CENTRAL LUZON DOCTORS’ HOSPITAL EDUCATIONAL INSTITUTION San Pablo, Tarlac City CASE STUDY FORMAT I. Introduction II. Objectives Nurse centered III. Nursing Process A. Data Base a. Nursing health history A 1. Demographic data 2. Chief complaint 3. History of present illness 4. Past medical history 5. Family history 6. Social and personal history 7. Review of system b. Nursing health history B 1. General Description Of Client 2. Health Perception-Health Management Pattern 3. Nutritional-Metabolic Pattern 4. Elimination Pattern 5. Activity-Exercise Pattern 6. Sleep-Rest Pattern 7. Cognitive-Perceptual Pattern 8. Self-Perception – Self-Concept Pattern 9. Role-Relationship Pattern 10. Sexuality-Reproductive Pattern 11. Coping-Stress Tolerance Pattern 12. Value-Belief Pattern c. Physical examination d. Laboratory Findings e. Review of anatomy and physiology f. Pathophysiology (highlight patient manifestation) B. NCP C. Drug Study D. Medical and Nursing Management E. METHOD IV.Evaluation a. Narrative evaluation of the objectives
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CENTRAL LUZON DOCTORS’ HOSPITALEDUCATIONAL INSTITUTION
San Pablo, Tarlac City
CASE STUDY FORMAT
I. IntroductionII. Objectives
Nurse centeredIII. Nursing Process
A. Data Basea. Nursing health history A
1. Demographic data2. Chief complaint3. History of present illness4. Past medical history5. Family history6. Social and personal history7. Review of system
b. Nursing health history B1. General Description Of Client2. Health Perception-Health Management Pattern3. Nutritional-Metabolic Pattern4. Elimination Pattern 5. Activity-Exercise Pattern6. Sleep-Rest Pattern7. Cognitive-Perceptual Pattern8. Self-Perception – Self-Concept Pattern9. Role-Relationship Pattern10.Sexuality-Reproductive Pattern11.Coping-Stress Tolerance Pattern12.Value-Belief Pattern
c. Physical examinationd. Laboratory Findingse. Review of anatomy and physiologyf. Pathophysiology (highlight patient manifestation)
B. NCPC. Drug StudyD. Medical and Nursing ManagementE. METHOD
IV. Evaluationa. Narrative evaluation of the objectivesb. Patient condition upon discharge
V. RecommendationVI. References/Bibliography
CENTRAL LUZON DOCTORS’ HOSPITALEDUCATIONAL INSTITUTION
(Follow IPPA format when documenting Physical Examination findings)
LIST OF IDENTIFIED NURSING PROBLEMS
PRIORITIZATION OF NURSING PROBLEM
1. Oxygenation2. Nutrition3. Elimination4. Activity and Exercise5. Comfort and Safety6. Sexual- Reproductive7. Psychological8. Psychosocial
LABORATORY FINDINGS
Review of anatomy and physiology
Pathophysiology (highlight patient manifestation)
NCP
ASSESSMENT INTERVENTIONEVALUATION
CUES NURSINGDIAGNOSIS
SCIENTIFICEXPLANATION
PROBLEM STATEMENT
(GOAL)
NURSINGINTERVENTION RATIONALE
Drug Study
DRUG NAME/
GENERIC
CLASSI-FICATION
DOSAGE/STOCKDOSE
ACTION INDICATION CONTRAINDICATION
SIDEEFFECTS
ARVERSEREACTION
NURSING RESPONSIBILITIES
Medical Management (
Nursing Management
Discharge Planning
METHOD (Example)
M (Medications):Lasix (Furosemide). Decreases swelling and blood pressure by increasing the amount of urine. Expect increased frequency and volume of urine. Report irregular heartbeat, changes in muscle strength, tremor, and muscle cramps, change in mental status, fullness, ringing/roaring in ears. Eat foods high in potassium such as whole grains (cereals), legumes, meat, bananas, apricots, orange juice, potatoes, and raisins. Avoid sun/sunlamps. Take with breakfast to avoid GI upset.Digoxin (Lanoxin). Used to treat CHF. Taking too much can result in GI disturbances, changes in mental status and vision. Report the following signs/ symptoms to your doctor: Nausea, vomiting, lack of appetite, fatigue, headache, depression, weakness, drowsiness, confusion, nightmares, facial pain, personality changes, sensitivity to light, light flashes, halos around bright objects, yellow or green color perception. Take pulse rate for one minute before dose and call doctor if pulse is below 60 before taking medication. Don’t increase or skip doses. Don’t take over the counter medications without talking to MD. Report for follow-up visits with your doctor to monitor lab values.
E (Exercise/Environment):Your eldest daughter will provide help with activities of daily living in the home. She will transport you to followup appointments. It is important to take steps to prevent falls: use of a 3-point cane for stability with ambulation; removing objects like throw rugs, cords that may cause fall; pausing before standing and again before walking to prevent drop in blood pressure. The “life line” allow you to access 911 for emergency help. You may resume activities as tolerated and you have a follow-up appointment with the doctor in 1 week.
T (Treatments):Apply A & D ointment to reddened coccyx and heels three times a day. Keep pressure off of these areas by keeping off of back and elevating heels off of bed. Keep skin clean and dry. Report any changes in skin condition to doctor. (i.e. open areas, drainage, elevated temp.)
H (Health knowledge of disease):Lasix can cause a loss of potassium. It is important to eat foods high in potassium and to have regular blood levels drawn to make sure potassium level stays normal. Monitoring the pulse rate before taking digoxin is important because this medicine can cause the pulse to drop. Call the doctor if pulse rate is below 60 beats per minute. New signs and symptoms should be reported to the physician, because they may indicate electrolyte imbalance &/or digoxin toxicity. Sodium causes water retention so it is important to limit sodium intake by eating a no added salt diet. Be careful to check labels for hidden salt content.
O (Outpatient/inpatient referrals): (include resources such as websites and organizations): American Heart Association www.americanheart.org Visiting Nurses’ Association for F/U skin assessment. Referral made to outpatient dietician for diet planning. Meals on Wheels.
D: (Diet):Do not add salt to your diet. Eat foods high in potassium such as bananas. We will arrange for you to meet with the dietician.