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ALMERIA, Krishna Rae Z., BERNARDO, Ryan Angelo, DE LOS SANTOS, Janet Alexis A., MENESES, Raza Crecia L., PEREZ, Ana Aumpta P., RUSSELL, Glynda
A case presentation should only include information that pertains to the case and refrain from providing confusing and superfluous data. Daily patient progress including normal VS, routine laboratory results, typical consultations with other disciplines, stepdown transfer to wards, and other irrelevant patient information MUST BE AVOIDED.
OUTLINE
I. II. III. IV. V. VI. ABSTRACT INTRODUCTION COMPREHENSIVE NURSING HEALTH HISTORY PHYSICAL EXAMINATION LABORATORIES & DIAGNOSTIC PROCEDURES ANATOMY & PHYSIOLOGY
PATHOPHYSIOLOGY SUMMARY OF CLINICAL FINDINGS PHARMACOLIGICAL SHEET NURSING CARE PLAN DISCHARGE PLANNING PROGNOSIS BIBLIOGRAPHY
ABSTRACT
Composed of 100-250 words
Should include 4 sections as the main text in a succinct form: Introduction and objective, Case Presentation, discussion and conclusion.
INTRODUCTION
Written concise and salient and not more than 3 paragraphs and need not be labeled with a heading. Should provide the background information that present clarity to the subject of discussion.
The introduction should provide the subject, purpose and merit of the case report.
1-2 sentences description of the patients case as a segway to the CASE PRESENTATION.
10
11
1z
PHYSICAL EXAMINATION
Cephalocaudal
Narrative
IPePaA IAPePa
PATHOPHYSIOLOGY
A. SCHEMA
OBSERVATION + PHYSIOLOGY +
PATHOPHYSIOLOGY
narrative pathophysiology.
Both POSSIBLE and ACTUAL MANIFESTATIONS are recorded provided that the former is emphasized/highlighted or otherwise written in two columns
PHARMACOLOGICAL SHEET
Should be patient focused. All medications of the patient should be written in a pharmacological sheet
DISCHARGE PLANNING
A. For patients with non complicated disease and
no surgeries in the ward and private areas:
edications
E
T H
xcercise
reatment and Visits ealth teachings /Hygeine
O
D S
M
I N
edications
ncision or wound care utrition
nvironment
U
B B
terus
ladder owel
L
E S H E
ochia
pisiotomy upport system / Spiritual omans sign motional
PROGNOSIS
May be written according to the students interpretation of the patients case
If there are prognosis written by the health team, it is encouraged to include it as an input.
BIBLIOGRAPHY
Family name, name of author, TITLE OF REFERENCE. Publisher. Year published.
Alphabetically arranged and categorized according to:
a. Books b. Journal c. Websites