1. Personal Information; – Name (pseudonym), age, sex, gender, ethnicity, religion. – Wt, ht, any chidren
2. Medical & Surgical History. – Past medical Hx. – Past Surgical Hx. – Obstetric hx(female)
B. Present Chief Complaints – Events leading to complaints
Explain what interventions (if any) were taken by patient from the time of getting ill leading up to the time of entering casualty. – What medical management and nursing management were given to the patient in casualty prior to the patient coming up to the ward. – State briefly how patient presented on the ward – Assessment of patient on admission
C. Medical /Surgical Management. – What was the patient diagnosed as? – Discuss the pathophysiology of the patient’s condition briefly. – What was the medical (doctor’s) management ordered for this patient. – What medication was ordered for this patient, list and say how each drug ordered assisted patient to feel better/ improved patients condition. – What Investigations/diagnostic tests were done? State briefly why you think these tests were done. – What is/ surgical management performed on this patient. – Describe briefly procedure and findings from surgical intervention done.
D. Nursing Management – List the nursing problems identified in this patient – State the nursing diagnosis formulated to address this problem – What was your desired outcome for your patient. – What nursing measures were done to meet your desired outcome/ alleviate this problem. (PRE-OP preparations, post –op care: IV, drains, tubes etc) – What are the possible complications the patient face and what interventions were done to prevent them from occurring. – State what topics will be taught to patient on discharge and discuss each briefly.. Recommendations: Explain what the patient should do in the future to continue recovery/ improve his or her condition.. This is your written submission.
Your paper will be graded on how well you complete each of the above sections, referencing according to APA style and your application of theory into the manifestation, treatment and intervention. Therefore: – Support all claims of what the disease is, why it occurs and how it is to be treated with reference to literature on the disease. – Make all citations to prevent plagiarism.