Epilepsy Patient Clinical log

EpilepsyPatientAssessment.docx

Diagnosis: Epilepsy

Patient Demographics:

Name : Patient Y

Age : 53 years old

Gender : Male

Nationality : Malaysia

Race : Chinese

Religion : Buddhist

Occupation : Asbestos company worker

Marital status : Married

Diagnosis : Epilepsy

FOCUSED ASSESSMENT

L. Body Systems Review (Subjective data via history taking on affected and related body systems based on

the patient’s diagnosis and chief complaint)

M. Focused Physical Examination (Objective data)

**depending on the patient’s medical diagnosis, chief complaint and affected body systems. For example, if the

patient is admitted with chest pain, then perform focused physical examination on Cardiovascular system. If

the patient also complained of coughing, then must include the examination of Respiratory system as well.

N. Identified patient’s problems:

____________________________________________________________________________________

O. Formulate THREE (3) nursing diagnoses using PES format:

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Student name: ………………………………………… ID: ……………………………………………

Student’s signature: ………………………………………

Date : ……………………………………… Time: ……………………………………………