Individual Case Study: Palawan State University College of Nursing and Health Sciences Puerto Princesa City

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Palawan State University

College of Nursing and Health Sciences


Puerto Princesa City

Individual Case Study


In Partial Fulfillment of all the Requirements of NCM – 103 B (RLE)

Presented to:

Presented by:
Emysue Mae D. Ballares, SN3
Group II
PALAWAN STATE UNIVERSITY
COLLEGE OF NURSING AND HEALTH SCIENCES
PUERTO PRINCESA CITY

Name: _______________________________________________ Date: _______________________


Ward: _______________________________ Group: ______________________

PATIENT ASSESSMENT
I. PATIENT’S PROFILE

NAME: EDUCATIONAL ATTAINMENT:

AGE: OCCUPATION:

GENDER: RELIGION:

STATUS: DATE AND TIME ADMITTED:

ADDRESS: CHIEF COMPLAINTS:

ATTENDING PHYSICIAN:

DIAGNOSIS/IMPRESSION:

II. HEALTH HISTORY


PALAWAN STATE UNIVERSITY
COLLEGE OF NURSING AND HEALTH SCIENCES
PUERTO PRINCESA CITY

Client’s Initials:______________________ Age:__________ Ward:____________________


Chief Complaints:________________________ Attending Physician:____________________________

III. PATTERNS OF FUNCTIONING AND CLINICAL EXAMINATION (PHYSICAL ASSESSMENT) GUIDE

PATTERNS OF FUNCTIONING CLINICAL EXAMINATION OTHER SOURCES


PATTERNS OF FUNCTIONING CLINICAL EXAMINATION OTHER SOURCES
PATTERNS OF FUNCTIONING CLINICAL EXAMINATION OTHER SOURCES

References: ________________________________________________________________________________
Name:___________________________________________ Group:____________________
PATTERNS OF FUNCTIONING CLINICAL EXAMINATION OTHER SOURCES

References: ________________________________________________________________________________
Name:___________________________________________ Group:____________________
PALAWAN STATE UNIVERSITY
COLLEGE OF NURSING AND HEALTH SCIENCES
PUERTO PRINCESA CITY

DISCHARGE PLAN
Client’s Initials:______________________ Age:__________ Ward:____________________
Chief Complaints:________________________ Attending Physician:____________________________

Nursing Orders Discharge Instruction

Medicine

Exercise

Treatment

Hygiene

Out-Patient Department (OPD)

Diet

Spirituality

Name of Student:___________________________________ Group:_________


PALAWAN STATE UNIVERSITY
COLLEGE OF NURSING AND HEALTH SCIENCES
PUERTO PRINCESA CITY

RELATED READING
Name: _______________________________________________ Date: _______________________
Ward: _______________________________ Group: ______________________
PALAWAN STATE UNIVERSITY
COLLEGE OF NURSING AND HEALTH SCIENCES
PUERTO PRINCESA CITY

REVIEW OF ANATOMY AND PHYSIOLOGY


Name: _______________________________________________ Date: _______________________
Ward: _______________________________ Group: ______________________
PALAWAN STATE UNIVERSITY
COLLEGE OF NURSING AND HEALTH SCIENCES
PUERTO PRINCESA CITY

PATHOPHYSIOLOGY
Name: _______________________________________________ Date: _______________________
Ward: _______________________________ Group: ______________________

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