case study form print now na
TRANSCRIPT
-
8/9/2019 Case Study Form Print Now Na
1/13
I. Introductio
II. Objectives
General Objectives
Special Objectives:
III. Developmental Task
Physical
Motor development
Language
Patients Profile
Name :
Address :
Age :
Gender :
Civil Status :
Religion :
Birth Date :
Attending Physician :
Date of Admission :
Diagnosis :
History of Past Illness
History of Present Illness
-
8/9/2019 Case Study Form Print Now Na
2/13
IV. Physical Assessment
Physical assessment done:
Level of Consciousness:
Body Part Normal Finding Actual Finding Interpretation
A. Head
1. Skull
Inspection Proportional to the
size of the body,
round, with
prominence in the
frontal area interiorly
and the occipital are
posterior symmetrical
in all planes, gently
curved.
Palpation No area of
tenderness, lumps,
and has a smooth
skull contour.
2. Scalp
Inspection White, clean, free
from masses, lumps,
scars, lice, nits and
dandruff and lesions.
Palpation No area of tenderness
3. Hair
Inspection Black evenly
distributed and covers
the whole scalp, thin
and shiny.
-
8/9/2019 Case Study Form Print Now Na
3/13
Palpation Coarse or fine. Hair
may feel thin, straight,
thick, or curly.
4. Face
Inspection Oblong or Oval or
round or square or
heart-shaped,
symmetrical, facial
expression that is
dependent on the
mood or true feelings,
smooth and no
voluntary muscle
movement.
5. Eyes
Inspection Parallel and evenly
distributed and placed
symmetrically, non-
protruding, with scant
amount of secretions,
both eyes bright and
clear.
6. Eyebrows
Inspection Black, symmetrical,
thick, evenly
distributed and
parallel to each other.
7. Eyelashes
Inspection Black evenly
distributed and turnedoutward.
8. Eyelids
Inspection Upper lid covers a
small portion of the
iris, cornea and the
sclera when the eyes
-
8/9/2019 Case Study Form Print Now Na
4/13
are open. When the
eyes are closed the
lids meet completely,
symmetrical.
Palpation Non palpable, not
tender
9. Lower Palpebral
Conjunctiva
Inspection Salmon, pink, shiny,
moist
10. Sclera
Inspection White, clear with
some small,
superficial vessels
and without exudates,
lesions and foreign
bodies.
11. Cornea
Inspection Transparent, shiny,and smooth with no
presence of discharge
and irregularity.
12. Pupils
Inspection Round, equal and
reacts to light and
accommodation:
constrict when light is
pointed to the eyesand dilate when light
is removed.
13. Iris
Inspection Proportional to the
size of the eyes,
round, black/brown
-
8/9/2019 Case Study Form Print Now Na
5/13
and symmetrical.
Ears
Inspection Parallel, symmetrical,
proportional to the
size of the head,
bean-shaped, helix is
in line with the outer
canthus of the eye,
skin is the same color
as the surrounding
area and is clean.
Palpation Firm cartilage and the
patient should not
complain of pain or
tenderness during
palpation.
Ear Canal
Inspection Pinkish, clean with
scant amount of
cerumen and a few
cilia.
14. Nose
Inspection In the midline,symmetrical and
patent and is without
swelling, bleeding,
lesions and masses.
Internal Nares
Inspection Clean, pinkish with
few cilia.
Septum
Inspection
Straight in the midline
and without
perforation.
-
8/9/2019 Case Study Form Print Now Na
6/13
15. Mouth
Lips
Inspection Pinkish, symmetrical
with lip margin, well
defined, smooth, and
moist. And show no
inflammation.
Gums
Pinkish, smooth,
moist no receding, no
swelling and no
discharge.
Teeth
Inspection Well-aligned, freefrom caries or filling,
no halitosis
Frenulum
Inspection Midline, straight and
thin.
Cheeks
Pinkish ,smooth and
moist. Free of lesions.
Tongue
Inspection Midline or medium,
red or pink, slightly
rough on top, smooth
along the lateral
margins moist, shiny
and freely movable.
Cheecks (buccal
mucosa )
Inspection Pinkish, smooth and
moist. Free of lesions.
Soft Palate
Inspection Pinkish, smooth, and
-
8/9/2019 Case Study Form Print Now Na
7/13
moist. No lesion or
malformation.
Inspection Slightly pinkish, many
ridges. No lesion and
malformation.
Neck
Inspection Proportional to the
size of the body and
head, symmetrical
and straight. Can
move the head
through a full range of
motion without
complaint ofdiscomfort .
Upper
Extremities
Inspection Clean no lesions,
digits/fingers equal in
number, symmetrical
no abnormalities.
Palpation No tenderness, ormasses; smooth and
temperature uniform.
Nails
Inspection Convex in curvature.
Normally have a pink
cast.
Palpation Smooth in texture;
prompt return of usualcolor upon release of
pressure.
Lower extremities
Inspection Lower extremities are
symmetrical and
equal in size, length.
-
8/9/2019 Case Study Form Print Now Na
8/13
Hair distribution
variable. Feet clean
and no lesions.
Palpation Texture smooth,
temperature uniform.
V. Gordons Functional Health Pattern
A. Health perception and health management
B. Nutritional and metabolic pattern
C. Elimination pattern
D. Activity-Exercise pattern
E. Sleep-Rest pattern
F. Cognitive-Perceptual pattern
G. Self perception and Self concept pattern
-
8/9/2019 Case Study Form Print Now Na
9/13
H. Role relationship pattern
I. Sexuality reproductive pattern
J. Coping stress tolerance pattern
K. Value belief pattern
VI. Anatomy and Physiology
VII. Pathophysiology
Disease:
PREDISPOSIN
G FACTOR:
PRECIPITATING
FACTOR:
Age :
Gender :
-
8/9/2019 Case Study Form Print Now Na
10/13
VIII. Laboratory Result
Urinalysis
Actual Normal Significance
Color :
Transparency :
Pus Cells :
straw yellow to amber
transparent
absent
DxS/Sx
MANAGEMENT:
-
8/9/2019 Case Study Form Print Now Na
11/13
Red Blood Cells :
Epithelial Cells :
absent
absent
Clinical Chemistry
Actual Normal Significance
Sodium :
Potassium :
135 148 mmo/L
3.5 5.3 mmo/L
Hematology
Actual Normal Significance
Hemoglobin :
Hematocrit :
Segmenters :
Lymphocyte :
F : 12 14 g/dLM : 14 16 g/dL
F : 0.37 0.47M : 0.40 0.57
60 70 %
30 40 %
-
8/9/2019 Case Study Form Print Now Na
12/13
Platelet count : 130- 400 x 10
XI. Discharge Planning
Medication-
Exercise-
Treatment-
Health teaching-
Outpatient-
Diet-
Spiritual-
Assessment Guide
I. General Data
Name :
Birth Date:
Address :
Rm & Bed No. :
Religion:
Age:
Informant:
Date:
-
8/9/2019 Case Study Form Print Now Na
13/13
II. Nursing History
A. Chief Complaint :
B. Past Health History :
C. Family History :
D. Usual pattern of Functioning
1. Physical activity
2. Food and Fluid Intake
a. Food dislikes:
b. Feeding problems:
3. Sleeping Pattern: takes
4. Elimination pattern:
a. Bowel :
b. Bladder: