STI COLLEGE SOUTHWOODS

Lot 2A Maduya, Carmona, Cavite

COLLEGE OF HEALTH CARE

CASE STUDY FORM

PATIENT’S HISTORY

A. BIOGRAPHICAL DATA
Name: __________________________________________________________________
Age: __________ Gender: ________ Civil Status: _____________________
Address: _________________________________________________________________
Educational Attainment: _____________________________________________________
Occupation: _______________________ Religion: __________________
Dialect / Language spoken: __________________________________________________
Health Insurance: _________________________________________________________
Chief Complaint: __________________________________________________________
Admitting Diagnosis: _______________________________________________________

B. NURSING HISTORY
1. History of Present Illness: ____________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
2. Family History of Illness: _____________________________________________________
_________________________________________________________________________
3. Childhood Illness: __________________________________________________________
_________________________________________________________________________
__________________________________________________________________________
4. Hospitalization history:

Date of Treatment
Hospital Diagnosis Medication
Hospitalization rendered

C. CURRENT HEALTH STATUS

Physiologic Mode
a. ACTIVITY
Frequency and regularity of exercises: ____________________________________
Duration and length of exercises: ________________________________________
Limitations of activity: _________________________________________________
Any complaints/discomfort during activity: _________________________________
Complaint of Fatigue: __________________________________________________
Measures done to relieve the discomfort / complaint: _________________________
b. REST
Usual no. of hours of sleep and rest at night: ____________at day time: ________
No. of hours of sleep and rest to feel rested: _______________________________
Change in sleep / rest pattern: __________________________________________
Discomfort or difficulty going to sleep: _____________________________________
Remedy done with the discomfort: _______________________________________
No. of pillows use when sleeping: ________________________________________

c. NUTRITIONAL METABOLIC PATTERN

Food Preference:_________________ Food restrictions:______________________
Volume and type of fluid taken per day: ____________________________________
Source of drinking water supply: __________________________________________
Frequency of taking meals at home:________________ at restaurant:____________
Any change in diet: _________________Specify:_____________________________
Any change in appetite: ________________________ specify: __________________
Medication used (if any) : ________________________________________________

d. ELIMINATION PATTERN
i. Bladder
Frequency and amount of urination per day: _________________________
Color and odor of urine:__________________________________________
Any discomfort in urination:_______________________________________
Remedy and intervention done: ___________________________________
ii. Bowel
Frequency of bowel elimination per day: ____________________________
Consistency and color of stools:___________________________________
Changes in bowel elimination:____________________________________
Discomfort in Bowel elimination:___________________________________
Intervention done: _____________________________________________

e. FLUID AND ELECTROLYTES

Skin Turgor: _____________________________________________________
Condition of mucous membrane: _____________________________________
Edema: _________________________________________________________
K, Ca, Na, supplements: ____________________________________________

f. OXYGENATION AND CIRCULATION

Do you smoke: _______________ No. of Cigarettes per day: ______________
Presence of Cough:_______ Characteristics: __________________________
Usual BP: ______________________
History of asthma, PTB in the family: _________________________________
History of heart disease and HPN :___________________________________
Chest pain (location, frequency, duration, and type of pain ) : _____________
_______________________________________________________________
Medication taken / maintenance drugs : ______________________________
Shortness of breath / DOB: ________________________________________

g. SENSES
Any disturbance / difficulty in:
Sight: ________________________
Hearing: ______________________
Touch: _______________________
Taste: _______________________
 Smell: _______________________
How long do you have the difficulty?____________________________
How do you manage it?______________________________________
How has this affected your lifestyle:____________________________
Device used?______________________________________________

h. SKIN INTEGRITY
Pigmentation: ___________________________________________________
Temperature:___________________
Smooth ( ) Rough ( ) Soft ( ) Dry ( )
Perspiration and odor problem: ________________________________________
Use of any beauty aid: ______________________________________________

i. ENDOCRINE FUNCTION
Age of menarche: _____________ Duration: ____________ Cycle:__________
Menstrual discomfort: _____________ Discomfort done: _____________________
Usual Blood sugar: _______________________
Supplement taken: _______________ Insulin schedule: ______________________

j. NEUROLOGICAL FUNCTION
Level of consciousness;_________________________________________________
Orientation:_____________ gait:__________________ Posture:______________
Changes in facial, mouth and neck function:_________________________________
Deep tendon reflex:____________________________________________________
Sense of pain and light touch : ___________________________________________

Self Concept Mode

a. PERSONAL SELF
Describe yourself:_________________________________________________________
Describe your Moods:______________________________________________________
What do you like about yourself: ____________________________________________
What do you want to change in yourself:_______________________________________
Hindrances to your change:__________________________________________________
Changes you feel about yourself: _____________________________________________
Reaction to illness / hospitalization: ___________________________________________

b. PHYSICAL SELF
Present weight: ___________ Lowest weight: ______________
How do you feel yourself and appearance:_______________________________________
Any physical changes in your body:____________________________________________
Has this changes affected your relationship with others?_____________________________

c. PERSONAL VALUES
What do you consider as the most valuable / important in your life:____________________
_________________________________________________________________________
With what and who do you find a source of strength or meaning? ____________________
________________________________________________________________________
Does illness / hospitalization interfere with your religious practices : __________________
How? ___________________________________________________________________

Role Function Mode

Type of family structure:___________________________________________________
How many members in the family : ____________________________________
 Who is the bread winner:_________________ Who is the decision Maker: ______________
How does the family feel about the illness: _______________________________________
Expectations to self: _________________________________________________________
Expectation from the attending physician: ________________________________________
Expectation from Nurses: _____________________________________________________

Interdependence Mode
Frequency of interaction with the family: _________________________________________
Duration of Interaction: ______________________________________________________
Frequency of interaction outside of family: ___________________________________
What social group do you belong to:___________________________________________
How do you make the decision: _____________________________________________
With whom: ____________________________________________________________
How does the family cope in time of crisis?: ______________________________________
Any big change in your life in the last year or two?:________________________________
What was the change: _____________________________________________

D. PSYCHOLOGICAL DEVELOPMENT

PSYCHOSEXUAL PSYCHOSOCIAL COGNITIVE INTERPERSONAL MORAL SPIRITUAL

(Freud) (Erickson) (Piaget) (Sullivan) (Kohlberg) (Fowler’s)

E. PHYSICAL EXAMINATION

Date performed: _______________________ No. of hospital Days: _________________________

1. Vital signs :

a. Temperature: ________________

b. Pulse Rate: ________________

c. Respiratory Rate: ________________

d. Blood pressure: ________________

2. Regional Examination:
Regions of the body Methods of Assessment (IPAP) Results
a. Hair
b. Head
c. Face
d. Eyes
e. Nose
f. Mouth and pharynx
g. Neck
h. Chest wall ( Anterior)
i. Chest wall (Posterior)
j. Breast and Axilla
k. Heart
l. Abdomen
m. Skin and nails
n. Anus and Rectum
o. Extremities (lower) *include
ROM and muscle strength
p. Extremities (upper) *include
ROM and muscle strength
q. Urinary
 r. Genitals
s. Musculoskeletal
t. Hematology
u. Gastrointestinal
v. Cranial Nerves (I-XII)
If applicable please include Neuromuscular Vital signs / assessment

F. LABORATORY EXAMINATIONS

Purpose of the Nursing

Date and
examination to Results of the responsibilities
Type of Normal Values Interpretation
the patient’s examination (before,
Examination
case during , after)

G. DIAGNOSTIC EXAMINATIONS

Purpose of the Nursing

Date and
examination to Results of the responsibilities
Type of Normal Values Interpretation
the patient’s examination (before,
Examination
case during , after)

H. MEDICAL PLAN OF CARE

Responsibility of the nurse Purpose of the given

Date of the order Doctor’s order
with the order order

I. ANATOMY AND PHYSIOLOGY

Include picture of system and brief explanation that relates to the patients.

J. PATHOPHYSIOLOGY

A. Diagram
Include precipitating and predisposing factors.

B. Tabular

Signs and Symptoms Signs and Symptoms

Definition of the diseases Evaluation or comparison
found in the book manifested by the patient

K. DRUG STUDY

Name of Drug, Classification,

Nursing Responsibility
Route, Frequency and Drug Indication Drug Action
(before, during , after)
Dosage

L. NURSING CARE PLAN

 Cues Nursing Intervention
Nursing Diagnosis Objectives Evaluation
(subjective/objective) and Rationale

M. PROGRESS NOTES

Day Status of the Patient

N. DISCHARGE PLAN OF CARE

Key Area Plan of Care

1. Nutrition
2. Medication
3. Activity
4. Self Care / knowledge on
treatments
5. Follow up check ups

O. HEALTH TEACHING PLAN

Topic Objective Methods of Teaching Visual aids Evaluation

P. SUMMARY OF CLIENTS STATUS OR CONDITION AS OF LAST DAY OF CONTACT

Date:
Condition of the patient on his/her last day.