Patient Profiles and/or careplans??

We did case studies in my LPN class which I believe is the same thing you are refering to. We all did ours a little different but same concept. On first page of MS Word: Name, School, etc. Second page would give a short paragraph on pt such as 99 year male admitted to the hospital on 1/1/05 for pneumonia, maybe add the patients history and social history.

Then format went like this

C/C:_________

Dx:_________-then gave definition of diagnosis

Allergies:_______ (if none, I would put NKA)

Past Medical History:-List each one and give definition from Taber's

Past Surgical History_

Then broke down info according to syStems

Neurological Assessment:
LOC:________
SPEECH:________
etc. and go through each system

Also add any special equipment used and pain status. Then we had to type up the labs and have the normal values listed
Example

CBC Result Normal Value

ANd then on to tests that were performed on the patient or that could have been performed on the patient with a definition and nursing care for that procdure.

Just remember this is a learning tool to get your critical thinking working. I hope what I wrote makes sense and does not confuse you. I wish you luck with your program.
Surgery Performed:-if applicable

We did something similar to the previous post, age, pt initials, pts doctor, dx, hx, surgeries, labs, and such. Then for care plans we had to do an in depth informational part from the patient (to put towards our subjective and objective information) this included how they looked, what they said and so on and so forth. After looking at all the info we acquired we would pick as many nursing diagnoses that applied to this patient and choose the one most pertinent (keeping ABC's and maslows hierarchy in mind) and go from there. I had a little careplan book that helped me tons - i think its by lippincotts.