Taif university

College of applied medical sciences

Adult nursing

Assigned case template.

Good morning, my name is ...... I would like to present an endorsement about my assigned patient .
My patient names is ...... he/she is ..... years old he was admitted on ...... from ......... to ......... unit.
He/she has been diagnosed with ........, he/she also is known for having ......... for ........ years
The current medications that he/she uses ........ doses…… , route……… , frequency …………
He/she admitted with e.g CC ……,……,……..,……..
Currently he /she complains of .........,……,…….
His/her family history is ..........
His/her main laboratory values related to his/her condition is ............
He/she performed a ............, .......... to confirm the diagnosis
On examination (physical assessment):

His/her general appearance.................

His/her orientation........
His/her bowel sounds ........
His/her movement......
His/her respiratory and breathing rhythm is ........
He/she has and IV catheter on his .......... it was inserted on ......... at .............
His current health problems are 1 ........ 2 ........ 3......... his perception about his condition is …….......
According to priorities my first nursing diagnosis will be 1………….2…………….3…………..

1........ short term goals ......... long term goals ........ dependent interventions ....... independent interventions......
2......... short term goals ........... long term goals ....... dependent interventions......... independent
interventions...........
3....... short term goals ........... long term goals ......... dependent interventions.......... independent
interventions.............