Circumference = __ cm (for pedia)
Abdominal Circumference = __ cm (for pedia0
C. General Appearance
1. Body build and height-weight proportionality
2. Posture and Gait
3. Over-all hygiene and grooming
4. Body and breath odor
5. Obvious signs of distress / illness
6. Mental status
7. Attitude
8. Affect/mood; appropriateness of responses
9. Quantity and quality of speech
10. Relevance and organization of thoughts
D. Focused Assessment
Body Part Examined
INTEGUMENT
Skin
I: color, uniformity,
edema, lesions
P: moisture, temp.
turgor
Hair
I: evenness of growth
thickness, texture,
oiliness, infection
or infestation, body
Actual Finding
Normal Finding
Clinical Significance
hair
P: smoothness
Nail
I: plate shape, texture,
bed color,
surrounding tissues
P: Blanch test
HEAD
Skull and Face
I: size, shape ,
symmetry
: facial features
: eyes for edema
and hollowness
P: nodules, masses,
depressions
Eyes and Vision
I: eyebrows for
distribution &
alignment, quality &
movement
: eyelashes for
evenness of
distribution &
direction of curl
: eyelids for surface
characteristics,
position in relation to
cornea, ability to
blink & frequency
: bulbar & palpebral
conjunctiva for
color, texture, and
lesion
I/P: lacrimal gland
sac, nasolacrimal
duct for edema,
tenderness / tearing
I: cornea for clarity,
texture & sensitivity
I: pupils for color,
shape, symmetry of
size, direct and
consensual reaction
to light, &
accommodation
* Visual Acuity (near
& far vision test)
* Visual Field Test
* EOM Test
Ears and Hearing
I: auricles for color,
symmetry and
position
: external canal for
cerumen, lesions,
pus or blood
P: auricles for texture,
elasticity and areas
of tenderness
* Gross Hearing Acuity
Tests: normal voice
tone and whispered
voice
* Watch Tick Test
* Tunning Fork Tests:
- Weber for bone
conduction
- Rinne’s to compare
air and bone
conductions
Nose and Sinuses
I: nose deviation in
shape size, color,
flaring, discharge;
: nasal mucosa for
redness, swelling,
growth or discharge
Pa: tenderness,
masses,
displacements;
: nasal patency
: maxillary and
frontal sinuses for
tenderness
Pe: the above sinuses
for tenderness
Transillumination Test
Mouth / Oropharynx
I: lips for symmetry of
contour, color,
texture, moisture,
lesion
: teeth for alignment,
loss, dental filings
and caries;
: gums for bleeding,
color, retraction,
lesions, swelling
: tongue for position,
color & texture;
movement, as well
as the base of the
tongue, mouth floor
and frenulum
: salivary gland
ducts for swelling,
redness
: palates for color,
shape, texture,
presence of bony
prominences
: uvula for position &
mobility
: oropharynx for color
& texture
: tonsils for color,
discharge, and size
Test for Gag Reflex
P: nodules, lump and
excoriated areas
NECK
Neck Muscles
I: abnormal swelling or
masses, head
movement, and
muscle strength
Lymph Nodes
P: enlargement
Trachea
P: lateral deviation
Thyroid Gland
I: symmetry and visible
masses, rise during
swallowing
P: smoothness
A: bruit
THORAX & LUNGS
Posterior Thorax
I: shape & symmetry
from posterior-lateral
views; spinal
alignment for
deformities
Pa: temperature,
bulges, tenderness,
abnormal
movements,
respiratory
excursion, vocal
fremitus
Pe: for symmetry of
resonance;
diaphragmatic
excursion
A: breath sounds
Anterior Thorax
I: breathing pattern,
coastal and
costovertebral angle
Pa: respiratory
excursion, tactile
fremitus
Pe: symmetry of
resonance
A: breath sounds
Heart
I: precordium for
pulsations & lifts or
heaves
A: heart sounds (S1,
S2, etc.)
Central Vessels:
Carotid Arteries
P: volume, quality
A: bruit
Jugular Veins
I: distention
Peripheral Vessels
I: presence or
appearance of
superficial veins,
signs of phlebitis
*Buerger’s Test
*Capillary Refill
Breast & Axillae
I: breast for size,
symmetry, contour or
shape, discoloration,
retraction,
hypervascularity,
swelling, edema
: areaola for size,
shape, symmetry,
color, surface
characteristics,
masses, lesions
: nipples for size,
shape, position,
color, discharge,
lesion
P: lymph nodes,
breast, areola &
nipples for
tenderness, masses,
nodules, discharge
ABDOMEN
I: skin integrity, contour
& symmetry, hernia,
distention (girth),
movements
associated w/
respiration,
peristalsis & aortic
pulsations
A: bowel, vascular, &
peritoneal friction rub
sounds
Pe: all quadrants /
regions for tympany
and deviations
Pa: light to deep
palpations ALL
quadrants from least
painful to most
painful for masses,
tenderness, muscle
guarding; liver
(bimanual) and
bladder palpation
* Leopold’s Maneuver
for OB clients for
presentation, lie,
engagement,
attitude, position
If necessary /
MUSCULOSKELETAL applicable / significant
Muscles
I: size, contractures,
fasciculations,
tremors
P: tonicity, flaccidity,
spasticity,
smoothness of
movement, strength
Bones
I: structure, deformity
P: edema, tenderness
Joints
I: swelling
P: tenderness,
smoothness of
movement, swelling,
crepitation, nodules
NEUROLOGIC
Mental Status
- Language
- Orientation
- Memory
- Attention Span /
Calculation
Consciousness Level
Glassgow Coma Scale
Cranial Nerves
- I to XII
Reflexes
- Deep, superficial &
pathologic
- Neonatal Reflexes
Gross Motor/Balance
* Walking Gait
* Romberg
* Standing on 1 foot w/
eyes closed
* Heel-toe walking
Fine Motor
- Upper Extremities:
* Finger-Nose Test
* Alternate Supination
& Pronation of hands
on knees
* Finger to Nose & to
RN finger
* Fingers-to-fingers
* Fingers-to-thumb
- Lower Extremities:
* Heel down opposite
skin
* Toe / Ball of Foot to
RN’s finger
Sensory Function
* Light/Deep Touch
* Pain Sensation
* Temperature
* Position / Kinesthetic
* Tactile Discrimination
GENITALS
*For males:
I: pubic hair for
distribution, amount,
characteristics
: penis shaft and
glans for lesions,
nodules, swelling,
inflammation
: urethral meatus for
swelling,
inflammation,
discharge
: inguinal areas for
bulges or swelling
For Adult
For Pedia
If necessary /
applicable / significant
P: penis for
tenderness,
thickening, nodules
: scrotum for
appearance, size and
symmetry, and
underlying testes,
epididymis and
spermatic cord
: inguinal areas for
palpable bulge
* For females:
I: pubic hair
distribution, amount,
characteristics; its
areas for parasites,
inflammation,
swelling, lesions
: clitoris, urethral
and vaginal orifices
for inflammation or
discharge
P: bartholin’s glands,
lymph nodes for
enlargement,
tenderness, swelling
* Internal Exam for OB
clients for cervical
dilation, effacement
and AP pelvic
diameter
RECTUM & ANUS
I: anus and
surrounding tissue
for color, integrity,
lesions
P: anal spinchter
tonicity, nodules,
masses and
tenderness
: if male, prostate
gland for tenderness
: if female, cervix
through the anterior
rectal wall for
tenderness
X. Diagnostic Test
A. Non-Invasive
Specific Test
Sputum Microscopy
If necessary /
applicable / significant
If necessary /
applicable / significant
Actual Finding
Normal Finding
Clinical Significance
Urinalysis
Fecalysis
Radiology
Other: ECG, MRI, CT
B. Invasive
Specific Test
Actual Finding
Normal Finding
Clinical Significance
Blood Chemistry
Hematology
Electrolytes
ABG
Visualization
procedures (surgical
approach)
Note: Please indicate ONLY those diagnostic tests that were actually performed to confirm the
identified pathology. For OB and Pedia clients, please utilize the appropriate tools for labor and
delivery as well newborn assessment.
XI. Review of System (include only those that are significant to the case under study)
A. Neurologic
B. Pulmonary
C. Cardiovascular
D. Hematologic
E. Immunologic
F. Gastrointestinal
G. Renal
H. Musculoskeletal
I. Reproductive
J. Integumentary
XII. Concept Maps
A. Theory-based Physiology (for 2nd year) / Pathophysiology (for 3rd year)
Predisposing Factors:
- Age, gender, family history, genetics
Precipitating Factors:
- Lifestyle, diet, exercise, medication,
etc.
Main Etiology
Effect
Effect
Sub-effect
Sub-effect
Sub-effect
Sub-effect
Clinical manifestations:
- s/sx
- s/sx
Clinical manifestations:
- s/sx
- s/sx
- s/sx
DISEASE CONDITION
B. Client-based (only those facts related to the case are included)
XIII. CASE MANAGEMENT
A. Medical (present only those that are applicable and w/c have been done for the patient)
1. Pharmacologic Intervention
Drug Features
Therapeutic
Effects
Nursing
Responsibilities
- Brand / Generic Name
Indication
Contraindication Desired Untoward
- Classification
- Prescribed Dosage
- Route
- Frequency
2. Dietary Prescription / Restriction
3. Procedures (If any)
a. Oxygenation by nasal prong, venture/face mask, mist-tent, ambubag, ventilator, Tpiece
b. Suctioning
c. Osteorized Feeding
d. Intravenous Fluids
e. Catheterization
- Gastric
- Urinary
- Intravenous
Lavage
f. Enema
g. Diversional Ostomies
h. Drains i.e. Hemovac, Pleurovac, JP, Ventriculostomy, etc.
i. Others
B. Surgical (for 3rd year)
1. Pre-operative
2. Intra-Operative
3. Post-Operative
C. Nursing Management
1. List of Nursing Problems (minimum of 5 for 2nd year; minimum of 10 for 3rd year)
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
2. Prioritization of Nursing Problems
Criteria
Weight
Nature and 3 Actual Problem
Extent
2 Risk / Potential
1 Wellness State
Modifiability 2 Easily Modifiable
1 Partially Modifiable
0 Not Modifiable
Peventive
3 High
Potential
2 Moderate
1 Low
Salience
2 Needs immediate
attention
action
1 Not needing immediate
attention
0 Not perceived as a
problem/
condition
needing
change
Multiplier Computation
Justification
1
3/3 x 1
Situational Urgency
based on:
- ABC Principle
- Maslow’s HON
- Nursing Concept
2
2/2 x 2
Availability of
resources and
interventions(financial)
1
3/3 x 1
Likelihood of
occurrence of
complication w/
respect to measures
taken
1
2/2 x 1
Client’s perception
and recognition of the
problem
TOTAL
3. Plans for Nursing Actions
a. Nursing Care Plan
Assessment
Diagnosis
Subjective:
Problem r/t
The client
Etiology, w/
verbalized,
Sign/symptom
“_______”
(defining
characteristics)
Objective:
 PE
Findings
 Lab
Findings
5
Priority # 1
Planning
Implementation
At the end
of 4 hours
of rendering
nursing
care, the
client will be
able to:
1.________ Independent Rationale &
Dependent
Reference
Collaborative
*Choose the
applicable:
1. Actual
2. Probable
3. Risk
4. Syndrome
2.________
5. Wellness Dx
3.________
Evaluation
After 4 hours of
nursing care,
goal was met /
unmet /
partially met,
as evidenced
by:
1.
Independent Rationale &
Dependent
Reference
Collaborative
2.
Independent Rationale &
Dependent
Reference
Collaborative
3.
b. Teaching Plan
Intended Outcomes Content
1. Cognitive
Topic
Subtopic
2. Affective
- concept
3. Psychomotor
- concept
Subtopic
- concept
- concept
Strategies
Teaching Learning
Activity
Activity
Resources
* Materials
* Human
Resources
* Time
Evaluation
Pen and paper
test
Recitation
Return
demonstration
Observation
c. Discharge Plan
Medication
Exercise
Generic/Brand - Type
- Dose
- Frequency
Frequency
- Route
- Time
- Side effects
Treatment
- Nebulization
- Chest
physiotherapy
- Physical /
Occupational /
Speech /
Psychotherapy
Health
Education
OPD
Diet
Signs and
FollowSymptoms
up
- Pertinent
- What
- Limits
- Things that
Knowledge, W/ - Inclusion need to be
Skill, or
whom
reported
Attitude
- When
immediately
- Where
to primary
care provider
XIV. ONGOING APPRAISAL
 Day 1
- Medical and Nursing Care provided for managing the case
- Significant conditions or improvements noted
 Day 2
- Medical and Nursing Care provided for managing the case
- Significant conditions or improvements noted
 Day 3 (last day of duty or encounter with the patient / day of discharge)
Prepared by:
NENITA B. PANALIGAN, RN, MAN
MARY ANTONIETTE D. VIRAY RN, MAN
CARLOS LOUIS RN, MAN
Level II Clinical Instructors
Noted by:
JOCELYN B. DIMAYUGA RN, MAN
Over-all Clinical Coordinator
Approved by:
EVELYN M.DEL MUNDO RN, MAN PhD
Dean, College of Nursing