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Case Presentation Format

This document outlines the format for case presentations at St. Jude College School of Nursing. It includes sections for biographical data, history of present and past illness, physical and Gordon's functional assessment, anatomy and physiology, pathophysiology, laboratory/diagnostic examinations, nursing care plan, drug study, and discharge plan. The case presentation format guides nursing students in comprehensively assessing, diagnosing, planning and evaluating care for patients.

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Reymart Bolagao
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236 views2 pages

Case Presentation Format

This document outlines the format for case presentations at St. Jude College School of Nursing. It includes sections for biographical data, history of present and past illness, physical and Gordon's functional assessment, anatomy and physiology, pathophysiology, laboratory/diagnostic examinations, nursing care plan, drug study, and discharge plan. The case presentation format guides nursing students in comprehensively assessing, diagnosing, planning and evaluating care for patients.

Uploaded by

Reymart Bolagao
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd

ST.

JUDE COLLEGE
Cradle of Global Professionals
URC Avenue, Salitran IV, Dasmarias, Cavite
[Link]
Tel. (046) 853-2954, 853-0505, 416-3818
SCHOOL OF NURSING
Case Presentation Format
Title: _____________________________
Group: ____________________________
Course/Year Level: ___________________
I.

INTRODUCTION
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

II.

BIOGRAPHICAL DATA
A. Name of Patient: Initials Only (eg. Patient NPA)
B. Age :____________________________
C. Gender:__________________________
D. Address :_________________________
E. Date of Admission: _________________
F. Occupation:_______________________
G. Healthcare Insurance:_______________
H. Chief Complaint:___________________

III.

HISTORY OF PAST AND PRESENT ILLNESS


A. History of Past Illness
________________________________________________________________________
___________________________________________________________________.
B. History of Present Illness
________________________________________________________________________
____________________________________________________________________.
ASSESSMENT
A. Physical Assessment (Head-to-Toe Assessment)

IV.

Body Part
Eg. 1. Head

Actual Findings
Cylindrical in
shape, skin
integrity is intact,
etc.

B. 11 Gordons Functional Pattern of Assessment


Gordons Functional Pattern
Before

Analysis
Presence of lesion in
the scalp
(characteristicspresence of drainage,
color, size in mm) due
to.

During

Analysis

Hospitalization

Hospitalization

1. Health Perception and

Management
2. Nutritional Metabolic
3. Elimination
4. Activity/ Exercise
5. Sleep Rest
6. Cognitive-Perceptual
7. Self Perception/
Self concept
8. Role Relationship
9. Sexuality/ Reproductive
10.
Coping-stress/
Tolerance
11.
Value-Belief Pattern
V.
VI.

ANATOMY AND PHYSIOLOGY


PATHOPHYSIOLOGY
A. Predisposing Factors
B. Precipitating Factors
C. Symptomatology (w/ Therapeutic and Non-Therapeutic Management)
D. Pathophysiology of the Disease

VII.

LABORATORY & DIAGNOSTIC EXAMINATION/S

VIII.

NURSING CARE PLAN (FDAR)


A. Potential Problem (1)
B. Actual Problems (2)
DRUG STUDY

IX.

Name of
Drugs

X.

Classificat
ion

Indicati
on

DISCHARGE PLAN
M- Medications
E- Environment and Exercise
T-Treatment
H- Health Teaching
O-Out-Patient
D- Diet
S- Spiritual Nursing

Contraindicat
ion

Side
Effec
ts

Adver
se
Effect
s

Nursing
Responsibili
ties

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