CASE STUDY ON

Presented by:
OBJECTIVES OF THE STUDY:
This study aims to:
1.
2.
3.
4.
5.
 DISEASE ENTITY

• Definition
• Introduction
CAUSES
RISK FACTORS
SIGNS AND SYMPTOMS
 INCIDENCE
Worldwide In Saudi Arabia
TREATMENT
ANATOMY AND PHYSIOLOGY
PATIENT’S PROFILE
HISTORY OF PRESENT ILLNESS
PAST MEDICAL HISTORY
SOCIAL HISTORY
 VITAL SIGNS
(On the day of admission)
Temperature:
Height:
Weight:
Pulse:
RR:
BP:

(On the day of discharge)

Temperature:
Height:
Weight:
Pulse:
RR:
BP:
PHYSICAL EXAMINATION
I. General Survey: Weak-looking
Conscious and coherent
Area Assessed Technique Findings Evaluation

II. Head
1. Eyes Inspection
2. Ears Inspection using Otoscope
3. Nose Inspection
4. Mouth Inspection using torch and
tongue depressor
III. Neck Palpation

IV. Chest Auscultation

V. Abdomen Inspection

Auscultation
Percussion
Palpation
VI. Skin Inspection
Palpation

VII. Nails Inspection

Palpation
DRUG STUDY

In-patient Medications
Generic Name Brand Name Classification Route Dosage and Caregiver’s
Frequency Responsibilities
Frequency Responsibilities
Generic Name Brand Name Classification Route Dosage and Caregiver’s
Frequency Responsibilities
Generic Name Brand Name Classification Route Dosage and Caregiver’s
Frequency Responsibilities
DRUG STUDY

Home Medications
Frequency Responsibilities
Frequency Responsibilities
Frequency Responsibilities
LABORATORY FINDINGS
TEST RESULT NORMAL VALUE INTERPRETATION
TEST RESULT NORMAL VALUE INTERPRETATION
NURSING CARE PLAN
Assessment Nursing Plan Intervention Rationale Evaluation
Diagnosis

a. Short a. Short term

term goal: evaluation:

b. Long term
goal: b. Long term
evaluation:
Assessment Nursing Plan Intervention Rationale Evaluation
Diagnosis

a. Short a. Short term

term goal: evaluation:

b. Long term
goal: b. Long term
evaluation:
Assessment Nursing Plan Intervention Rationale Evaluation
Diagnosis

a. Short a. Short term

term goal: evaluation:

b. Long term
goal: b. Long term
evaluation:
Assessment Nursing Plan Intervention Rationale Evaluation
Diagnosis

a. Short a. Short term

term goal: evaluation:

b. Long term
goal: b. Long term
evaluation:
 DISCHARGE PLANNING
On the day of follow up after discharge, we
instructed the patient to do the following:
M- Medications
E- Exercise
T- Treatment
H- Health teachings
O- OPD (follow up check up)
D- Diet