Professional Documents
Culture Documents
Nursing Department
Dumaguete City
A Case Presentation
on
“SEPSIS”
Prepared by:
Presented to:
Clinical Instructor
Biographical Data
Psychosocial Profile
Health Practices and Beliefs: Patient doesn’t believe in Medical doctors but
believes in quack doctors.
Nutritional Pattern: Soft diet
Activity and exercise Pattern: Patient usually spends her time in doing
household chores.
Recreation, pet, hobbies: None
Sleep Pattern: Usually sleeps at 1o pm and sleeps at least 8 hours.
Personal Habits: No vices in particular.
Family History:
Family Genogram:
- Male
- Female
- Patient
Psychosocial History:
Patient has a good and strong relationship with her family. She loves
her family thus in times of some problems she was there to help them. She is
also close to their relatives and always communicates to them. Aside from
her family, she is also a good friend. She is a good daughter and a good role
model to her younger siblings.
Environmental History:
Spiritual History:
The patient and her family is a Roman Catholic. They participated in
some religious activities of the church. They also attended mass every
Sunday.
Physical Assessment
Integumentary System
• Uniform in skin color with slightly darker exposed area
• Presence of generalized black area at the neck
• Presence of scar at shin of left leg
• Presence of dead nail on thumb of right foot
• Presence of nevus at left upper arm
• Presence of wound at the abdomen with length of 16 cm and
width of 18 cm
• No unusual skin odor
• Skin is cold to touch
• Good skin turgor
• Hairs evenly distributed
• Scalp intact with no lesions
Eyes
• Upper eyelids covers on half of the upper iris
• Eyelids in contact with eyeballs with no lesions
• Lacrimal glands no swelling, redness and drainage
• Positive corneal reflex
• Sclera white in color
• Lens clear, smooth and glistening
• Brown iris color
• Pupil equally round, reactive to light and accommodation
Ears
• Normal in shape, no lesions, skin intact, color consistent with skin color
• Soft and pliable, non-tender
• No presence of drainage and secretions
Nose
• Midline placement, shape is symmetrical and consistent with age
• No nasal flaring, no drainage
• Non-tender, sinuses are non-tender
• Mucosa pink and moist
• Naris patent
Mouth
• Oral mucosa pink, moist, intact, no lesions
• Tongue pink, moist, papillae intact
• Lips midline, symmetrical, cracked and dry
• Uvula in midline placement, moist, with no lesions
Neck
• Black color around the neck
• Symmetrical, no lesions, no secretions
• No masses, non-tender
Lymph Nodes
• Non-palpable and non-tender
Abdomen
• Bloated abdomen with circumference of 88 cm.
• Presence of infected stitched wound
• Skin color lighter than exposed areas
• Tenderness noted when palpated at all four quadrants.
Musculoskeletal
• Muscle soft, slightly weak, non-tender
• No abnormal movement
Abdominal Cavity
The cavity within the abdomen, the space between the abdominal wall and
the spine. The abdominal cavity is hardly an empty space. It contains a number of
crucial organs including the lower part of the esophagus, the stomach, small
intestine, colon, rectum, liver, gallbladder, pancreas, spleen, kidneys, and bladder.
Sepsis can be frightening because it can lead to serious complications that affect
the kidneys, lungs, brain, and hearing, and can even cause death. Sepsis can affect
people of any age, but is more common in:
Final Diagnosis:
Sepsis