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Case study/ case presentation

. ntroduction
Theoretical view of case
Definition
ncidences (local and abroad) 5 years or less
Abstract case of pt. "we, group B, studied the case of patient X..
Explain why you chose the case.
Objectives- general ,3/ specific
. Assessment

A. Nsg History
O Client profile
O Chief complaint
O History of present illness
O Family hx of illnesses
4 Genogram (up to 3 generations)

B. Gordon's Functional Health Patterns
Health Perception Past (prior to
hospitalization
Present (during
hospitalization)
Analysis/ nterpretation
with References


C. Physical Assessment (objective data/ signs)
Body Part Normal Findings Actual Findings Analysis/ nterpretation
with References


D. Diagnostics always include date and time
O Nursing interventions
O Nursing considerations
O Nursing responsibilities
Ex.
K+ Normal findings Actual findings Analysis/ nterpretation



. Anatomy and Physiology
Discuss what systems the disease is affecting

V. Pathophysiology theory-based, client-based


V. Medical Surgical Management/ Treatment
A. Medical (Pharmacological treatments used by pt.)
Ex.
Drug
name
(generic
and
brand
names)
Classification ndication
(client-
based)
Dosage
(client-
based)
Side effects/
adverse effects
Contraindic
ations/
precautions
Nsg.
responsibilities


B. Surgical Management (discuss surgeries performed on patient)
Paragraph form

Nursing responsibilities pre-, intra-, post-surgery

V. Course in the Ward
Ex.
Date/ time Problem/ focus Management Pt. responsibilities/
evaluation
Nsg.
responsiblities
11/22/10
9:30am
Fever
T: 39
Give Paracetamol
1 cap stat

TSB> tendered


V. Nursing Care Plans (3)

V. Methods
edication
xercise
%reatment
ygiene
ut-patient
iet
$afety, Spirituality, Sex

X. Evaluation
Assessment of your case
Recommendations and suggestions for your case
non
modlflable
ulsease Modlflable