Partial Fulfillment of the Requirements

St. Mary’s College

Nursing Program

Tagum City

A Case Study

On

_______________

Introduced to:

___________________

In Partial Fulfillment of the Requirements

In

Related Learning Experience

(RLE)

By:

Duno, Levi Mark S.

BSN 3A

Date

I. Presentation

Goals:

GENERAL:

Particular:

II. Appraisal

A. Historical DATA

Name:

Address:

Age:

Sex:

Common Status:

Occupation:

Conceding Physician:

Conceding Diagnosis:

Religion:

Nationality:

Instructive Attainment:

Companion Name:

Occupation:

Father’s Name:

Mother’s Name:

Date of Admission:

B. Boss COMPLAINT

C. HISTORY OF PRESENT ILLNESS

D. PAST MEDICAL AND NURSING HISTORY

E. Individual, FAMILY AND SOCIO-ECONOMIC HISTORY

F. PATIENT NEED ASSESSMENT

Name: Age:

Sex: Status:

Confirmation Date/Time:

Conceding Medical Diagnosis:

Landed on unit by: From:

Joined by:

Customer’s Perception of Reason for Admission:

How was the issue being overseen at home:

Drug taken at home:

PHYSIOLOGICAL NEEDS

I. Oxygenation

BP: PR/CR: RR:

Lungs (per auscultation: character; lung sound; symmetry of mid-section development; breathing character and example):

Cardiovascular Status (per auscultation ?sounds, character: mid-section torment?):

Hairlike Refill:

Skin Character and Color:

Life-supporting Apparatus:

Different Observations Related:

II. Temperature Maintenance

Temperature:

Skin Character:

Different Observations Related:

III. Nourishing Fluids

Stature/Weight:

Measure of Food Consumed:

Endorsed Diet:

Issue (queasiness, heaving: no. of times and recurrence, sum and character):

Eating Pattern:

IV. Disposal

Last Bowel Movement (Frequency, sum, character):

Typical Pattern:

Pee (Frequency, sum, character, sensation):

Different Observations Related:

V. Rest and Sleep

Bed Time: Waking up:

Rest (Pattern, measure of rest):

Issue (as verbalized):

Different Observations Related:

VI. Torment Avoidance

Rate Pain: Time Started:

Character: Location:

Recurrence:

Term:

Conduct (eager, outward appearance, peevish, diaphoretic):

Different Observations Related: none

VII. Sexuality-Reproductive

LMP AOG:

Gravida/Parity: Prenatal:

Menstrual Cycle:

EDC: Menarche:

Family arranging technique utilized:

Youngsters:

VIII. Incitement Activity

Work:

Entertainment/Past Time:

Side interests:

Wellbeing SECURITY NEEDS

Neuro V/S:

Mental Status (intelligent, responsive, oblivious):

Enthusiastic issue (diaphoretic, trembling, fretful?):

LOVE AND BELONGING NEEDS

Youngsters:

Spouse:

SELF-ESTEEM NEEDS

SELF ACTUALIZATION NEEDS

PHYSICAL ASSESSMENT

General Survey

Wholesome status

Neurologic Status

Evaluation OF THE HEAD

Evaluation OF THE EYES

Evaluation OF THE EARS

Evaluation OF THE NOSE

Appraisal OF THE MOUTH

Appraisal OF THE NECK

Appraisal OF THE LUNGS AND THORACIC REGION

Appraisal OF THE HEART

Appraisal OF THE ABDOMEN

Appraisal OF THE UPPER EXTREMITIES

Appraisal OF THE LOWER EXTREMITIES

V/S and INTAKE/OUTPUT MONITORING

Date &shift

Time

Temp.

BP

RR

PR

Consumption

Yield

G. COURE IN THE WARD

III. Research facility AND DIAGNOSTIC EXAMINATIONS

IV. Survey OF ANATOMY AND PHYSIOLOGY

V.SYMPTOMATOLOGY

Clinical Manifestation

Real SYMPTOMS

Suggestion

VI.ETIOLOGY OF THE DISEASE

ETIOLOGY

Real SYMPTOMS

Suggestion

VII. PATHOPHYSIOLOGY

A. Composed Pathophysiology

B. Chart Of Pathophysiology

VIII. Arranging

A. Nursing Care Plan

B. Release Plan

IX. PHARMACOLOGICAL MANAGEMENT

X.PERIOPERATIVE IMPLEMENTATION {surgical cases}

A. Pre-Operative Implementation

B. Intra-Operative Implementation

C. Post-Operative Implementation

XI. Combination OF CLIENT’S CONDITION FROM ADMISSION TO PRESENT

A. Conclusion

B. Persistent’s Prognosis

C. Suggestions

XII. Assessment OF THE OBJECTIVE OF THE STUDY

XII. Book reference

A. Diary

B. Course readings

C. Web