CENTRO ESCOLAR UNIVERSITY

Department of Nursing

FUNDAMENTALS OF NURSING

CASE STUDY 3 -- CLINICAL CASE STUDY

ASSESSMENT

NURSING HEALTH HISTORY Personal

Data

Ms. Y is a 26-year-old female. She lives at Las Piñas City. She stands 5'4" tall and
weighs 115 pounds. Ms. Y is the eldest among 4 siblings. The client's father is a retired
accountant while her mother is a college professor in a prestigious university. She is a
Roman Catholic and was born on February 22, 1984. She is a call center agent in Ortigas.

Chief Complaint

"I feel so weak and wobbly that I can't get up from bed to go to work" as verbalized by the
client.

History of Present Illness

The client has been reporting to work from 12mn to 8am a week prior to admission.
Ms. Y gets home by 10am and does household chores. She was able to get some sleep at
around 5pm and wakes up at 8pm to prepare for work.

The client experienced lingering headaches 2 days prior to admission. She was
relieved by a pain reliever which she has been taking every 4 hours 1 day prior to
admission. 4 hours prior to admission, she felt body weakness and headache which
prompted her to seek consultation at Las Piñas Doctor Hospital.

Upon admission, her body temperature is 37.8 °C and appears to be pale and weak.

Past Medical History

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 Ms. Y has no known food or medication allergies. As far as she can remember, she
has completed all her vaccines when she was in grade 3. She had undergone appendectomy
when she was a 3rd year high school student.

Family Health History

There is no heredo-familial disease from both parents according to Ms. Y.

Social History

Ms. Y has irregular working hours as a call center agent, depending on the schedule
given to her. She reports to work from 11 pm to 7am of the next day most of the time. She
helps with the household chores first when she gets home from work and cooks lunch for
her father. She goes to sleep the earliest at 3pm. She needs to wake up at 7pm to start
preparing for work. She needs to allot 2 hours of travel time going to her workplace.

Review of Systems PSYCHOLOGICAL

The client says she is a very hardworking person. She is happy with her life even
though she is single. She feels really very weak.

Ms. Y values her family the most, she works and earn for herself and she helps in the
finances of their family. She sends her 2 nieces to a public school. Her parents share in
decision-making for their family. She earns 18,000 PHP every payday.

She is an active lector of their Parish Church. She serves every Sunday mass and
holy days of obligation. They immediately bring their family member to the hospital for
consultation when someone of their family member is sick.

She has no hearing and visual difficulty. She just feels so weak and tired. She
manages stress by going out with friends, barhopping or hanging out with them the whole
night. She simply enjoys conversation with her friends though she is not an alcohol drinker.

She had several boyfriends but she hasn’t found the right one yet. She is in a
relationship with a co-call center agent at present. They had been together for 6 months
already.

Their family pays particular attention to one's health that they take vitamin
supplements regularly and immediately seeks consultation as soon as they get to feel
something unusual in their system. All of their family members have health insurance.

FUNDAMENTALS OF NURSING BSN1AS1

Elimination

Ms. Y urinates four to five times a day with approximately 550 cc. She does not
experience any pain or discomfort. She defecates once a day, every morning. The client do
not perspire excessively.

REST AND ACTIVITY

She rests during her day off only which is one day within a week. She spends her
whole day chatting with her friends in the internet. She approximately gets a minimum
sleep of 4 hours a day.

SAFE ENVIRONMENT

Ms. Y lives in an exclusive subdivision in Las Piñas. The place is peaceful and safe.

OXYGENATION

Ms. Y gets tired easily according to her. It is easier for her to breathe when seated.
She puts pillows under her head and back to be able to breathe easier.

NUTRITION

She often eats vegetables because she wants to maintain her body figure. She
sometimes skips meals when she has a lot of work to do. She takes vitamin supplements
and Stress tabs regularly.

24 HOUR DIET RECALL

Dinner: She bought a McChicken Sandwich meal with a Large Fries and Coke and ate it
inside the taxi on her way to work.

Breakfast: She was not able to eat breakfast because she gets home almost lunch time
already and she

gets pre-occupied with the household chores. Lunch: She had small bowl of a vegetable
salad.

PHYSICAL ASSESSMENT

General Appearance

She has a medium-frame boy built and has an upright posture. She walks with a
smooth rhythmic gait. She looks weak and tired. She is appropriately dressed and

FUNDAMENTALS OF NURSING BSN1AS1

well-groomed. She has no obvious physical deformity. There is the presence of insect bites.
She stands 5'4" tall and weighs 115 pounds. She has the following vital signs: temperature
is 37.8 ° C, respiratory rate of 20 breaths per minute, cardiac rate of 85 beats per minute
and her blood pressure is 120/80.

Mental Status

She is conscious and coherent. She is well-oriented of the time, place, and person she
is with.

Skin

She has a brown skin color. Skin is warm and smooth to touch, turgor is elastic and
mobile and hair is evenly distributed.

Hair

She has black and shiny hair. Her hair is thick and evenly distributed. There are no
infestations and infections present on her head but there is a presence of flakes in her scalp.

Nails

Ms. Y has pale nail beds. Her nails are long and have a blue nail polish on it that's
why capillary refill is not observed. Her nail plate shape is convex 160 and has a smooth
texture.

Head and Face

Her skull is proportionate to her body size. Her face is symmetrical and her face
moves easily.

Eyes

She has straight normal eyes. There are no fallen eyelashes or eyebrows observed
and blink response is present. Eyeballs are symmetrical and firm. Her sclera is white and
pupils are 2-3 mm in diameter. The client is able to see objects clearly that are 20 feet away.
She has pale conjunctiva and moist lacrimal apparatus.

Ears

Her ears are of normal racial tone. The pinna recoils when folded. It is elastic and
non-tender. There is presence of some cerumen on the external canal. She responds to
whispered voice.

FUNDAMENTALS OF NURSING BSN1AS1

Mouth and Oropharynx

Her lips are symmetrical but pale. Her tongue rests at midline. Oral mucosa is pink
in color. Her hard palate and soft palates are intact. The uvula is located in the midline and
her tonsils are not inflamed. Her gag reflex is present and she has a complete tooth.

Nose

Her nose is of normal racial tone. Septum is located in the midline and her nostrils
are both patent. Sinuses are not tender and there are no nasal secretions.

Neck

The client has a strong neck muscle. Trachea is located in the midline. Thyroid gland and
lymph nodes are not palpable.

Breast and Axilla

She has asymmetrical breasts and no masses observed and palpated.

Chest and Lungs

She has regular breathing pattern. Lung expansion is symmetrical both in anterior and
posterior. Normal breath sounds are heard on auscultation. She does not use accessory
muscle when breathing.

Abdomen

She has a normal racial tone abdomen and is flat. Bowel sounds were heard and is within
the normal range. Her bladder is not distended.

Upper and Lower Extremities

She has strong and firm muscles. Her muscle tone at present is poor. Lymph nodes are not
palpable and peripheral pulses are present.

Genitals

This part was not assessed.

FUNDAMENTALS OF NURSING BSN1AS1

 THE NURSING PROCESS: ASSESSMENT

Module 4 – Post-Task

CLUSTERING OF DATA

A. BODY SYSTEM/ PHYSICAL ASSESSMENT

Neurological ● Ms. Y said, “I feel so weak and wobbly that I can’t get
up from bed to go to work.”
● The client experienced lingering headaches 2 days
prior to admission.
● 4 hours prior to admission, she felt body weakness
and headache which prompted her to seek
consultation at Las Piñas Doctor Hospital.
Respiratory ● Respiratory rate of 20 breaths per minute.
● She has a regular breathing pattern.
● Lung expansion is symmetrical both in the anterior
and posterior.
● Normal breath sounds are heard on auscultation.
● She does not use accessory muscles when breathing.
● It is easier for her to breathe when seated. She puts
pillows under her head and back to be able to breathe
easier.
Cardiovascular ● Cardiac rate of 85 beats per minute and her blood
pressure is 120/80.
Abdomen and ● She had undergone appendectomy when she was a
Gastrointestinal 3rd-year high school student.
● She defecates once a day, every morning.
● The abdomen is flat.
● Bowel sounds were heard and are within the normal
range.

FUNDAMENTALS OF NURSING BSN1AS1

Renal ● Ms. Y urinates four to five times a day with
approximately 550cc.
● Her bladder is not distended.
Musculo-Skeletal ● She has a medium-frame body built and has an
upright posture.
● Her skull is proportionate to her body size.
● The client has strong neck muscles.
● She has strong and firm muscles.
● Her muscle tone at present is poor.
Skin ● There is the presence of insect bites.
● She has a brown skin color. Skin is warm and smooth
to the touch.
● Ms. Y has pale nail beds. Her nails are long and have
blue nail polish on them that’s why a capillary refill is
not observed.
● Her nail plate shape is convex 160 and has a smooth
texture.
● Appears to be pale.
● Turgor is elastic and mobile, and hair is evenly
distributed.
Head and Neck Head:
● There are no infestations and infections present on
her head but there is a presence of flakes on her
scalp.
Neck:
● The client has strong neck muscles.
Eye, Ears, Nose, and Throat Eyes:
● She has straight normal eyes.
● There are no fallen eyelashes or eyebrows observed
and a blink response is present.
● Eyeballs are symmetrical and firm.
● Her sclera is white, and her pupils are 23mm in
diameter.
● The client is able to see objects clearly that are 20
feet away.
● She has pale conjunctiva and moist lacrimal
apparatus.
Ears:
● She has no hearing and visual difficulty.
● Her ears are of normal racial tone.
● There is the presence of some cerumen on the
external canal. She responds to a whispered voice.

FUNDAMENTALS OF NURSING BSN1AS1

 ● The pinna recoils when folded. It is elastic and
non-tender.
Throat:
● The trachea is located in the midline. The thyroid gland
and lymph nodes are not palpable.
● Oral mucosa is pink in color.
● Her hard palate and soft palates are intact.
● The uvula is located in the midline and her tonsils
are not inflamed.
● Her gag reflex is present.
Nose:
● Her nose is of a formal racial tone.
● The septum is located in the midline and her nostrils ar
both patents.
● Sinuses are not tender and there is no nasal secretion.
Others: ● Upon admission, her body temperature is 37.8˚C,
and appears to be pale and weak.
● Her lips are symmetrical but pale.
● Her tongue rests at the midline.
● She stands 5’4 tall and weighs 115 pounds.

B. MASLOW’s HIERARCHY OF NEEDS

5 Self ● At 26, she has a job that pays Php18000 every payday which
-Actualization she uses for herself, family finances, and sending her 2 nieces
to school.
● As for her mental state, she is well-oriented about the time,
place, and person she is with.
● She is selfless as she values her family the most even
sacrificing herself by overworking.
4 Esteem ● She is an Active Lector of their Parish Church
● One of her top priorities is her family.
● Helps out with the finances.
● Maintains her body figure
● She is very hardworking.
● She is content with her life.
3 Love and ● She is happy with her life.
Belonging ● She values her family the most.
● She is an active lector of their Parish Church, and she serves
every Sunday mass and holy days of obligation.

FUNDAMENTALS OF NURSING BSN1AS1

 ● In terms of stress, she manages it by going out with friends,
bar hopping, or hanging out with them the whole night.
● She simply enjoys conversing with her friends, despite the
fact that she is not an alcohol drinker.
● She spends her whole day chatting with her friends on the
internet when it is her day off.
● She had several boyfriends though she hasn't found the right
one yet. She is currently in a relationship for 6 months now
with her co-call center agent.
2 Safety Needs ● Ms. Y lives in a peaceful and safe exclusive subdivision in Las
Piñas.
● She is a call center agent in Ortigas.
● She works and earns 18,000 PHP every payday for herself,
and she helps in the finances of their family.
● Their family is so concerned about their health that they take
vitamin supplements on a regular basis and seek medical
advice as soon as they notice something strange in their
system. Their entire family is covered by health insurance.
● Ms. Y has no known food or medication allergies. As far as
she can remember, she completed all her vaccines when she
was in grade 3.
● They immediately bring their family member to the hospital
for consultation when someone of their family member is
sick.
● According to Ms. Y, there is no heredo-familial disease from
both parents.
1 Physiologic ● Sleeps the earliest around 3 pm and wakes up at 7 pm.
● Allots 2 hours for travel time to get to work.
● There are times when she skips meals.
● Regularly takes vitamin supplements.
● She eats vegetables to maintain a good body figure.
● The minimum amount of sleep is around 4 hours.
● Resides in a subdivision where it is peaceful.

C. IDENTIFYING SUBJECTIVE AND OBJECTIVE CUES

SUBJECTIVE OBJECTIVE
● “I feel so weak and wobbly that I ● Vital Signs:
can’t get up from bed to work.” Temperature: 37.8°C
Respiratory Rate: 20 bpm
Cardiac Rate: 85 bpm

FUNDAMENTALS OF NURSING BSN1AS1

 ● The client experienced lingering Blood Pressure: 120/80
headaches 2 days prior to ● The client looks weak and tired
admission. and has no obvious physical
● The client felt body weakness and deformity.
headache 4 hours prior to ● The client completed all her
admission. vaccines at the age of 3 when she
● It is mentioned that she just feels so had an appendectomy.
weak and tired. And according to ● The client managed her stress by
her, she gets tired easily. going out with her friends.
● She puts pillows under her head and ● The client urinates four to five
back to be able to breathe easier. hours a day for approximately
● The client has no food or medication 550cc. She reports to work from
allergies. 11 pm to 7 am the next day most of
● The client manages her stress the time.
● She has no hearing and visual ● The client does not perspire
difficulty. excessively.
● She rests during her day off only ● The client’s skin is warm and
which is one day within a week. smooth to touch, and its turgor is
● She spends her whole day chatting elastic and mobile.
with her friends on the internet. ● There are no infestations or
● She sometimes skips meals when infections on the client’s head, but
she has a lot of work to do. flakes on her scalp can be seen.
● The client has pale nail beds and
has a convex 160. Nails are long
and have blue nail polish. That is
why capillary is not observed.
● The client has no fallen eyelashes
or eyebrows, and a blink response
is present.
● The client’s sclera is white, and the
pupils are 2-3 mm in diameter.
● The client is able to see objects 20
feet away. Her conjunctiva is pale,
and her lacrimal apparatus is
moist.
● The pinna recoils when folded. It is
also elastic and non-tender. There
is the presence of some cerumen
on the client’s external canal.
● The client’s lips are symmetrical
but pale.
● The client’s face is symmetrical,
and her face moves easily.
● The client’s muscle tone at present
is poor.

FUNDAMENTALS OF NURSING BSN1AS1

 ● The client’s sinuses are not tender
and there are no nasal secretions.
● Normal breath sounds are heard
on auscultation, and do not use
accessory muscles when breathing.
● The client has asymmetrical
breasts and no masses observed
and palpated.
● Bowel sounds were heard and are
within the normal range.

D. ORGANIZE THE DATA ACCORDING TO GORDON’s 11 FUNCTIONAL HEALTH

PATTERNS
Functional Health Pattern Pattern Description
Health Perception / Health Management Prior to admission:
● Takes pain relievers every 4 hours for
1 day before admission.
● Recalls completing all vaccinations
during 3rd grade.
● Undergone appendectomy during 3rd
year of high school.
● Immediately brings family members
to hospitals for consultations when
onsets of illness are observed.
● Takes vitamin supplements and
stress tabs regularly.
● Has no vices such as drinking.
● Admits to intermittent fasting.
● All family members have health
insurance.
● Attentive on health conditions of
family members.
● Lives in a peaceful and safe
subdivision.
During admission:
● Conscious and coherent.
● Concern for body weakness and
headache.
Nutritional Metabolic ● Eats more vegetables.
● Skips meals sometimes.
● Regularly taking vitamin
supplements and stress tabs.
For 24-hour diet recall:

FUNDAMENTALS OF NURSING BSN1AS1

 ● Skipped breakfast.
● Ate a small bowl of vegetable salad.
● Ate a McChicken sandwich meal with
large fries and coke for dinner.
During physical assessment:
● Height: 5’4 tall
● Weight: 115 lbs.
● Temperature: 37.8 ° C
● Respiratory rate: 20bpm
● Cardiac rate: 85bpm
● Blood pressure: 120/80
Physical appearance:
● Skin: Brown skin, warm and smooth
to touch.
● Hair: Black and shiny, thick, and
evenly distributed, flakes in the scalp
are present.
● Nails: Pale nail beds, long nails, have
blue nail polish. The nail plate shape
is convex 160.
● Head and face: Skull are
proportionate to body size, the face is
symmetrical, the face can move easily.
● Eyes: Straight normal eyes. No
dropped lashes or brows are seen,
blink reflex is present, eyes are solid
and round, can see things 20 feet
away clearly and lacrimal apparatus
is moist and pallid.
● Ears: Normal racial tone, pinna
recoils, it is elastic and tough. The
Exterior canal has some cerumen and
hears a whisper.
● Mouth and oropharynx: Lips are
symmetrical, the tongue is centered.
The oral mucosa is pink. Soft and
hard palates remain intact, tonsils are
not inflamed, the uvula is midline.
Teeth are complete and have gag
reflex.
● Nose: Nose is racial tone normal. The
septum is midline, nostrils are patent.
No nasal secretions and no sinus
tenderness.

FUNDAMENTALS OF NURSING BSN1AS1

 ● Neck: Has strong neck muscles. The
trachea is located in the midline. The
thyroid gland and lymph nodes are
not noticeable.
● Breast and axilla: Breasts are
asymmetrical, no masses observed
and noticeable.
● Chest and lungs: Have regular
breathing pattern, anterior and
posterior lung expansion is
symmetrical. Normal breath sounds
are heard, respiration is not assisted.
● Abdomen: Has flat and normal racial
tone abdomen, bowel sounds were
heard and are in the normal range.
The bladder is not swollen.
● Upper and lower extremities: Has
strong and firm muscles. Present
muscle tone is poor, lymph nodes are
not palpable and peripheral pulses
are present.
Elimination ● Urine: About 550 cc of urine is peed
every four to five times a day. Ms. Y
doesn’t feel any discomfort at all.
● Stool: She defecates once a day every
morning.
● Perspiration: She doesn’t sweat too
much.
Activity / Exercise ● Reports to work from 11 pm to 7 am
of the next day most of the time.
● Helps with the household chores.
● Cooks lunch for her father.
● 2 hours of travel time going to her
workplace.
Cognitive/Perceptual ● Conscious and coherent.
● Well-oriented of the time, place, and
person she is with.
● “I feel so weak and wobbly that I can’t
get up from bed to go to work.”
● Has no hearing and visual difficulty
and can respond to whispered voices.
● Has no visual impairment, can see
objects 20 feet away clearly.
● Feels tiredness and weakness.
● Feels very weak.

FUNDAMENTALS OF NURSING BSN1AS1

 ● Experienced lingering headaches for
2 days prior to admission.
● Gets tired easily.
● Easier to breathe when seated and
puts a pillow under the head and
back to aid in breathing.
Sleep / Rest ● Rests during her day off only which is
one day within a week.
● Spends her whole day chatting with
her friends on the internet.
● Approximately gets a minimum sleep
of 4 hours a day.
● Goes to sleep the earliest at 3 pm.
Self-perception / Self concept During assessment:
● She has good posture, moves with a
smooth and steady rhythm.
● Even she looks tired and weak, she
manages to dress and groom
appropriately.
Role Relationship ● Call center agent.
● Eldest among 4 siblings.
● Do household chores such as cooking
lunch for father.
● Helps manage and sustain family
finance.
● Sends 2 nieces to public school
● Is part of the decision-making in the
family along with parents.
● Single but is currently meeting with a
co-worker for the past 6 months.
Sexuality/Reproductive ● Has had several boyfriends.
● Currently in a relationship with a
co-call center agent.
● Not indicated if the current
relationship is heterosexual or
homosexual.
● The current relationship length is 6
months.
Coping / Stress Tolerance ● Resides in a safe environment.
● House in the subdivision is peaceful &
quiet.
● Manages stress by going out with
friends and bar hopping or hanging
out the whole night.

FUNDAMENTALS OF NURSING BSN1AS1

 ● Enjoys conversations with friends.
Values - Beliefs ● Religious affiliation is Roman
Catholic.
● Active lector in the Church.
● Serves in the Parish Church every
Sunday mass and holy obligations.
● Values family the most.
(NOTE: Type “ND” if no data given in the case scenario)

NURSING DIAGNOSIS: CASE SCENARIO

Module 5 – Post-Task

Actual Nursing Diagnosis:

Assessment Data Nursing Diagnosis Scientific Explanation

Subjective Data: Fatigue-related to sleep The patient is fatigable as

● “I feel so weak and deprivation manifested by the patient shows signs and
wobbly that I can’t body weakness, headaches, symptoms of difficulty in
get up from bed to and fever. performing her tasks which
work.” was directly verbalized by
● The client the patient during the
experienced assessment period.
lingering headaches According to the patient,
2 days prior to she feels weak and wobbly,
admission. and she can’t get up from
● The client felt body bed to work. As stated by
weakness and Enoka and Duchateau
headache 4 hours (2016), fatigue is defined as
prior to admission. a disabling symptom in
● It is mentioned that which physical and
she just feels so cognitive function is limited
weak and tired. And by interactions between
according to her, she performance fatigability
gets tired easily. and perceived fatigability.
Perceived fatigability is
Objective Data: derived from the sensations
● Vital Signs: that regulate the integrity of
Temperature: 37.8°C the performer based on the
Respiratory Rate: 20 maintenance of homeostasis

FUNDAMENTALS OF NURSING BSN1AS1

 bpm and the psychological state
Cardiac Rate: 85 of the individual. With this
bpm statement from Enoka and
Blood Pressure: Duchateau, along with the
120/80 data from the assessment,
we can conclude that the
patient experienced these
symptoms due to the
disruption of homeostasis
brought by a lack of rest and
sufficient nutrition due to
her activity and lifestyle in
which both categories affect
her integrity to accomplish
tasks.

References:
● ENOKA, R. M., &
DUCHATEAU, J.
(2016). Translating
Fatigue to Human
Performance.
Medicine & Science in
Sports & Exercise,
48(11), 2228–2238.

Risk Diagnosis:

Assessment Data Diagnosis Scientific Explanation

Subjective Data: Risk for Fall related to Defined by Doenges,

● “I feel so weak and injury as evidenced by the Moorhouse, & Murr (2019),
wobbly that I can’t weakness and headache Risk for Falls is susceptible
get up from bed to experienced by the client. to increased [risk for]
work.” falling, which may cause
● The client physical harm and
experienced compromise health. Risk for
lingering headaches falls can be a cause of acute,
2 days prior to even short-term situations
admission. that can affect any client
● The client felt body such as sudden dizziness,

FUNDAMENTALS OF NURSING BSN1AS1

 weakness and headaches, sleeplessness,
headache 4 hours insufficient automobile
prior to admission. restraints, recent use of
● It is mentioned that alcohol and other drugs,
she just feels so new medication, and so on.
weak and tired. And The signs and symptoms as
according to her, she evidenced in the patient
gets tired easily. show she has a high risk for
Objective Data: falling. According to her, she
● Vital Signs: feels so weak and wobbly
Temperature: that she can’t get up from
37.8°C bed to work. Two days prior
Respiratory Rate: to her admission, the client
20 bpm experienced lingering
Cardiac Rate: 85 headaches, these symptoms
bpm can already increase her
Blood Pressure: risk for falling. Based on
120/80 Dinges et al., (2005), sleep
● Her conjunctiva is loss, while neither a formal
pale. syndrome nor a disorder,
● The client looks has a serious consequence
weak and tired and for health, performance, and
has no obvious safety. Based on the
physical deformity. assessment data that was
● She approximately gathered and the definition
gets a minimum of risk for fall, the patient's
sleep of 4 hours a poor sleep pattern, body
day. weakness, wobbly feeling,
pale conjunctiva, and fever
is a risk factor for fall that
can lead to injuries to an
individual in which this
factor is evident by the
client.

References:
● Doenges, Moorhouse,
and Murr. (2019).
Risk for falls. Nurse’s
Pocket Guide 15th
Edition.
● Institute of Medicine
(US) Committee on
Sleep Medicine and

FUNDAMENTALS OF NURSING BSN1AS1

 Research; Colten,
Altevogt. (2005).
Sleep Disorders and
Sleep Deprivation: An
Unmet Public Health
Problem.

Health Promotion / Wellness Diagnosis:

Assessment Data Nursing Diagnosis Scientific Explanation

Subjective Data: Readiness for Enhanced According to Jensen and Herr

● It is mentioned that Sleep 1993, sleep is an essential
she just feels so component of health, affecting
weak and tired. And the well-being and quality of life
according to her, she of individuals. This means that
gets tired easily. lack of sleep can cause tiredness
● She has an unhealthy and wobbly which Ms. Y has
sleeping pattern been experiencing. Lack of sleep
since she is a call can lead to sleep deprivation
center agent worker. that can be acute or chronic and
results from insufficient or
Objective Data: disrupted sleep.
● ND
The excess fatigue resulting
from exhausting or stressful
work makes falling asleep
difficult. This is often seen in
adolescents who keep long,
stressful schedules because of
work. Sleep deprivation can
cause illness, emotional stress,
medications, environmental
disturbances, and variability in
the timing of sleep as a result of
shift work. It is shown in the
patient's assessment that has an
unhealthy sleeping pattern since
she is a call center agent worker.

References:
● Potter, Perry, Stockert, &
Hall. (2020).

FUNDAMENTALS OF NURSING BSN1AS1

 fundamentals of nursing
(10th ed., pp. 3393-3401).
● Fox, M. (2013). The
importance of sleep.
Nursing Standard, 13(24),
44.

MODULE 6: POST-TASK – PLANNING

PRIORITIZING

Rank Diagnosis Cue Justification

1 Fatigue related Subjective Data: As defined in Maslow’s

to sleep ● “I feel so weak and wobbly hierarchy of needs,
deprivation that I can’t get up from bedphysiological needs are all
manifested by to work.” about the basic human
body weakness, ● The client experienced survival needs including
headaches, and lingering headaches 2 days food and water, sufficient
fever. prior to admission. rest, clothing and shelter,
● The client felt bodyoverall health, and
weakness and headache 4 reproduction. In
hours prior to admission. accordance with Maslow’s
● It is mentioned that she justhierarchy of needs, this
feels so weak and tired. Andfalls under physiological
according to her, she gets needs. The patient’s
tired easily. · fatigue is given top priority
● She approximately gets a due to the symptoms it
minimum sleep of 4 hours a causes such as lingering
day. headaches, tired feelings,
body weakness, and fever.
Objective Data: These symptoms are
● Vital Signs: warning signs that the
Temperature: 37.8°C patient’s health is at risk
● The client looks weak and thus it is essential to
tired. prioritize this diagnosis
when providing nursing

FUNDAMENTALS OF NURSING BSN1AS1

 interventions.

ASSESSMENT - DIAGNOSIS - PLANNING

Assessment Nursing Scientific Explanation Planning

Diagnosis

Subjective Data: Fatigue related The patient is fatigable Discharge

● “I feel so weak to sleep as the patient shows Outcome/Long
and wobbly that I deprivation signs and symptoms of Term Outcome:
can’t get up from manifested by difficulty in performing
bed to work.” body weakness, her tasks which was ● After 7 days of
● The client headaches, and directly verbalized by following the
experienced fever. the patient during the nursing care
lingering assessment period. plan, the client
headaches 2 days According to the
should be able
prior to patient, she feels weak
admission. and wobbly, and she to perform
● The client felt can’t get up from bed to activities of
body weakness work. As stated by daily life
and headache 4 Enoka and Duchateau (ADL) well.
hours prior to (2016), fatigue is ● After 7 days
admission. defined as a disabling nursing
● It is mentioned symptom in which
that she just feels physical and cognitive intervention,
so weak and function is limited by the client will
tired. And interactions between be able to
according to her, performance attentively
she gets tired fatigability and monitor her
easily. · perceived fatigability. conditions
● She Perceived fatigability is
given her
approximately derived from the
gets a minimum sensations that work-life
sleep of 4 hours a regulate the integrity of schedule.
day. the performer based on
the maintenance of
homeostasis and the Short Term
psychological state of Outcome:
the individual. With
this statement from ● After 8 hours

FUNDAMENTALS OF NURSING BSN1AS1

 Enoka and Duchateau, of nursing
along with the data intervention,
from the assessment, the client
we can conclude that
should be able
the patient experienced
these symptoms due to to feel
the disruption of well-rested.
homeostasis brought ● After 8 hours
by a lack of rest and of nursing
sufficient nutrition due intervention,
to her activity and the client will
lifestyle in which both
categories affect her be able to plan
integrity to accomplish a schedule for
tasks. daily activity
and adequate
rest.

FUNDAMENTALS OF NURSING BSN1AS1

 MODULE 7 POST TASK: IMPLEMENTATION

ASSESSMENT-DIAGNOSIS-PLANNING-IMPLEMENTATION

Assessment Nursing Scientific Planning Implementation Rationale

Diagnosis Explanation

Subjective Data: Fatigue The patient is Discharge Independent N.I. INDEPENDENT

● “I feel so weak related to fatigable as the Outcome/Long 1. Dysfunction in
and wobbly sleep patient shows signs Term Outcome: 1. The nurse will sleep (too much,
that I can’t get deprivation and symptoms of evaluate the too little, or too
up from bed to manifested difficulty in ● After 7 adequacy of many
work.” by body performing her tasks days of nutrition and interruptions) can
● The client weakness, which was directly following sleep hygiene aggravate fatigue.
experienced headaches, verbalized by the the nursing (napping Inadequate
lingering and fever. patient during the throughout the nutrition can also
care plan,
headaches 2 assessment period. day, inability contribute to
days prior to According to the the client to fall asleep fatigue, particularly
admission. patient, she feels should be or stay if anemia is
● The client felt weak and wobbly, and able to asleep) of the present.
body she can’t get up from perform patient. 2. Clients who feel as
weakness and bed to work. As activities of Encourage if they have control
headache 4 stated by Enoka and daily life the client to over their fatigue
hours prior to Duchateau (2016), get adequate and its impact on
admission. (ADL) well. rest, limit their lives have
fatigue is defined as a
● It is disabling symptom in ● After 7 naps, use a lower levels of
mentioned which physical and days of routine fatigue.
that she just cognitive function is nursing sleep/wake 3. Cognitive
feels so weak limited by intervention schedule, plan behavioral therapy
and tired. And interactions between and prioritize has been shown to

FUNDAMENTALS OF NURSING BSN1AS1

 according to performance , the client for daily be effective in
her, she gets fatigability and will be able activities as reducing fatigue.
tired easily. · perceived fatigability. to tolerated, Education,
● She Perceived fatigability allow counseling, and
attentively
approximately is derived from the exposure to expressive therapy
gets a sensations that monitor her sunlight have also been
minimum regulate the integrity conditions during shown to be
sleep of 4 of the performer given her daytime hours effective for
hours a day. based on the work-life by going managing fatigue.
maintenance of schedule. outside or In addition,
Objective Data: homeostasis and the Short Term opening cognitive
● Vital Signs: psychological state of Outcome: shades and behavioral therapy
Temperature: the individual. With curtains in the in combination
37.8°C this statement from ● After 8 home, use with hypnosis may
● The Client Enoka and Duchateau, hours of relaxation improve fatigue in
looks weak along with the data techniques breast cancer
and tired nursing before clients undergoing
from the assessment,
we can conclude that intervention bedtime such radiotherapy.
the patient , the client as meditation, (Reference)
experienced these should be music therapy, Ackley, Ladwig, & Makic.
symptoms due to the able to feel or guided (2017). Nursing
disruption of well-rested. imagery avoid Diagnosis Handbook.
homeostasis brought caffeine in the 11th Edition pp. 372-375
● After 8
by a lack of rest and late afternoon
sufficient nutrition hours of or evening, DEPENDENT
due to her activity nursing and eat a
and lifestyle in which intervention well-balanced 1. To review the
both categories affect , the client diet that medication given
her integrity to will be able includes fresh by the physician
accomplish tasks. fruits, for possible side
to plan a
vegetables, effects affecting
schedule

FUNDAMENTALS OF NURSING BSN1AS1

 for daily and lean the client’s desire
activity and meats. to be involved in
adequate 2. Nurse will any activity.
encourage the
rest. 2. treat the condition,
client to keep
a journal of specifically the
activities that headache, by
contribute to implementing pain
symptoms of medication with
fatigue, the authorization
patterns of of a physician.
symptoms
across (References)
days/weeks/m Carpenito, L. J. (2016).
onths, and Handbook of nursing
feelings, diagnosis (15th ed.).
including how Lippincott Williams and
fatigue affects Wilkins. pp.11, 328
the client’s
normal daily
activities and
roles. COLLABORATIVE
3. The nurse will 1. To improve
encourage the stamina, strength,
client to and muscle tone
express and to enhance
feelings, sense of
attribution of well-being
cause and 2. Complementary
behaviors therapies may be
about fatigue, helpful in reducing
muscle tension

FUNDAMENTALS OF NURSING BSN1AS1

 including and pain to
potential promote relaxation
causes of and rest
fatigue, and 3. Supplements can
possible supply the patient
interventions with needed
to alleviate vitamins, and
fatigue. Such minerals for their
interventions body to function.
could include Micronutrients
setting small, support the
easily amount of cell
achieved energy production
short-term which plays a
goals and pivotal role in
developing cognitive function.
energy
management 4. Collaborating with
techniques; a caregiver with
use active the use of
listening assistive devices
techniques to will improve the
help identify client’s comfort, so
sources of that the pain
hope. doesn’t limit the
(Reference) patient in raising
Ackley, Ladwig, & its activity level.
Makic. (2017). Furthermore, the
Nursing Diagnosis caregiver will
Handbook. 11th assist the client to:
Edition pp. 372-375 (1) promote restful
sleep; (2) have

FUNDAMENTALS OF NURSING BSN1AS1

 various alternative
Dependent N.I. therapies that will
1. The nurse will lessen muscle
administer the tension and; (3)
given refer to physical
medication and occupational
based on the therapy for
physician's programmed daily
order. exercises that will
2. The nurse will strengthen the
explain certain client physically
procedures to and promote
improve the well-being.
wellness of
the patient.
Discussing a
well balanced Reference:Doenges,NA
diet. Based on NDA 15th ed. p.330-331
the patient’s
(References)
dietician.
Tardy, A.-L., Pouteau, E.,
3. Following the
Marquez, D., Yilmaz, C.,
physician’s
& Scholey, A. (2020).
order, the
Vitamins and Minerals for
nurse will
Energy, Fatigue and
administer an
Cognition: A Narrative
IV infusion
Review of the
with the type
Biochemical and Clinical
of solution
Evidence. Nutrients,
that provides
12(1), 228.
energy and
doi:10.3390/nu12010228
rehydrates the
Doenges, M. E.,

FUNDAMENTALS OF NURSING BSN1AS1

 body. Moorhouse, M. F., & Murr,
(Reference) A. C. (2019). Nurse's
Fight your fatigue. pocket guide: Diagnoses,
(n.d.). iVboost.Uk. prioritized interventions,
and rationales.
https://ivboost.uk/iv-so
Philadelphia, PA: F.A.
lutions/fight-your-fatig Davis.
ue/

Doenges, M. E.,
Moorhouse, M. F., &
Murr, A. C. (2019).
Nurse's pocket guide:
Diagnoses, prioritized
interventions, and
rationales.
Philadelphia, PA: F.A.
Davis.

FUNDAMENTALS OF NURSING BSN1AS1

 MODULE 8 POST TASK: EVALUATION

Nursing Diagnosis Outcome(Goal/Objectives) Evaluation

Fatigue related to sleep Short-term Outcome: The goals are met as

deprivation manifested by body ● The patient will feel evidenced by:
weakness, headaches, and well-rested after 8
fever. hours of implementing Short term Outcome:
the nursing After 8 hours of nursing
intervention. intervention, the patient:
● Verbalized relaxation
Long Term Outcome: and shows signs of
● The patient will relief.
perform activities of ● Demonstrates
daily life (ADL) well participation in
within 7 days of activities that are both
implementing the necessary and
nursing intervention. desired.
● Patient's headache
alleviates and is able
to function better.

Long Term Outcome:

Within the 7 days of nursing
intervention, the patient:
● Is able to balance
sleep and carry out
regular tasks.
● Had noticeable
improvements when
the nursing plan was
incorporated in their
life.
● Understands the
importance of
appropriate sleep.

FUNDAMENTALS OF NURSING BSN1AS1

FUNDAMENTALS OF NURSING BSN1AS1