EEE’ cic Nursing Department Format : Case Study / Presentation ( as of June 2010) 1. Introduction : General / Specific Objectives include: ~ Case of the patient > Background of the disease ~ Reason why you chose the case or students motivation in choosing this study ~ Statistics of the disease / case TL. Assessment: A. Nursing History: Personal Data includes: > Chief complaint ~ (HPI History of Present Illness rt present problem tracing back if either acute / chronic - (PMHx) Past Medical History + Family History - For Pedia / OB history is needed > Gordon's Table Gordon's Table of Health Patterns Gordon's Health Prior to During Analysis & Interpretation, | Pavers Hospitalization Hospitalization include References E - B. Physical Assessment: Table Physical Assessment _ ] Normal Findings Body Pats | peeecar | Ceased on | Actua Findings Avalsis Ineaion Assessment | pictgro ond) II. “Anatomy & Physiology: IV. Pathophysiology: Book based & Client based a. Th Based Modifiable Non-Modifiable = Lifestyle = Physical activity ~_ Nutrition age, weather b. Client Based a 7 Medical Surgical Management ¢. Diagnostic Procedure: Table Diagnostic Procedures Date/ | Tab? Normal N pe N 7 ursing Analysis & Problem [P Teens | Findings | Actual Findings Responsibilities Interpretation V. Pharmacological Management Date Ordered: ——_____ E'SPharmacological Management Name of Drug, Classification Indication (Client Based) Dosage & Route |. ‘Nursing (Client Based) | SH°EA | Consideration VI. Coarse in the Ward Date / Shift Student Nurse Activity Patient Response includes Doctors orders, ‘nurses assessment, identification of problem & intervention VII. Nursing Management : Priority Nursing Diagnosis NCP A Interference puma ( Scientific Goal ‘Cues jagnos! reasons for | (Long/ | Intervention | Rationale | Evaluation (Problem, nursing Short) Etiology, S/s) | giaenocis Subjective Independent Objective dependent interdependent Please support your analysis & intervention with supporting study & include the reference VIII. Reference - please use APA format