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