FORMAT (Case study PPS 3rd)

Introduction

Anaphy (affected organ system only)

Gordons (present all info gathered but highlight the abnormalities)

PE (present all info gathered but highlight the abnormalities)

Labs

Pls include : Name of Lab/Diagnostic exam, clients results, normal values (reference), significance: state the relationship of the clients
condition to results (how the disease condition cased such results). Also, be able to identify possible effecs of the results in the clients
health

Pathophysiology

-Be client centered. Focus on the clients condition and manifestation

-Be familiar with the ideal pathophysiology of the disease

-Signs and symptoms should be traceable from the course of the illness

-Risk factors: are universally applicable (ex. Age) factors that predispose a disease

-Precipitating factors: are those applicable only to the client, which cause the disease

-Etiology: most specific cause of disease of the client. It includes microorganisms

Medications (CAICAN)
Discharge instructions

1. MEDICATIONS instructions
2. EXERCISE applicable to the client
3. TREATMENT modalities
4. HEALTH TEACHINGS generally acceptable
5. OUT PATIENT instructions
6. DIET modifications applicable
7. SPIRITUAL advise; culture-sensitive

NCPs (minimum: 5)

-Prioritization of problems

-Nursing goal: should be SMART, and directed to the client

Should be NANDA- acceptable and completely stated, which includes problems, etiology, and secondary factor.

Scientific basis-explains the nursing problem, and why such problem occurred on the clients condition

-Interventions: include independent, collaborative and dependent

Must be realistic, resource based and directed to the client

-Rationale for each interventions

-Outcome: expected output of care or response of the client for every intervention done

-Evaluation