35711536-Case-Study-Format

35711536-Case-Study-Format - Case Study Format I....

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Unformatted text preview: Case Study Format I. Biographic Data Name: client Xpired Address: # 56 Roosevelt Park Subdivisions, San Pablo, Dinalupihan Bataan Age: 32 Gender: Male Religious Affiliation: Roman Catholic Marital Status: Single Occupation: student Room and Bed #: N/A Chief Complaint: N/A Provisional Diagnosis: N/A Attending Physician: N/A II. Nursing History a. Past Health History The client verbalized ´Nakaranas na ako na magkaroon ng Bulutong, nagkabeke na rin ako, oo syempre naman nilagnat na ako. May allegy rin ako sa alikabok. Nakumpleto ko yung mga baku-bakuna na iyan sabi sa akin ng nanay ko. May allergy ako sa malalansang pagkain, tulad ng itlog, sa seafoods, especially yang hipon. Allergic din ako sa alikabok, madalas ako bumabahing kapag pumasok sa ilong ko yang alikabok nayan.µ ´Nung limang taon ako, sabi sa akin ng nanay ko na nalaglag ako sa tricycle at nabagok daw ako tapos maraming dugo ang lumabas sa ulo ko kwento sa akin ng nanay ko. Dahil masyadong maraming dugo ang lumalabas at hindi humihinto, kinailangan na tahiin , kaya nga natahi tong ulo ko eh, dito sa may bandang noo ko.µ ´Madalas pag may nararamdaman akong masakit iniinoman ko na lang ng paracetamol o kaya naman pas masakit ang mga kasukasuan ko tulad ng muscle pain o kaya headache ibuprofen ang iniinom ko.µ b. History of Present Illness: N/A c. Family History: ´Ang lola ko diabetic siya, tapos ang lolo ko naman hypertensive, wala na sila pareho, namatay na. Ang Mama ko normal hypertensive o kaya naman diabetic, ang Papa ko lang ang Hypertensive wala naming sakit ang mga kapatid ko.µ d. Obstetric History (OB cases only): N/A e. Developmental History: N/A III. Patterns of Functioning A. Health-perception/ health-management Pattern ´Siguro ang health sa akin ay kapag masaya ako sa nararamdaman ko, sa ginagawa ko na wala akong mararamdam sakit, yun yung healthy pero pag medyo iritado ako,syempre may masakit pag ganun ahh.. Kasi di ka komportable sa nangyayari sa iyo.µ µNaliligo ako pag-gising ko at bago ako umaalis sa bahay tsaka bago matulog at pag-nanlalagkit, naliligo ako, sa tingin ko okey naman yung hygiene ko eh, nagtutoothbrush ako pagkatapos nito, at pag sa tingin ko mahaba na ang kuko ko, kailangan ko ng putulin yung kuko koµ ´Naninigarilyo ako, nakaka 10 sticks nga ako sa isang araw eh minsan nakadepende sa nakakasama kung malakas manigarilyo mapapalakas ka rin at kung mahina lang sa pagconsume ng yosi syempre ikaw rin mababawasan ang gamit, Marlboro red ang gamit ko. Pagkatapos pag umiinom naman ako ng alak, nag-smoke din ako, siguro sa isang lingo, tatlong beses ako umiinom kasama ng mga tropa ko kasi nayayaya eh, nag-kakayayaan kaya napapainom din ako, madalas red horse at yung the bar, yun lang naman ang iniinom naming eh. At kung may pera syempre di maiiwasan na mapainom ng hard ahh.. tulad ng Fundador.µ Interpretation: The client has a good perception in health and relates it to his emotions, he also has a good hygiene taking at least 2 baths a day or whenever he feels uncomfortable with his body odor but the client·s intake of his vices (smoking and alcohol consumption) is hazardous to his health though he does not use any form of illegal drugs. Analysis: based on WHO health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity (Fundamentals of Nursing: The Art and Science of Nursing Careµ 5th ed. By Taylor, Lillih, LeMone Chapter 4 Health Illnesses p. 60) B. Nutritional-Metabolic Pattern ´Ang kaen ko, anu almusal, tanghale, hapunan tapos siyempre may mga miryenda na rin kasama, madalas kasabay ko yung family ko, pero pag may pasok,kasabay ko mga classmates ko, lutong ulam n lang kam. Makatubig akong tao,kadalasan, nakaka 3-4 akong baso ng tubig sa isang kainan pero minsan depende padin yun sa kinakaen ko tsaka mas gusto ko kasi yung pantay lang, di masyadong karne siyempre gulay din,ganunµ Interpretation: The client is considered to have a glance diet because he meets the adequate nutrients needed by the body accordingly to the client·s BMI and consumes adequate food/fluid. Analysis: Nutrient intake is sufficient for meeting metabolic needs. Demonstrate behaviors to attain/maintain appropriate weight at a satisfactory level for height, weight, body build, age and gender (Nurse·s Pocket Guide ed. 11 by Doenges, Moorhouse, Murr p.488) C. Elimination Pattern ´7-10 times a day ako umihi,kadalasan yellow or clear yung color niya. Tapos pag tuwing umaga, regular yung bowel ko, brown siya tsaka malambot-lambot siyempre mabaho din pero minsan depende din sa kinakain ko kung magiging matigas o anong kulayµ Interpretation: The client has normal elimination pattern and no difficulty in eliminating and excretion of urine, the appearance of the client·s stool depends on what he eats. Analysis: Establish/maintain regular pattern of bowel functioning possible (Nurse·s Pocket Guide ed. 11 by Doenges, Moorhouse, Murr p.488) D. Activity-Exercise Pattern 5·10µ; 72 kg. (muscle tone) FAIR ´Tuwing umaga, pagpapasok, mula sa bahay,naglalakad na lang ako hanggang sakayan mga 2mins na paglalakad ,parang exercise na din tapos nag-lalaro kami ng mga classmates ko ng basetball para naman mabanat-banat yung butoµ Interpretation: the client has a good activity-exercise pattern. He tries to maintain an active body by the regular exercise, sport engagement and other recreational activities to have an appropriate body build for his weight, height and age and he has no difficulties in activities he engages in. Analysis: client·s form of exercise is regular and light just to maintain currnet body build appropriate for height and weight. ( Nurse·s Pocket Guide ed. 11 by Doengenes, Moorhouse, Murr p.70-73) E. Sleep-rest Pattern ´ Hirap ako matulog kaya 5 oras lang ang tulog ko palagi tapos humihilik ako, tapos maaga pa nagigising dahil layo ng bahay ko eh, kaya pag-dating sa school panay ang hikab ko pero di naman apektado yung activities ko sa school, tsaka energetic padin naman, nakakapagkulitan pa ko sa mga classmates koµ Interpretation: The client has poor sleep and rest pattern because of difficulty in sleeping and insufficient sleep taken a day or every night shown by the client·s frequent yawning but has enough energy to sustain his everyday activities. He does not do any interventions to cope with his difficulties in sleeping. Analysis: The client has disrupted sleeping patterns. Difficulty falling asleep; waking up too early; dissatisfaction with sleep ( Nurse·s Pocket Guide ed. 11 by Doengenes, Moorhouse, Murr p.422 and p. 429) F. Cognitive/Perceptual Pattern ´Tapos na ko ng BSManagement, bale 2nd course ko na ito, anu, ok naman, walang problema, di ako nahihirapan kasi parang may background na ko sa college kahit na magkaiba yung course ko, wala din naman problema kunyari sa oras kasi sarili ko naman yung oras ko, di ako nagtratrabaho, focus lang sa studies.µ Interpretation: The client already finished a four year course which his highest educational attainment and is expresses motivation to enhance his cognitive/perceptual pattern and no sign of difficulties, conflicts, emotional changes, mental disorders. Analysis: The client has no cognitive dissonance; memory deficit and no signs of mental impairments (Nurse·s Pocket Guide ed. 11 by Doenges, Moorhouse, Murr pp.451-454 ) G. Self Perception/ Self Concept Pattern ´Masaya naman ako sa aking pangangatawan, walal naman akong ninais na baguhin sa katawan ko. Kung may mga ideas ako na naiisip o kaya naman may mga masaya o malungkot akong nararamdaman, ikinukwento ko s amga tropa ko yon. Pag ayaw ko naman ang isang bagay na ginagawa sa akin, hindi ko na lang pinapatulan, ang ginagawa ko hindi ko na lang iniintindi yun .µ ´Ayaw na ayaw ko yung ini-interupt yung pag-uusap namin ng kausap ko, yung tipong tatawagin nila yung pangalan mo dahil may kailangan silang malaman na information. Ang ginagawa ko di ko talaga sila nililingon kaya nga ang akala ng iba, may hearing problem ako, pero ang totoo di ko lang talaga sila pinapansin.µ ´Sa tingin ko naman maganda ang relationship ko sa mga taong malapit sa akin, pero sa iba marahil hindi gaano, dahil nga sa ginagawa kong hindi pagpansin sa kanila. Baka piling nila bastos ako ohh kung anuman.µ Interpretation: The client is able to perform his daily hygiene and feels good about his appearance. The client is satisfied and comfortable with the totality of his image and feelings. Analysis: The client has a good pattern of perceptions or ideas about the self hat is sufficient for well- being and can be strengthened. Actions are congruent with expressed feelings and thoughts ( Nurse·s Pocket Guide ed. 11 by Doengenes, Moorhouse, Murr p.90) H. Role-Relationship Pattern ´Kasama ko sa bahay yung family ko, tsaka yung pamangkin ko, bayaw ko kasi nasa abroad so bale, extended kami,mas marami, mas masaya. Sa neighborhood namin, bago lang kami pero ok naman lahat nakakasundo namig, sa mga classmates ko, ok din,masaya kasi wala ako near akakaawayµ ´Tatay ko siyempre yung decision maker sa bahay, tapos hati-hati yung mga gawaing bahay kahit matanda na ko,para din a din mahirapan nanay namin sa gawaing bahay.µ Interpretation: The client has a healthy role-relationship pattern. He demonstrates a wide base of socialization with others in his community, family, friends, and classmates. He has satisfying personal relationship and adequate personal resources. He helps in the division of activities in their household Analysis: The client meets physical, social and psychological needs of family members. No signs of altered state of wellness and has accepted social behavior/values. Has the ability to engage in satisfying personal relationships. Participates in activities/ programs in the community and expresses increased selfworth and does not demonstrate any sign of social isolation (Nurse·s Pocket Guide ed. 11 by Doenges, Moorhouse, Murr pp. 639-640) I. Sexuality- Reproductive Pattern ´Bago naman ako umaalis ng bahay sinisigurado ko naman na maayos ang pananamit ko, hindi lang naman ako nagiging maayos, kapag nakainum at biglang pasok sa school, syempre di mu na makukuhang maayos ang sarili mo naman nun kung may toma ka na diba? Lalo na di maiiwasan na maapektuhan ang amoy mo, hininga mo, at pati salita mo syempre maaapektuhan na diba nagiging makulit kapag makakausap mo.µ ´Kahit na single ako hanggang ngayon, hindi ibig sabihin na nagkakaroon ako ng identity crisis sa gender ko. Sa edad ko ba namang ito magkakaroon pa ako ng alinlangan sa sarili kong kasarian, single ako kasi naeenjoy ko ang status ko. Besides, hindi ko pa talaga nahahanap ang right woman ko!µ ´Ang pagiging lalaki kasi ay yung ikaw ang magtataguyod sa pamilyang bubuoin mo, ´haligi ng tahananµ ika nga. kaya naman ako bilang lalaki ang mga gawaing panlalaki ginagawa ko talaga, hindi ko hinahayaan nagawin ng isang babae yun kasi mas malaks kami sa kanila.µ ´Sa pagiging lalaki, naeenjoy ko talaga yung wala kang limitasyon sa gagawin mu kasi nga lalaki ka parang lahat pwede mo magawa, na hindi mu kailangan magalinlangan, tulad ng pag-inom kasama ng mga kaibigan mu, kahit nga di ka na umuwi tapos may pasok kinabukasan deretso school agad.µ Interpretation: As a man, the client enjoys being free and feels that men are more dominant than women. He is satisfied by being able to express his feelings toward with someone. He also enjoys the privileges that a man has. Analysis: The client is sexually healthy and no signs of any sexual dysfunctions. The client has no conflicts with orientation and is comfortable with his sex preferences (Nurses·s Guide Pocket ed. 11 by Doenges, Moorhouse, Murr p.611,p.615) J. Coping/Stress-tolerance Pattern ´Ang mga magulang ko pa rin ang sumusuporta sa akin. Sila rin minsan nakakaalam kung anong problema pero minsan lang, madalas mga kaibigan ko ang nilalabasan ko ng sama ng loob kasi nasa tamang edad naman na ako diba? Kaya makagagawa na ako ng tamang desisyon para sa sarili ko, pam paalis ng stress, naidadaan ko na lang pag-gagala at pag nagkayayaan, inuman na lang oh kaya yosiyosi sa tabi tabi habang nagkukwentuhan parang dyan ko nailalabas yun bang mawala ang stress sa katawan ko.µ Interpretation: The client has a good coping stress mechanism because of his different recreational activities to strengthen or improve his stress levels. Analysis: Meet psychological needs as evidenced by appropriate expression of feelings, identification, of options and use of resources. Verbalizes or demonstrates reduced stress reaction. Has available support systems, family, friends can provide client with ability to handle current stressful events. (Nurse·s Pocket Guide ed. 9 by Doenges, Moorhouse, Murr p. 183) K. Value-Belief Pattern ´Roman Catholic ako, nagsisimba ako tuwing linggo kasama ko pa nga ang mga magulang ko. Dati nai-involved ako dyan sa mga activities sa church kaso nung magsimula na magcollege na ako nahinto na ako sa pag attend-attend dya kasi siyempre busy na tapos laging gala lang kasama yung tropa. Malakas ang pananalig ko sa Diyos syempre kaya ngayon pag may oras ako, nag-sisimba ako di katulad dati nalilimutan ko na«µ Interpretation: The client is a Roman Catholic with a strong spiritual belief and social development became a barrier to client practicing religion but shows motivation for change. Analysis: The client has strong values and beliefs which affect the client·s worth as a person, object, idea, or actions. The client·s values also influence decisions and actions. Expresses desire to strengthen religious belief patterns/customs that had provided comfort/ religion in the past (Nurse·s Pocket Guide ed. 11 by Doenges, Moorhouse, Murr pp. 559-562) ...
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This note was uploaded on 03/22/2012 for the course ECON 1 taught by Professor Tuki during the Spring '12 term at CSU Pueblo.

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