Title of your case

Prepared By:

Submitted To:
Ms. Rovie V. Gozales RN, MAN
Clinical Instructor

Area: Pedia Ward

Date:
INTRODUCTIONS
NURSING CASE STUDY OF A PATIENT WITH .......
Biographic Data
NAME :
AGE :
SEX :
NATIONALITY :
DATE OF ADMISSION :
CHIEF COMPLAINTS :
DIAGNOSIS :






Medical History
Past:



Present:
Theoretical Frameworks
Lab
orat
ory
Res
ult
Normal Range Parameters Normal Range
Hemoglobin 140 (male)- 140-160
g/l
(female)- 120-160
g/l
Platelet count
ESR
177 150/450*10g/l
Hematocrit 0.42 (female)- 0.37-
0.47
Bleeding time 1-3 mins.
RBC Count 4.62 (male)- 4.5-6.5*10
12/L
(female)- 3.9-
5.6*10 12/L
clothingtime
retic count
3-5 min
WBC Count 5.0 5-10x10g/L APTT 26-38sec.
Different Count Control 32sec.
Neutrophiles 46 50-70% Protime 10-15sec.
Lymphocytes 54 25-40% Control
Monocytes 3-6% Activity
Eosinophils 1-4%
Basophils 0-1%
Stabs 6-5% Malaria
ANATOMY AND PHYSIOLOGY OF .....
PATHOPHYSIOLOGY
Drug Study
Medication Dosage Actions Indications Side Effects
Nursing
Consideratio
ns
Prioritization
Problems Rank Remarks
Nursing Care Plan
Assessment Diagnosis Planning Intervention Rationale Evaluation
Discharge Plan
M
E
T
H
O
D
S