Republic of the Philippines

MARIANO MARCOS STATE UNIVERSITY

COLLEGE OF HEALTH SCIENCES
Department of Nursing
Batac, Ilocos Norte

June 28, 2010

JOSE B. OROSA III, MD, FPSO-HNS, FPCS, FPAHNSI

Chairman, Department of ENT-HNS
Mariano Marcos Memorial Hospital and Medical Center
Batac, Ilocos Norte

Thru: MIRIAM I. RAMONES, RN, MAN

Nurse III, Training Officer

Dear Sir:

Our warmest greetings and salutation!

The Bachelor of Science in Nursing III-C Group 1 students of the

College of Health Sciences, Mariano Marcos State University represented by
the undersigned, are currently enrolled in RLE 103. One of the requirements
for the subject is to present a case analysis regarding a patient with a
urinary system disorder.

In view thereof, we would like to ask permission to copy relevant data

for our case study from the patient’s record. It is further requested that we
conduct interview and a thorough clinical assessment with the said patient.

Rest assured that all data obtained will be used for academic purposes
only and will be kept confidential.

We look forward to your very kind consideration and approval of this

request.

Thank you very much and God bless!

Very truly yours,

CZARINA JOY B.
ALONZO

MARK EVON L.
BAGUINON
Group 1
Representatives

Noted by:

FLORDELIZA I. TABANIAG
Level III Coordinator
NORMA L. ECLARIN
Chairman, Department of Nursing

LAILANI S. GALUTIRA
Dean, College of Health Sciences
 Republic of the Philippines
MARIANO MARCOS STATE UNIVERSITY
COLLEGE OF HEALTH SCIENCES
Department of Nursing
Batac, Ilocos Norte

June 28, 2010

Dear Patient,

We are students from Mariano Marcos State University, taking up

Bachelor of Science in Nursing. As one of our requirements in our subject RLE
103, we are scouting for a patient who is suffering from any kind of disease
involving the urinary system for our case analysis.

In connection to this, we would like to ask permission that our group be

allowed to get you as our patient. With regards to this, we would like to ask
your permission from the time of your admission to the time of discharge,
that we will conduct interviews, assessment and appraisal. We would also
like to ask permission to copy all pertinent data that are available in your
chart.

We assure you that your personality will be kept confidential and

whatever information that we will obtain from you will be used for academic
purposes only, and no other reasons.

The time you will spend with us will help us a lot for the success of our
case analysis.

Thank you very much and God bless.

Sincerely yours,

CZARINA JOY B.
ALONZO
Representative
 Republic of the Philippines
MARIANO MARCOS STATE UNIVERSITY
COLLEGE OF HEALTH SCIENCES
Department of Nursing
Batac, Ilocos Norte

June 28, 2010

Patpatgen mi nga Pasyente,

Kablaawan daka iti naimbag nga aldaw!

Dakami ket estudyante iti Mariano Marcos State University nga

mangal-ala iti kurso nga Bachelor of Science in Nursing. Kas maysa nga
kasapulan para iti sabjek mi nga RLE 103, agsarsarak kami iti maysa nga
pasyente nga addaan ti anyaman nga sakit mainaig iti urinary system para
iti case analysis mi.

Iti daytoy nga panggep, kayat mi kuma nga sika iti alaen mi nga
agbalin nga pasyente mi. Ipakaammo mi met kenka nga masapol daka nga
umay sarsarungkaran manipod iti pinagyan mo yanta ospital aginggana nga
rumwar ka dita ospital. Kadagita nga oras, umay mi sarungkaran iti kasasaad
mo, agala iti impormasyon maipanggep kenka ken agsakar iti chart mo.

Maisigurado mi nga iti kinataom ket konpidensyal. Maisigurado mi pay

kenka nga dagiti impormasyon nga maadaw mi ket agserbi laeng iti
pinagadal mi ken awanen iti anyaman nga rason.

Agyaman kami iti oras mo nga ited mo kadakami. Diyos unay iti
agngina!

Toy
agpateg,

CZARINA JOY B.
ALONZO
Representante iti
Grupo
 Republic of the Philippines
MARIANO MARCOS STATE UNIVERSITY
COLLEGE OF HEALTH SCIENCES
Department of Nursing
Batac, Ilocos Norte

ASSESSMENT TOOL

I. PERSONAL DATA

Name:
________________________________________________________________________
Address:
______________________________________________________________________
Sex: __________________ Age: __________________ Civil Status:
______________________
Religion: ________________ Date of Birth: ______________ Place of Birth:
_______________
Educational Attainment: ______________________ Occupation:
_________________________
Date and Time of Admission: ______________________ Hospital Number:
________________
Admitting Diagnosis:
____________________________________________________________
Chief Complaint:
_______________________________________________________________
Attending Physician:
____________________________________________________________
Final Diagnosis:
________________________________________________________________
Date and Time of discharge (if available):
___________________________________________

II. FAMILY BACKGROUND

– Who are his immediate family members who are living and not living
with him?
– How much is the actual earnings of the family?
– Are there money coming from other sources?
– What are the sources of income?
– Who decides in the allocation for health services?
– Is the budget adequate to meet the needs of the family?
– How is his relationship with family members?
– What are the social activities as a family?

III. HEALTH HISTORY

A. Family Health History

– Are there occurrences of familial or hereditary diseases?
 – Who are the members of the family who have the disease?
– What are the causes of morbidity and mortality in the family?
– What are the immunizations received by the family members?
– How are health services utilized?
– Management, drugs, dosage, route, mechanism of action of the
drug, use of OTC drugs, prescribed drugs, use of herbal medicines?
– What are the lifestyles of the family members? (vices, diet, sleeping
patterns)?
– Hospitalization of family members?

B. Past Health History

– What are the disorders suffered by the patient since he/she was
born?
– Management, drugs, dosage, route, mechanism of action of the
drug, use of OTC drugs, prescribed drugs, use of herbal medicines?
– How is his lifestyle?
– What are his immunizations?
– Hospitalization (date, chief complaint)?
– Have you ever experienced undergoing a surgery?

C. Present Health History

– When did the client first experience the s/s of the disease?
– Onset, location, quality, precipitating factors, aggravating factors,
alleviating factors of each manifestation?
– What are the drugs and different diagnostic procedures undergone
by the client before admission?
– Remission/reduction of s/s of the disease?
– How is your present lifestyle could have contributed to your present
illness?

IV. DEVELOPMENTAL DATA

A. Erik Erickson’s Developmental Theory

– What are the activities/behaviors expected of that stage?
– Is he able to achieve the tasks?

B. Havighurst Theory
– What are the activities/behaviors expected of that stage?
– Is he able to achieve the tasks?

V. PATTERNS OF FUNCTIONING

A. Eating (both before and during the illness)

– What are the foods you prefer to eat? What is the amount?
– What is your usual time of eating?
– Do you have food allergies? What are they?
 – What are your food likes and dislikes?
– How are the foods being prepared?

B. Drinking (both before and during the illness)

– How many glasses of water/fluids do you drink everyday?
– What drinks do you prefer to take in?
– What are your usual times of drinking?
– Do you have allergies?
– Likes and dislikes?

C. Bladder and Bowel Elimination (both before and during the illness)
– What is the usual amount, color, odor, ritual and frequency of
bladder elimination?
– Does he have any belief/preference in eliminating?

D. Sleeping (both before and during the illness)

– What is usual time of sleeping?
– What are your rituals, frequency, sleep aids, duration, naps, rest
periods and interruptions while sleeping?

E. Bathing (both before and during the illness)

– What is your usual time of bathing?
– How frequent?
– Does he have any belief/preference in bathing?

VI. LEVELS OF COMPETENCIES

A. Physical
– How does the patient perform activities of daily living?
– Can he tolerate them alone?
– What are your activities of daily living since you suffered from
illness?
– Can he tolerate them alone?

B. Emotional
– Can he control/express his feelings before he had an illness?
– How?
– Are his reactions normal?
– Can he control/express his feelings since he had an illness?
– How?
– Are his reactions normal?

C. Social
– How does the patient interact with others before he had an illness?
– Is he able to maintain good relationship with other people?
– How does the patient interact with others since he had an illness?
– Is he able to maintain good relationship with other people?

D. Intellectual
 – How does he make decisions, retain and comprehend information
before the illness?
– Is he able to maintain a good relationship with other people in
making decisions?
– How does he make decisions, retain and comprehend information
since the illness?
– Is he able to maintain a good relationship with other people in
making decisions?

E. Spiritual
– What are his different religious practices before the illness?
– What are his different religious practices since the illness?
 Republic of the Philippines
MARIANO MARCOS STATE UNIVERSITY
COLLEGE OF HEALTH SCIENCES
Department of Nursing
Batac, Ilocos Norte

ASSESSMENT TOOL

I. PERSONAL DATA

Nagan:
_______________________________________________________________________
Pagnaedan:
____________________________________________________________________
Sex: __________________ Tawen: ________________ Istatus Sibil:
_____________________
Religion: __________ Aldaw ti pinakyanak: _________ Lugar ti pinakayanakan:
____________
Naturpos yanta pagadalan: _______________________ Trabaho:
________________________
Aldaw ken oras ti admisyon: ___________________ Numero yenta Ospital:
________________
Umuna nga Diagnosis:
___________________________________________________________
Kangrunaan nga Marikrikna:
______________________________________________________
Physician nga Akin-iggem:
_______________________________________________________
Maudi nga Diagnosis:
___________________________________________________________
Aldaw ken oras ti Discharge (no adda):
_____________________________________________

II. FAMILY BACKGROUND

– Asinno da iti asideg nga kabagyan iti pasyente aggigyan weno haan
kenyana?
– Mano iti binulan nga kitkitaen iti pamilya?
– Ada da kwarta nga aggapgapo iti sabali nga tao?
– Ana dagitay pagsapulan nga mangmangted iti agserbi?
– Sino iti agdesdesisyon iti pinagbudget iti kwarta?
– Mano iti maibadbadyet para iti agas, pinagpapaospital weno
pinagpacheck-up?
– Deta kadi budget ket usto lang tapno masustentuan iti inaldaw nga
agserbi?
– Kasano iti relasyon iti miyembro iti pamilya yo yanti mesa ken mesa?
– Ana dagitay ububraen yo nga sanga pamilyaan kaslang kuma sports?
III. HEALTH HISTORY

A. Family Health History

– Ana dagitay sakit nga mamanmana nga adda dita pamilya yo?
– Sinno da nga adda kastoy nga sakit na?
– Ana dagitay rason iti panagsaksakit ken ipupusay iti miyembro iti
pamilya?
– Ana dagitya bakuna nga natanggap iti pamilya?
– Kaano yo nga maususar dagitay pacilidades kaslang kuma RHU ken
ospital?
– Ana dagitay tumtumaren yo nga agas prescribe man weno haan,
ken tay dosage, route, frequency? Agususar kau iti herbal
medicines?
– Ana dagitay bisyo iti pamilya, kankanen ken pattern iti pinagturog?
– Sino iti miyembro iti pamilya nga naiospitalen?

B. Past Health History

– Ana dagitay saksakit nga napadasan ta pasyenten manipod
naiyanak?
– Ana dagitay tumtumaren yo nga agas prescribe man weno haan,
ken tay dosage, route, frequency? Agususar kau iti herbal
medicines?
– Kasano iti inaldaw aldaw nga pinagyan?
– Ana dagitay bakuna nga nalpas na?
– Napadasan na iti naiyospital idin? Ana iti gapo na? Kaano?
– Napadasan na iti naoperan?

C. Present Health History

– Kaanom nga umuna nga narikna iti signs ta sakit mo?
– Kaano nangrugi, ayana iti sakit na, kasano kasakit, ana dagitay mas
lalo pay nga mangpaspasakit , dagitay mangpalpalag-an iti sakit iti
kada manipestasyon?
– Ana dagitay agas ken procedure nga naubra yanta pasyente sakbay
nga naiospital?
– Ada nagbalbaliwan na ta sakit?
– Kasano ngata nakatulong ta inaldaw aldaw mo nga ububra yanta
pinagsaksakit mo?

IV. DEVELOPMENTAL DATA

D. Erik Erickson’s Developmental Theory

– Ana dagitay dapat na nga maubra ditoy nga tawen?
– Kaya na nga ubraen dagijay nga task?

E. Havighurst Theory
– Ana dagitay dapat na nga maubra ditoy nga tawen?
– Kaya na nga ubraen dagijay nga task?
V. PATTERNS OF FUNCTIONING

A. Eating
– Ana dagitay makan nga kayat mo nga kanen? Kasano nga kaado?
– Pasaray ana oras ka nga mangmangan?
– Adda allergy’m iti makan? Ana dagijay?
– Ana dagitay kayat mo ken haan mo kayat nga makan?
– Kasano nga maisagsagana iti makan?

B. Drinking
– Mano nga baso iti danom iti mainom mo iti mesa nga aldaw?
– Ana iti klase iti mainom nga hilig mo?
– Ana iti oras iti pinaginom mo?
– Adda allergy’m iti maininom?
– Ana dagitay kayat mo ken dimo kayat nga ininomen?

C. Bladder and Bowel Elimination

– Ana iti kankanayon nga color, kinaado, angot, ritwal ken mamin ano
ka nga umisbo sakbay ka nga nagsakit?
– Ada pammatim nga sursuruten iti pinagisbom sakbay ka nagsakit?
– Ana iti kankanayon nga color, kinaado, angot, ritwal ken mamin ano
ka nga umisbo idi agsakit ka?
– Ada pammatim nga sursuruten iti pinagisbom idi agsakit ka?
D. Sleeping
– Ana iti oras iti pinagturog mo?
– Ana dagitay ritwal, mamin ano, kasapulan nu maturog, kabayag,
nap ken mangdisturbar iti pinagturog mo?

E. Bathing
– Ana tay oras iti pinagdigdigos mo?
– Mamin ano?
– Ada da pammatim iti pinagdigos nga ububraem?

VI. LEVELS OF COMPETENCIES

A. Physical
– Kasano na nga gamgamanan iti aktibidades na iti inaldaw aldaw?
– Kaya na nga ubraen amin dagijay nga agmemesa?
– Ana garod lang dagitay kayam nga ubraen idi adaan ka iti sakiten?
– Kayam nga ubraen amin dagijay nga agmemesa?

B. Emotional
– Kayam kadi nga ikontrol iti emosyon mo?
– Kasano?
– Normal kadi metlang iti pakikitungo na iti sabali nga tao sakbay
nga nagsakit?
– Normal kadi metlang iti pakikitungo na iti sabali nga tao idi adaan
iti sakit?
C. Social
– Kasano ka nga makitungo kadagita aglawlaw mo sakbay ka nga
nagsakit?
– Kayam nga imentenar iti nasayaat nga relasyon iti daduma nga tao
sakbay ka nagsakit?
– Kasano ka nga makitungo kadagita aglawlaw mo idi nagsakit kan?
– Kayam nga imentenar iti nasayaat nga relasyon iti daduma nga tao
idi nagsakit kan?

D. Intellectual
– Kasano ka nga agdesisyon ken makaala iti impormasyon sakbay ka
nagsakit?
– Kasano ka nga agdesisyon ken makaala iti impormasyon idi
nagsakit kan?

E. Spiritual
– Ana dagitay pammatim sakbay ka nagkasakit?
– Anat nagbaliwan iti pammatim idi ada sakit mon?
 CONSENT FOR CLINICAL APPRAISAL AND INTERVIEW

I, _____________________________ hereby authorize the students of Group

1, BSN III-C of Mariano Marcos State University, College of Health Sciences,
Department of Nursing to conduct a clinical assessment and interview
regarding my condition.
Moreover, I attest that I am in full knowledge regarding the appraisal
that they will accomplish for their case analysis which is about a patient with
any disease involving the urinary system.
I also give authorization for these students to provide information from
any medical to my attorney for my insurance claims.
Rest assured that all information gathered will be used for academic
purposes only for the sake of my confidentiality.

________________________ ________________________
SIGNATURE OF WITNESS SIGNATURE OF
PATIENT

DATE: ________________________

This authorization must be signed by the patient or by the next of kin

and in case of minors and/or the patient is physically and mentally
incompetent.
Patient is minor for _____ years.
Patient is unable to sign because
_____________________________________________.
I, _________________________ being next to kin of
________________________, hereby authorize the aforementioned students to
perform the necessary clinical assessment and interview.

________________________ ___________________________
SIGNATURE OF WITNESS SIGNATURE OF NEXT
TO KIN
DATE: ________________________

PAMMALUBOS

Siyak ni _____________________________ ikkak ti pammalubos dagiti

Group I BSN III-C nga estudyante ti Mariano Marcos State University, College
of Health Sciences, Department of Nursing nga mangisayangkat iti clinical
assessment ken interbyu panggep iti kondisyon ko.
Kas nayun na, aminado ak kadagiti ubraen da kenyak ket para tay
case analysis da nga panggep iti maysa nga pasyente nga adda ti anyaman
nga sakit na.
Ikkak pay iti pammalubos dagitoy nga estudyante nga mangted iti
impormasyon nga aggapu iti anyaman nga medical record nga kasapulak.
Ket amin nga impormasyon nga naited ket agserbi laeng iti pinagadal
ken para iti kapakanak.

________________________ ________________________
SAKSI
PASYENTE

DATE: ________________________

Detoy nga pammalubos ket pirmaan tay pasyente wenno tay kabagyan
na gapu iti kina menor nga edad wenno diay pasyente ket adda problema na
iti nainpisikalan wenno panagpanunut.
Ti pasyente ket adda iti menor nga edad _____.
Ti pasyente ket marigatan nga agperma gapu ta
_________________________________.
 Siyak, ______________________ kas kabagyan ni ______________________
mangted iti pammalubos kadagitoy nga estudyante nga mangisayangkat iti
clinical assessment ken interbyu.

________________________ ________________________
SAKSI
KABAGYAN

DATE: ________________________