Liceo de Cagayan University

Rodolfo N. Pelaez Boulevard, Cagayan de Oro City

College of Nursing

NCM 501204
A Care Study

[Name of Client]

Submitted to

[Name of Faculty]

As Partial Requirement for NCM501204

Submitted by

[Name of Student]

[Date of Submission]
 TABLE OF CONTENTS

CONTENT PAGE

I. Developmental Data #

II. Health History and Present Illness #

III. Medical Orders, Rationale #

IV. Pathophysiology #

V. Ideal Nursing Management #

VI. Actual Nursing Management #

VII. Evaluation and Implication #

VIII. Referrals and Follow-up #

IX. Organization and Grammar/ Bibliography #

I. Developmental Data
II. Health History and Present Illness
 III. Medical Orders, Rationale

DATE DOCTOR’S ORDERS RATIONALE

 Laboratory Results

Complete Blood Count (CBC)

DATE DIAGNOSTIC RESULT NORMAL VALUES INTERPRETATION

ORDERED EXAM
 White Blood Cells 5,000 – 10,000/mm3

Red Blood Cells F:3.69 – 5.13 mil/mm3

M:4.35 – 5.90 mil/mm3

Hemoglobin F: 11.7 – 14.5 g/dl

M: 13.7 – 16.7 g/dl

Hematocrit F: 34.1 – 44.3 vols %

M: 40.5 – 49.7 vols %

Platelet F: 174,000 – 390,000

M: 144,000 – 372,000

MCV F: 81.5 – 96.7 U3

M: 79.7 – 97,0 U3

MCH F: 26.5 – 33.5 pg

M: 26.1 – 33.3 pg

MCHC F: 31.9 – 35.3 g/dl

M: 32.2 – 35.0 g/dl

Differential Blood Count

Neutrophils 43.4 – 76.2 %

Lymphocytes 17.4 – 48.2 %

Monocytes 4.5 – 10.5 %

Eosinophils 2 -3 %

Basophils 0 – 0.5%

Stabs 1–2%

Urinalysis
DATE CHARACTERISTIC FINDINGS INTERPRETATION
ORDERED

Color:
Ph
Transparency:
Sugar
 Albumin
Pus:
RBC
Epithelial Cells;
Crystal:

X-Ray/ CT-Scan Report

DATE FINDINGS INTERPRETATION

ORDERED

IV. Pathophysiology
 V. Ideal Nursing Management

NURSING DIAGNOSIS:

INTERVENTION RATIONALE
NURSING DIAGNOSIS:

INTERVENTION RATIONALE
NURSING DIAGNOSIS:

INTERVENTION RATIONALE

NURSING DIAGNOSIS:

INTERVENTION RATIONALE
NURSING DIAGNOSIS:

INTERVENTION RATIONALE
NURSING DIAGNOSIS:

INTERVENTION RATIONALE
 VI. Actual Nursing Management

E
S

O
A

E
S

S
O

O
A

VII. Evaluation and Implication

VIII. Referrals and Follow-up
IX. Organization and Grammar/ Bibliography