Professional Documents
Culture Documents
College of Nursing
I. INTRODUCTION
A. Background of the study
B. Objective (general & specific showing Knowledge, Skills & Attitude)
C. Scope and Delimitation
D. Theoretical Framework
I. BIOGRAPHIC DATA
Name
Address
Age
Gender
Race
Marital Status
Occupation
Religious orientation
Health care financing and usual source of medical care
Interpretation:
Analysis: (with reference)
II. PHYSICAL ASSESSMENT (all objective findings; indicate date performed; Head to Toe Assessment; follow IPPA
sequence)
1. General Survey (Short Paragraph)
2. Vital Signs
BODY PART (Technique used) NORMAL FINDINGS ACTUAL FINDINGS INTERPRETATION / ANALYSIS
w/ Reference
Drug Study
DRUG TRADE / PHARMACOLOGIC INDICATION AND ADVERSE DESIRED NURSING
ORDER BRAND ACTION OF DRUG CONTRAINDICATIONS EFFECTS ACTION RESPONSIBILITIES
NAME OF THE ON YOUR / PRECAUTIONS
(Generic, DRUG CLIENT
name,
dosage,
route,
frequency)
Treatments Given
TREATMENT / CLASSIFICATION INDICATION CONTRAINDICATION NURSING
INFUSION RESPONSIBILITIES /
PRECAUTIONS
• Summary of day to day medical/nursing management from the date of admission up to the time case study was done
• Patient’s Status:
a. General condition of the client (ex. LOC, VS, and other Subjective & Objective, complaint during the day)
b. 4 D’s with inference / analysis:
○ Diet
○ Drugs/IVF
○ Lab/Diagnostics procedure
○ Disposition
I. PRIORITIZED LIST OF NURSING PROBLEMS (Table)
• Prioritized using ABC’s and Maslow’s Hierarchy of Needs
II. PROPOSED / DISCHARGE PLAN (to be submitted by students whose patients are for discharge)