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I. INTRODUCTION

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II. OBJECTIVES

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III. PATIENT’S DEMOGRAPHIC DATA

Patient’s Code Name

Age
Birthday
Birthplace
Sex
Status
Religion
Nationality
Address
Educational Attainment
Occupation
Date of Admission
Physician
Station/Room
Admitting Diagnosis
Final Diagnosis

IV. HEALTH HISTORY

a. Family Socio-Economic Background

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b. History of Past Illnesses

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c. History of Present Illnesses

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d. Genogram

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V. DEVELOPMENTAL DATA (At Least 3 Theories)

Erik Erikson’s Stages of Psychosocial Development

Outcome
Psychosocial Rationale Significance
(Achieved or Not
Age
Crisis Achieved/ Fixated or (Ideal) (Justification)
Not)
Infant- 18 Trust vs (Citations by (Relate to the

mos Mistrust the book) pt’s case)

18 mos- 3 yrs Autonomy vs

Shame and

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Doubt
Initiative vs
3-5 yrs
Guilt
Industry vs
5-13 yrs
Inferiority
Identity vs

13-21 yrs Role

Confusion
Intimacy vs
21-39 yrs
Isolation
Generativity
40-65 yrs
vs Stagnation

VI. DEFINITION OF COMPLETE DIAGNOSIS

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VII. ANATOMY AND PHYSIOLOGY

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VIII. PHYSICAL ASSESSMENT

a. Review of Systems –verbatim-

1. General Overall Health State

2. Integument (Skin, Hair, Nails)

3. Head

4. Eyes

5. Ears

6. Nose and Sinuses

7. Mouth and Oropharynx

8. Thorax and Lungs

9. Heart and Central Vessels

10. Peripheral Vascular System

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11. Breast and Axillae

12. Abdomen

13. Musculoskeletal System

14. Neurological System

15. Genitals and Inguinal Area

16. Rectum and Anus

b. Cephalocaudal Physical Assessment

1. General Appearance and Mental Status

2. Vital Signs/Measurements

3. Integument

- Hair

- Nails

4. Head

- Skull

- Face

5. Eye Structures and Visual Acuity

- External Eye Structures

- Visual Fields

- Extraocular Muscle

- Visual Acuity

6. Ears and Hearing

- Auricles

- External Ear Canal and Tympanic Membrane

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- Gross Hearing and Acuity

7. Nose and Sinuses

- Nose

- Facial Sinuses

8. Mouth and Oropharynx

- Lips and Buccal Mucosa

- Teeth and Gums

- Tongue/Floor of the Mouth

- Salivary Glands

- Palates and Uvula

- Oropharynx and Tonsils

9. Neck

- Neck Muscles

- Lymph Nodes

- Trachea

- Thyroid Gland

10. Thorax and Lungs

- Posterior Thorax

- Anterior Thorax

11. Heart and Central Vessels

- Precordium, Aortic and Pulmonic Areas, Tricuspid Area,

Apical Area, Epigastric Area

- Carotid Arteries

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- Jugular Veins

12. Peripheral Vascular System

- Peripheral Pulses

- Peripheral Veins

- Peripheral Perfusion

13. Breast and Axillae

14. Abdomen

15. Musculoskeletal System

- Muscles

- Bones

- Joints

16. Neurological System

- Language

- Orientation

- Memory

- Attention Span and Circulation

- Level of Consciousness

- Cranial Nerves

o Cranial Nerve 1- Olfactory

o (So on and so forth)

- Reflexes

17. Genitals and Inguinal Area

18. Rectum and Anus

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19. Upper and Lower Extremities

IX. ETIOLOGY AND SYMPTOMATOLOGY

Ideal S/Sx Actual Rationale Significance

(by the book, (in relation to your
(Check or X)
citations) case)

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X. PATHOPHYSIOLOGY

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XI. MEDICAL MANAGEMENT

a. Doctors Order

Date/Time Progress Notes Doctors Order Rationale and

Significance

b. Diagnostic Examinations

(Test) Result Normal Value Rationale and

Significance

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XII. DRUG STUDIES

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XIII. NURSING THEORIES (At least 3)

Theorist Theory Application to the Case

(by the book) (significance)

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XIV. NURSING CARE PLANS (Minimum of 5, prioritize the actual)

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XV. LEVELS OF PREVENTION

Primary

Secondary

Tertiary

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XVI. DISCHARGE PLAN (METHOD)

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XVII. PROGNOSIS

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XVIII. EVALUATION

-whether you met your objectives-

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XIX. RECOMMENDATIONS

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XX. REFERENCES

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