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'SPharmacological 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