Nursing Case Study
Content Outline
I. Student’s Profile
Name: Maria Rose Ann Yee
Year level: 2
Course: BS Nursing
Clinical Instructor: Mr. Dennis Machado Jr.
Date of Clinical Duty: June 15, 2019
Area of Exposure: Roxas Memorial Provincial Hospital
II. Introduction
• Objectives:
a. General objective
The nursing students will be able apply their basic learnings such as taking vital sign and
assisting to the patient and to have exposure in clinical settings and can perform their task
well, based on their level of competency and can attribute positive and proper attitude in
dealing with the staffs.
b. Specific objectives
Knowledge
1. To identify the needs of the patient for nursing intervention
2.
III. Biographical data
Name: J.D.F
Address: Lawaan Roxas City
Age: 20 years old
Birthdate: June 24, 1998
Birthplace:
Gender: Female
Marital Status: Single
Religion: Catholic
Educational Level: 2nd year high school
Occupation: None
Nationality: Filipino
Person next to Kin (Optional):
Date and time of admission: June 13, 2019
Area of admission: OB Ward
Attending Physician (Initial): Lucino D. Delfin
Admitting Diagnosis: G2 PI (1001) Pregnancy Uterine 32 weeks AOG Cephalic in Preterm Labor, I/C
Hyperthyroidism
Principal diagnosis
Sources (Primary/secondary data):
I. Nursing Health History
a. Reason for seeking
Patient experience uterine contractions 1 day PTC
Labor pains
b. History of present illness
A 20 years old pregnant woman arrived at the hospital because of the complaint
of labor pains. She also experienced uterine contractions. The patient is 1 day
PTC.
c. Past health history
The patient suffered from hyperthyroidism as claimed by incomplete work up to
follow up. The patient do not take any medicines.
d. Family History
Hereditary Diseases Paternal Maternal
None
e. Environmental History
The patient’s house is made up of cement. They have mango tree on their house. They
have a fresh and clean environment with a lot of plants around there house.
f. Medication and Substance
The patient is taking cefixime, ferrous sulfate and oral iron supplement
g. Adult Medical Surgical Assessment Tool
Adaptation uses in Nursing Care Plans, Guidelines for individualizing Client Care Across the Life Span
(Doenges, M. et al, 2008) 7th edition (See Attachments at end of page)
h. OB history (If Applicable)
History of pregnancies
• Date of LMP: November 1, 2019
• Prenatal visit/prenatal care: once a month
• AOG: 7 months
• Gravida (present pregnancy): 1
• Para: 0
• TPAL: T(0) P(1) A(0) L(0)
Body Parts Inspection Palpation Percussion Auscultation
II. Anatomy and Physiology
Ovaries
The ovaries are the ultimate life-maker for the females.
For its physical structure, it has an estimated length of 4 cm and width of 2 cm and is 1.5
cm thick. It appears to be shaped like an almond. It looks pitted, like a raisin, but is
grayish white in color.
It is located proximal to both sides of the uterus at the lower abdomen.
For its function, the ovaries produce, mature, and discharge the egg cells or ova.
Ovarian function is for the maturation and maintenance of the secondary sex
characteristics in females.
It also has three divisions: the protective layer of epithelium, the cortex, and the central
medulla.
Fallopian Tubes
The fallopian tubes serve as the pathway of the egg cells towards the uterus.
It is a smooth, hollow tunnel that is divided into four parts: the interstitial, which is 1 cm in
length; the isthmus, which is2 cm in length; the ampulla, which is 5 cm in length; and the
infundibular, which is 2 cm long and shaped like a funnel.
The funnel has small hairs called the fimbria that propel the ovum into the fallopian tube.
The fallopian tube is lined with mucous membrane, and underneath is the connective
tissue and the muscle layer.
III. Pathophysiology (Please include reference/s) CREATE CONCEPT MAP
Predisposing/precipitating factors
Disease process
Signs and symptoms (Manifested and not manifested by the patient)
Complication
IV. Physical Assessment
Head to toe assessment (cephalocaudal)
Documentation: By System or Review of System –follow format from health
assessment
Initial assessment Final assessment
5/22/11; 8-12am 5/25/11; 8-12am
Abdomen 6/8/19; 4:30pm 6/8/19; 8:00pm
A. Vital Signs (Admission & Assessment)
Temperature: 36.5
Pulse/ Cardiac Rate: 85 b/min.
Respiratory Rate: 20
Blood Pressure: 120/80
Oxygen Saturation: 99%
Pain(Pain Scale): 8
B. General Survey
Appearance
The patient appears to be alert and attentive, facial features are symmetric. Her neck has a lump
due to hyperthyroidism. Patient shows the absence of emotional discomfort. No signs of distress
and able to fix herself. Patient has a mole on her left lower eyelid. Her skin appears to be
brownish in color.
Body structure/mobility
Patient Weight and Height is within normal range, with the BMI of 30-Normal. Body parts are
bilaterally equal. Patient is able to stand and sit by her own. She is well balanced and can be able
to walk without assistance. There is no sign of mobility dysfunctions
Behavior
Patient is well responsive in answering the questions.; she maintains eye contact with a desired
expressions. Her speech is clear and calm. She is clean and well groomed.
Body Parts Inspection Palpation Percussion Auscultation
A. Hair The hair of the
patient is black
medium length, thin
and straight. Patient’s
hair is normally
distributed on scalp
and perineum. There
are also no signs
of infection and
infestation observed.
B. Nail The patient has nails When pressed,
pink in color and has the fingers
no detachmen of return to its
position and
nailplate. Hands are
color
well-manicured with
a colorless enamel.
C. Head and Face The head of the There is no
patient is oval. The lesions or
face appeared to be bumps.
smooth.
D. Neck The neck is There is .
symmetrical and bulging masses
trachea is in the palpated.
midline.
E. Ears The ears are equal in The auricles
size bilaterally. are mobile,
The auricle are firm and not
aligned with the tender, when
corner of each eye palpate
and extra ocular
movement is smooth.
F. Eyes
Eyelids are
normally position.
No redness or
discharge noted.
Conjunctiva and
sclera are moist
and smooth.
There is a mole
on the left lower
eyelid. No
redness or
swelling appear
G. Mouth and
The lips
Throat
of the
patient is
pink,
smooth
and moist.
Gums are
pink
without
redness or
swelling.
Tongue is
smooh
and shin
pink wih
visible
veins
present.
Tonsilar
pillars are
pink and
symmetric
H. Nose The nose appeared When lightly
symmetric, straight palpated, there
and uniform in color. were no
There was no tenderness and
presence of discharge lesions
or flaring.
I. Thorax and There is no pain or Percussion
Vesicular
Lungs tenderness on tones
breah
palpation. resonant
sounds
over all
auscultated
the lungs
on the lungs
area
area
J. Breast Free movement of No masses or
breasts with with tenderness
position changes of palpated
arms and hands. No
dimpling, retraction,
lesions or
inflammation noted.
No discharge noted
on the nipple
K. Abdomen The skin of abdomen When palpate,
is free of scars, the abdomen is
lesions, or rashes firm.
L. Genitalia
M. Upper
Extremities and
Lower Extremities
