RNSG 1262 Nursing Case Study
Student Name: _________________________________________ Dates of Care: _______________________
Client Initials: ________ Gender: _____ Age: ____ RM# _____ Med Team/MD: ___________________
Admitting Diagnosis: _______________________________________________ Date of Admission: __________________
Concurrent Diagnoses: ___________________________________
Surgery: ________________________ Date: ______________
Allergies to Drugs or Foods: _____________________ Advanced Directives / Code Status: ______________
Therapeutic Modalities/ MD Orders:
Data Collection Day Clinical Day 1 Clinical Day 2
Vital Signs/SpO2: Frequency
I & O/ Fluid Restrictions
Diet
Scheduled Diagnostics
Activity Level
Dressing Change Orders
Resp. Therapy
Physical Therapy
Daily Weights
SCD, TEDS, CPM
Accuchecks
Daily Labs:
Other Treatments:
Summaries of Progress Notes:
Doctor’s Doctor’s Nurse’s Nurse’s
Data Collection Day Data Collection Day #1 Data collection Day Data Collection Day #1
and or Day #2 and/or Day #2
Pathophysiology of Admitting Diagnosis:
Pathophysiology of Concurrent Diagnoses:
Description of Surgical Procedures:
Lab Data Sheet - highlight abnormals
Labs/X-rays/Dx Normal Date Date Date Correlation to Pathophysiology: Interpret results as well as correlating
Tests Results Range Result Result Result with the client’s medical condition:
Complete Blood Count:
WBC 3.6-11.0
RBC 4.5-5.90
Hg 13.5-17.5
Hct 41-53
Platelets 150-450
ESR N/A
Differential
Other:
MCV 30-98
MCH 26-34
MCHC 31-37
RDW 12.0-14.6
Mean Platelet 6.8-10.2
Chemistry:
Na 135-145
K 3.5-5.1
Cl 94-106
Glucose 60-100
Total Protein 6.2-8.1
Albumin 3.5-5.0
CO2 20-29
BUN 7-25
Cr 0.7-1.60
Calcium 8.2-10.3
Other:
Bilirubin Total 0.2-1.2
Bilirubin Direct 0.0-0.4
ALT 0-35
AST 0-38
Mg 1.6-2.2
Phos 2.4-4.6
Alk Phos 32-108
Lactic Acid 0.5-2.2
(Plasma)
Anion Gap 5-19
Coagulation Studies:
INR 0.8-1.2
PT 22-37
PTT
Urinalysis:
Clarity ------
Color -----
Bilirubin Negative
Blood Negative
Glucose Negative
Ketones Negative
Leukocytes Negative
pH 5-8
Protein Negative
Sp Gravity 1.001-
1.035
Urobilonogin 0-1mg/dL
Microscopic:
WBC 0-5 HPF
RBC 0-5 HPF
Epithelial 0-5 HPF
Bacteria 0-450
HPF
Casts 0-1
UDS
Amphetamine Negative
Barbituate Negative
Benzodiazapine Negative
Cannabinoids Negative
Opiates Negative
PCP Negative
Cocaine Negative
Arterial Blood Gases:
pH 7.35-7.45
PCO2 32-48
PO2 83-108
O2 sat -----
HCO3 21.0-28.0
Culture & Sensitivity:
note source/growth and sensitivity
Exudate Culture -------
Gram Stain --------
Fungal Calcaflour --------
Radiological Studies:
X-Ray - Chest
Sonogram
Extremity
CAT Angiograph
EKG:
Diagnostic Tests: describe results
Vancomycin ------
Level
Blood Antibody
Screen
Immunology
Hep B- Antigen Non Reactive
Hep B- Antibody Non Reactive
Hep A Non Reactive
Hep C Non Reactive
Trade Name Pharmacological Class Dose/Route Rationale for this client Major Side Effects Nursing Implications for
Safe Administration and
Generic Name Mechanism of Action Max Dose Evaluation of Therapeutic
Effects
Trade Name Pharmacological Class Dose/Route Rationale for this client Major Side Effects Nursing Implications for
Safe Administration and
Generic Name Mechanism of Action Max Dose Evaluation of Therapeutic
Effects
Trade Name Pharmacological Class Dose/Route Rationale for this client Major Side Effects Nursing Implications for
Safe Administration and
Generic Name Mechanism of Action Max Dose Evaluation of Therapeutic
Effects
Trade Name Pharmacological Class Dose/Route Rationale for this client Major Side Effects Nursing Implications for
Safe Administration and
Generic Name Mechanism of Action Max Dose Evaluation of Therapeutic
Effects
Trade Name Pharmacological Class Dose/Route Rationale for this client Major Side Effects Nursing Implications for
Safe Administration and
Generic Name Mechanism of Action Max Dose Evaluation of Therapeutic
Effects
Trade Name Pharmacological Class Dose/Route Rationale for this client Major Side Effects Nursing Implications for
Safe Administration and
Generic Name Mechanism of Action Max Dose Evaluation of Therapeutic
Effects
Physical Assessment - Data Collection Day
Neurosensory Musculoskeletal Respiratory
Level of Consciousness: Motor Strength: 0 = complete paralysis, 1= flicker of Respiratory Rate: ____
Alert: Oriented: Confused: Lethargic: movement, 2 = overcome gravity, 3 = 50% of normal Pattern: _____ Normal _____ Shallow _____
Unresponsive: to Verbal stimuli Y N 4= 75 % of normal strength, 5= 100% of normal Rapid_____ Labored_____
Painful Stimuli: Y N strength Cough: Non –Productive ___ Productive ___
Glasgow /coma Scale Rating (if needed) ______ RUE ____ LUE ____ RLL ____ LLE ____ Describe:___________________________________
Disoriented: Person Place Time ___________________________________________
Behavior: _________________________ Describe:__________________________
Chest inspection (expansion, deformities): _________
Communication/Speech Pattern: ______________ Mobility: ____________________________ ___________________________________________
___________________________________________ ___________________________________________
Pupil size: Rt. ______ Lt. ______
Reaction: __________ ROM - L= Limited Use of accessory muscles: yes ___ no: __
Vision Impairment: Y N Lung Sounds: 1 = clear, 2 = diminished, 3 = crackles,
Activity/ Restrictions: _________________________ 4 = rhonchi, 5 = wheezing, 6 = friction rub.
Describe: ___________________________________ ___________________________________________
RUL ___ RML __ RLL _____ LUL ___
Risk for Fall: : Y N LLL_____
Glasses: Y N
Use of Assistive Devices: O2 saturation: Room Air:___ ______
Sensation: Intact Losses
___________________________________________ On Oxygen Therapy:________
Describe:___________________________________
___________________________________________
______________________________
Hearing loss: : Y N
Describe:___________________________________
History or current alterations affecting this system:
History or current alterations affecting this system: History or current alterations affecting this system:
Sedative medications
Possible Nursing Dx:
Possible Nursing Dx: Possible Nursing Dx:
Cardiovascular: Gastrointestinal Genitourinary
Apical pulse: ____ Abdomen: distended non-distended Patterns: continent ___ incontinent ___ nocturia___
Rhythm: regular irregular Bowel Sounds: describe as A = absent, N = normal, ___ frequency ___ urgency ___ dysuria _____
Heart Sounds: Aortic _____Pulmonic ______ HA= hyperactive, HO= hypoactive urinary retention ___
Tricuspid _____Mitral ______ ___ RUQ ___RLQ ___LUQ ____LLQ
Describe abnormalities: ______________________ Appearance: clear ___ cloudy ___yellow
___________________________________________ Last BM: __4/10/11___(date) ___ pink ___ amber ____bloody____
diarrhea _____ constipation ____ normal__x___
Capillary Refill: < 3sec > 3 sec. Catheter: : Y N
Ostomy: Y N Type-____________________________________
Pulses: describe as 0 = absent, 1 = doppler, 2 = weak, Type/describe fistula: _________________________
3 = normal and 4 = bounding __________________________________________ 24 hour I&O______________________________
___RR __LR ____RDP ___LDP ___ RPT ___LPT N/G decompression: : Y N
Describe:
Dialysis Shunt: : Y N Condition: _______ ___________________________________________
___________________________________________ ___________________________________________
Feeding tube/PEG: : Y N
Homan’s sign: ____ Positive ____ Negative N/A Feeding type/rate: ____________________________
Patency/Residual:____________________________
Edema: describe as 0=none, 1+= barely detectable, 2+
indentation, 3+ indentation, 4+ indentation = > 10mm History or current alterations affecting this system: History or current alterations affecting this system:
RUE ____ LUE ____ LLE ____ RLE _____
Periorbital_____ Sacral______
JVD: : Y N
History or current alterations affecting this system:
Possible Nursing Dx:
Possible Nursing Dx:
Possible Nursing Dx:
Integument Nutrition Pain Assessment (describe)
Temp: ___warm, ___hot, ___cool Adm. Weight: ________ Type of Pain: Acute______ Chronic____
Moisture: ___dry, ___moist, ___diaphoretic Current Weight:_______
Color: ___normal, ___ pale, ___ cyanotic, ___ Ideal Body Weight:____ Location: ________________________
flushed ___ History of Weight loss: ________________________
Other (describe)______________________________ ___________________________________________ Intensity/Rating:_____________________________
Skin Condition:_____normal__________________
___________________________________________ Diet History: ___ _____________________ Pattern: ____________________________________
___________________________________________
Incision/wounds: ___________________________________________ Nature : ______________
(describe)___________________________________ ___________________________________________
___________________________________________ Appetite:____ _________________________ ___________________________________________
_____________________________ ___________________________________________
Percent of meal eaten: Breakfast:________
Dressing Lunch:_________ Dinner: _________
Orders:______________________________ Snacks:_____________________________________
___________________________________________
___________________________________________ Describe condition of teeth/denture/oral mucosa:
___________________________________________
Braden Scale Score: _____ ___________________________________________
PUSH Tool Score: __________ ___________________________________________
Other: _____________________________________
Blood glucose monitoring:
Reading/time ______________
Reading/time_____________
History or current alterations affecting this system: History or current alterations affecting this system:
History or current alterations affecting this system:
Possible Nursing Dx:
Possible Nursing Dx:
Possible Nursing Dx:
List all scheduled, prn, and IV medications
Physical Assessment - Data Collection Day of Care# 1 Vital Signs:__________________________
Neurosensory Musculoskeletal Respiratory
History or current alterations affecting this system: History or current alterations affecting this system: History or current alterations affecting this system:
Possible Nursing Dx: Possible Nursing Dx: Possible Nursing Dx:
Cardiovascular: Gastrointestinal Genitourinary
History or current alterations affecting this system: History or current alterations affecting this system: History or current alterations affecting this system:
Possible Nursing Dx: Possible Nursing Dx: Possible Nursing Dx:
Integument Nutrition Pain Assessment:(describe)
History or current alterations affecting this system: History or current alterations affecting this system: History or current alterations affecting this system:
Possible Nursing Dx: Possible Nursing Dx: Possible Nursing Dx:
Wound / Surgical Incision Assessment:
Assessment Wound #1 Wound #2 Wound #3
Type of wound
and Stage
Location
Length
Width
Depth
Drainage
Odor
Undermining /
Tunneling
Wound bed
tissue type
Factors affecting wound healing:
Miscellaneous Information:
Physical Assessment - Data Collection Day of Care# 2 Vital Signs:___________________________
Neurosensory Musculoskeletal Respiratory
History or current alterations affecting this system: History or current alterations affecting this system: History or current alterations affecting this system:
Possible Nursing Dx: Possible Nursing Dx: Possible Nursing Dx:
Cardiovascular: Gastrointestinal Genitourinary
History or current alterations affecting this system: History or current alterations affecting this system: History or current alterations affecting this system:
Possible Nursing Dx: Possible Nursing Dx: Possible Nursing Dx:
Integument Nutrition Pain Assessment:(describe)
History or current alterations affecting this system: History or current alterations affecting this system: History or current alterations affecting this system:
Possible Nursing Dx: Possible Nursing Dx: Possible Nursing Dx:
Wound / Surgical Incision Assessment: Document changes for day two.
Assessment Wound #1 Wound #2 Wound #3
Type of wound
and Stage
Location
Length
Width
Depth
Drainage
Odor
Undermining /
Tunneling
Wound bed
tissue type
Factors affecting wound healing:
Miscellaneous Information:
Assessment Data: Psychosocial/ Cultural
Stressors: Behaviors/Coping Strategies
Identified culture/ethnicity Religion Occupation Family Role
Developmental Task: Understanding of Illness/Treatments
Clients Developmental Task According to Erikson:
Describe if the client has/has not achieved their developmental task.
Include positive/negative resolution and justify your conclusion.
Community Referral
Psychosocial Diagnosis:
Nursing Dx Priority_1__
Hospital Outcome/Goal: Nursing Interventions: Scientific Rationale Evaluation
Designate I: independent D: dependent (Specify as goal met/unmet/or
C: collaborative/interdependent partially met)
Nursing Diagnosis/Analysis:
Correlation to Patho or Psycho-physiology
Discharge Goal: Teaching Plan:
Nursing Dx Priority___ Hospital Outcome/Goal: Nursing Interventions: Scientific Rationale Evaluation
Designate I: independent D: dependent (Specify as goal met/unmet/or
C: collaborative/interdependent partially met)
Nursing Diagnosis/Analysis:
.
Correlation to Patho or Psycho-physiology
Discharge Goal: Teaching Plan:
Nursing Dx Priority____ Hospital Outcome/Goal: Nursing Interventions: Scientific Rationale Evaluation
Designate I: independent D: dependent (Specify as goal met/unmet/or
C: collaborative/interdependent partially met)
Nursing Diagnosis/Analysis:
Correlation to Patho or Psycho-physiology
Discharge Goal: Teaching Plan:
Dx Priority____ Hospital Outcome/Goal: Nursing Interventions: Scientific Rationale Evaluation
Designate I: independent D: dependent (Specify as g
C: collaborative/interdependent partially met)
Diagnosis/Analysis:
on to Patho or Psycho-physiology
e Goal: Teaching Plan:.
