Republic of the Philippines
Western Mindanao State University
College of Nursing
Zamboanga City
Tel. No. (062) 9911040 loc.111, (062) 9931339, (062) 9902706
COMPREHENSIVE CLINICAL CASE STUDY IN THE CARE OF
CLIENT WITH CELLULAR ABERRATION
(HEPATIC ADENOMA, RIGHT LOBE)
In partial fulfilment for requirement of
MSN INTENSIVE PRACTICUM
1st Semester S.Y. 2019-2020
Presented to:
DR. NURSIA M. BARJOSE
PROF. ANTONIO D. PATIŇO, JR.
Presented by:
Dino Loie T. Rebollos, R.N.
Page no.
CHAPTER I
INTRODUCTION
A. Background of the Study …………………………………… 1
B. Objectives of the Study
…………………………………………….. 8
C. Significance of the Study …………………………………… 9
CHAPTER II
THEORETICAL BACKGROUND
A. Theoretical Source …………………………………………….. 10
B. Theoretical Framework ……………………………………………..
17
C. Conceptual Framework ……………………………………………..
18
C. Definition of Terms …………………………………………….. 19
CHAPTER III
THE NURSING PROCESS
A. Assessment Phase
1. Biographical Data …………………………………………….
21
2. Clinical History ……………………………………………. 22
3. Genogram .......................……………………………………
24
4. General Assessment .................................................25
5. Laboratories .............................................................
37
6. Problem Identification and Prioritization ………….
40
B. Planning Phase ……………………………………………………..
43
C. Implementation Phase …………………………………………….
53
D. Evaluation Phase ……………………………………………………..
63
CHAPTER IV
A. Summary .........................................................
……………………. 67
B. Conclusion ...........................................................................
68
C. Recommendation
........................................................................... 69
Bibliography …………………………………………………………………………
70
Appendices
Letter of Intent …………………………………………………..……. 71
Consent Letter ……………………………………………………..…. 72
Health Teaching Plan ……………………………………………………....
73
Virginia Henderson’s 14 Fundamental Needs Assessment
Tool….... 81
Gordon’s 11 Functional Health Patterns Assessment
Tool…………... 82
Dillon’s Physical Assessment Tool ……………...……………..... 83
Insomnia Severity Index
.................................................................... 88
LIST OF FIGURES
Figure 1. Anatomy of the Liver ..............
………………………………………. 5
Figure 2. Micrograph of Hepatic Adenoma ………………………………...6
Figure 3. Virginia Henderson ………………………………………………… 10
Figure 4. Virginia Henderson’s 14 Fundamental Needs Theory as
applied to
Maslow’s Hierarchy of Needs ……………………………………….
17
Figure 5. The Nursing Process Flow Chart ………………………………. 18
LIST OF TABLES
Table 1. Assessment Utilizing Faye Abdellah’s 21 Nursing Problems
…….. 25
Table 2. Gordon’s Functional Health Pattern Assessment ………………
27
Table 3. Dillon’s Physical Assessment Tool …………………………………
30
Table 4. Laboratories ………………………………………………………….. 37
Table 5. Drug Study …………………………………………………………………..
38
Table 6. Prioritized Nursing Problems ………………………………………..
40
Nursing Care Plans
7.a. Acute pain related to trauma to skin, tissues and nerves
(incision site)…………………………………………………………. 43
8.a. Impaired skin integrity related to surgical site incision ………
45
9.a. Risk for infection related to presence of surgical wound
……… 47
10.a Constipation related to low fiber diet and inactivity
……………… 49
11.a. Knowledge deficit related to unfamiliarity of disease
condition 51
NIC Activity List
7.b. Acute pain related to trauma to skin, tissues and nerves
(incision site)…………………………………………………………. 44
8.b. Impaired skin integrity related to surgical site incision ………
46
9.b. Risk for infection related to presence of surgical wound
……… 48
10.b Constipation related to low fiber diet and inactivity
……………… 50
11.b. Knowledge deficit related to unfamiliarity of disease
condition 52
Implementation Phase
12.a. Acute pain related to trauma to skin, tissues and nerves
(incision site)…………………………………………………………. 53
12.b. Impaired skin integrity related to surgical site incision
……… 54
12.c. Risk for infection related to presence of surgical wound
……… 55
12.d. Constipation related to low fiber diet and inactivity
.......... 56
12.d. Knowledge deficit related to unfamiliarity of disease
condition 57
Table 13. Progress Notes ………………………………………………………….
58
Table 14. Evaluation …………………………………………………………………..
63
Table 15. Health Teaching Plan …………………………………………………
73
Patient’s Name: Alarde, H.J.
Diagnosis: Cystic Hepatic Adenoma
COMPLIANCE SHEET
SUGGESTIONS/REVISIO
REMARKS PAGE
NS
1. Add insights on
background of the Done Page 2
study
2. Restate specific
Done Page 8
objectives
3. Discuss Gordon’s 11
Functional Health
Pattern and Dillon’s Done Page 15-16
Physical Assessment
Tool
4. Include genogram Done Page 24
5. Revisit Gordon’s 11
Fiunctional Health
Pattern and come up
with written Done Page 27-29
comprehensive
descriptions of the
systems involved
4. Justify findings on
Dillon’s Physical Done Page 31 - 35
Assessment Tool
5. SLEEP PATTERN
NCP???
Submitted by:
Dino Loie T. Rebollos, R.N.
