COLLEGE OF ST.

JOHN – ROXAS
De La Salle Supervised
Gov. Atila Balgos Ave., Banica, Roxas City
5800 Capiz, Philippines

Nursing Case Study

I. Student’s Profile
Name: Charles Dorado
Kevin James Fenequito
Justine Carl Relano
Jeandra Bandejas
Roshel Besana
Rolyn Dacumos
Julia Marie Delfin
Sophia Mae Delfin
Rovimae Teves
Maria Rose Ann Yee

Year Level: II

Course: BSN

Clinical Instructor: Sir Dennis Machado Jr. RN, MAN

Area of Exposure: The Health Centrum Hospital, Teodorico Atila Balgos Ward

II. Introduction
 Objectives:
a. General objective
 Nursing students will perform basic procedures such as vital signs

taking and to have an exposure to clinical context. And also

nursing students perform the basic skills and procedure with

freedom and competence, and manifest positive and desirable

attitudes necessary in dealing with the staffs.

b. Specific objective
Knowledge
1. To identify patient needs necessary for nursing intervention.
2. To familiarize basic procedure in clinical context.
3. To determine Do’s and Dont’s in the hospital

Skills

1. To demonstrate a variety of caring, interactions within the

clients and patient.

2. To apply all the learning in clinical exposure.
3. To perform correct procedures such as vital signs taking.

Attitudes
1. To show the Lasallian values in the clinical context
2. To encourage patients participation in the health care process.
3. To influence positivity despite of circumstances and illness.

III. Biographical data

Name: Almosara Ma. Kristina
Address: Roxas City
Age: 25 years old
Birthdate: December 25, 1993
Birthdate: Roxas City
Gender: Female
Marital Status: Single
Religion: Catholic
Educational Level: College Graduate
Occupation: Asst. Manager
Nationality: Filipino
Person next to Kin (Optional):
Date and time of admission: 5/31/19
Area of admission: Teodorica Atila Balgos Ward
Attending Physician (Initial): Dr. O. M.
 Admitting Diagnosis: Calculous Cholecystitis
Principal Diagnosis: Calculous Cholecystitis
Sources (Primary/Secondary Data): Secondary data

IV. Nursing Health History

A. Reason for seeking

Client M.K.A. seek medical attention with the following Chief Complaint:
Severe abdominal pain. Her parents brought her to the hospital. The initial

diagnosis upon diagnosis: Calculous Cholecystitis.

History of present history
Patient M.K.A was brought to The Health Centrum Hospital beacause of chief

complaint severe abdominal pain.

Past health history
Patient M.K.A stated that, “ wala man”
Family history

Hereditary Diseases Paternal Maternal

Diabetes
Gall stone  

Environmental history
According to the client, she is living in the city side.
Medication and substance use
Patient stated, “ indi ko na matandaan kung ano ang pangalan sang bulong pero

mostly pain reliever man sya.”

V. Anatomy and Physiology

 Focus only on the affected body part/system (Reference/s)

VI. Pathophysiology (Please include reference/s) CREATE CONCEPT MAP

 Predisposing/precipitating factors
  Disease process
 Signs and symptoms (Manifested and not manifested by the patient)
 Complication

VII. Physical Assessment

 Head to toe assessment (Cephalocaudal)
 Documentation: By System or Review of System –follow format from health

assessment

Area of 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: 37.7 C

Pulse/ Cardiac Rate: 85 b/min

Respiratory Rate: 13

Blood Pressure: 120 /80

Oxygen Saturation: 97%

Pain: (Pain Scale) 0

B. General Survey

Appearance

The 25 year old female patient appears to be alert & oriented, facial features are

symmetric; no deformities observed, free from emotional discomfort, no signs of acute

distress, presentable and able to fix herself.

Body structure/mobility

Weight and Height is within normal range, with the BMI of 24.5-Normal. Body parts are

bilaterally equal; able to stand and sit comfortably with assistance; walk is smooth and

well balanced; partial mobility of joints due to operation.

Behavior

Actively answers questions, maintains eye contact with appropriate expressions;

comfortable and cooperative; speech clear; clothing appropriate; looks clean; appears

well-groomed, calm and stays awake.

Body Parts Inspection Palpation Percussion Auscultation

A.Hair the hair of the client is

thick, silky hair is

evenly distributed and

has a variable amount

of body hair. There are

also no signs

of infection and

infestation observed.
B.Nail The client has a light

brown nails and has the

shape of convex curve.

It is smooth and is

intact with the

epidermis. When nails

pressed between the

fingers (Blanch Test),

the nails return to

usual color in less than

4 seconds.
C.Head and Face The head of the client

is rounded;

normocephalic and

symmetrical.

The face of the client

appeared smooth and

 has uniform

consistency and with

no presence of nodules

or masses
D.Neck Positioned at the No masses .

midline without palpated.

tenderness and flexes

easily.
E.Ears The Auricles are When palpating

symmetrical and has for the texture,

the same color with his the auricles are

facial skin. The auricles mobile, firm and

are aligned with the not tender.

outer canthus of eye.

F.Eyes
The pupils of the

eyes are black and

equal in size. The

iris is flat and

round. PERRLA

(pupils equally

round respond to

light

accommodation),

illuminated and

non-illuminated

pupils constricts.
 Pupils constrict

when looking at

near object and

dilate at far object.

Pupils converge

when object is

moved towards the

nose.

G.Mouth and
The lips of
Throat
the client

are

uniformly

pink;

moist,

symmetric

and have a

smooth

texture.

The client

was able to

purse his

lips when

asked to

whistle.
H.Nose The nose appeared When lightly

symmetric, straight and palpated, there

uniform in color. There were no

was no presence of tenderness and

discharge or flaring. lesions

I.Thorax and The chest wall is intact
The client
Lungs with no tenderness and
manifested
masses.
quiet,

rhythmic and

effortless

respirations.

J.Breast

K.Abdomen The abdomen of the

client has an blemished

skin and is not uniform

in color.
L.Genitalia

M.Upper

Extremities and

Lower Extremities
VIII. Diagnostic Test

Diagnostic Test Result Normal Values Interpretation Implica

Ultrasound
HBT (Liver)  Not enlarged  Normal liver  Chole
 Borders are well defined
with dilated with
 Parenchyma have
intrahepatic chole
homogenous echoe
ducts
pattern  Dilated
 Intrahepatic ducts are
common bile
dilated measuring 0.81 –
duct with
0.95 cm
 There is a high intensity distal
echoe with posterior choledochol
sonic shadowing in the ethiasis
distal emd of common
bile duct
 Portal veins measures
0.84- 0.86 cm
 There is no fluid in the
morison’s pouch

 The gallbladder
(Gallbladder)
measures approximately
6.95x3.63x4.34 cm. with
a volume of 54.46 ml
 The gallbladder wall
 measures approximately
0.42 – 0.70 cm in
thickness
 There are intraluminal
high intensity echoes in
the gallbladder neck
measuring 0.35-0.66 cm.

0.5769 mg/dL

141.8 mmol/L

Creatinine 0.5 to 1.0 mg/dL  Normal  Norm

3.64 mmol/L
creatinine kidne
level
Sodium 135-148 mmol/L  Normal
 Norm
sodium level
kidne

 Norm
Pottasium 3.5-5.3 mmol/L  Normal
kidne
sodium level

XIII. ACCOMPLISHMENT REPORT

The thing about a first experience is that, it may have been daunting or challenging since

you get to do a lot of things that you haven't done before, but it also gives you that

satisfaction of being able to surpass it and learning a few things that is yet to be unfold.

During our first RLE duty at The Health Centrum, we can't help but feel a myriad of

emotions. To be honest, we are feeling a bit nervous since we didn't know what to expect

but at the same time, we also felt excited because this would be our first time in the field.

Of course, as a first timer, you couldn't help but feel clueless unto what type of problem

you will be facing, or you wouldn't know what type of people you are going to encounter.

So that's why you should prepare yourself emotionally, mentally, and physically to the

challenges that awaits you.Yes, this could be quite a nerve wracking experience, so the

first thing to do is PRAY and act normal when you're in front of the patients and the folks.

Indeed its true when they say experience is the best teacher. Because during our duty to

our designated patients, there, we were able to get to know them, the different cases of

ailments each of them have, and even on how to handle different types of people with

different types of attitude that we encounter.

One thing to keep in mind in this type of work is that, whatever type of person you

encounter each day, learn how to adjust to them. Each people have a story to tell and

sometimes it's easy to let our emotions get the better of us, but then, it is also our job to

have unlimited PATIENCE FOR THE PATIENTS. We never know what they really feel

and the best thing we could do aside from taking care of them is to give them a sense of

sympathy and hope from our positive mindset in life. Being a nurse is definitely not a bed

of roses. And seeing what they do now is just a perspective from the tip of the iceberg.
No work is easy. Everyday we encounter challenges and difficulties. And this experience

made us realize that being a nurse is really a tough job. You have to check the charts

related to the patients, taking care of them every minute, and making sure your

observations are accurate because their lives depends on us.

We also experienced not being able to sit for hours. But we know that this is still a part of

our training so that, we will be prepared if ever we start our actual work in this field. No

matter how tiring this first experience was for us, at the end of the day, we were still

thankful for the opportunity that was given to us and the learnings we acquire that is

surely benificial to us and for the next challenges that we are about to encounter. Because

of the sense of satisfaction and fulfillment it gives to us that we are able to help

nonetheless.

References

 Nurseslabs. (2019). 4 Cholecystitis and Cholelithiasis Nursing Care

Plans.https://nurseslabs.com/4-cholecystitis-cholelithiasis-nursing-care-plans/2/
 Idgateway.wustl.edu. (2019). http://idgateway.wustl.edu/normal%20lab

%20values.pdf
 Emedicine.medscape.com. (2019).Cholecystitis:practice essentials, background,

pathophysiology. https://emedicine.medscape.com/article/171886-overview
 Nurseslabs. (2019). Free cheat sheet: head-to-toe physical assessment for nurses.

https://nurseslabs.com/nursing-assessment-cheat-sheet/