Académique Documents
Professionnel Documents
Culture Documents
John Colleges
Chipeco Ave., Calamba City
I. Biographic Data
Name:
Address:
Age: Gender: Religious Affiliation:
Marital Status: Occupation:
Room and Bed #:
Chief Complaint:
Provisional Diagnosis:
Attending Physician:
B. Socio-Cultural Patterns
1. Cultural Patterns
2. Significant Relationships
3. Recreation Patterns
4. Environment
5. Economic
Interpretation:
Analysis:
C. Spiritual Patterns
1. Religious Beliefs and Practices
2. Values and Valuing
2
Interpretation:
Analysis:
V. Physical Assessment
2
VIII. Anatomy and Physiology
IX. Pathophysiology
X. Ecologic Model
A. Hypothesis
B. Predisposing Factors
1. Host 2. Agent 3. Environment
a. Age a. Mechanical a. Physical
b. Sex b. Physical b. Biologic
c. Race c. Chemical c. Socio-economic
d. Nationality
e. Behavior
f. Customs
g. Heredity
C. Ecologic Model
1. Lever
2. Wheel
3. Web
4. Triangle
D. Analysis (with reference)
E. Conclusions and Recommendations
Discharge Plan
(to be submitted by students whose patients are for discharge)
E - Exercise
T - Treatments
H - Health Teachings
D - Diet
2
Case Study Output Format
I. Introduction
II. Objectives
III. Biographic Data
IV. Nursing History
V. Patterns of Functioning
VI. Activities of Daily Living
VII. Physical Assessment
VIII. Laboratory and Diagnostic Examinations Results
IX. Medications, IV Infusions, Blood Transfusions, Treatments Given
X. Anatomy and Physiology
XI. Pathophysiology
XII. Ecologic Model
XIII. Prioritized List of Nursing Problems
XIV. Nursing Care Plan
XV. Conclusion/Recommendation