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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

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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
Age (Achieved or Not

Crisis Achieved/ Fixated or (Ideal) (Justification)

Not)

Trust vs (Citations by (Relate to the

Infant- 18 mos
Mistrust the book) pt’s case)

Autonomy vs

18 mos- 3 yrs Shame and

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

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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

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

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- 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

- 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

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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

- Jugular Veins

12. Peripheral Vascular System

- Peripheral Pulses

- Peripheral Veins

- Peripheral Perfusion

13. Breast and Axillae

14. Abdomen

15. Musculoskeletal System

- Muscles

- Bones

- Joints

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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

19. Upper and Lower Extremities

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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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