COLLEGE OF NURSING

CASE PRESENTATION FORMAT

Page 1 Title Page

Page 2 Table of Contents

Page 3 Acknowledgment

I INTRODUCTION

Includes information to orient the reader. Includes general statement of the patient’s illness and his reason/s for
seeking admission.

The student’s reason for selecting the case for a special study and other important statement deemed necessary in the

Conduct of the study is also a part of the introduction (Statistics of the incidence - global, national, local)

II. Objectives (General & Specific)

III. Patient’s Data (Include the following)

1. Patient’s code name

2. Age/Nationality/Civil status/Occupation/Sex/Religion/Educational attainment/Ward or Unit/Room/Bed number

3. Date of Admission

4. Vital signs on admission

5. Date of discharge

6. Chief complaint/s

7. Admitting/final diagnosis

8. Surgical procedure performed if any (date and time performed)

9. Attending Physician

10. Source of Information/Informant’s

IV. Family Background/Health History (Genogram)

1. Family Health history (narrative/paragraph form)

2. Effects/Expectations of illness to self/family

3. Client’s Health History

- Past Illness/es

-Present Illness/es

(Include all medical, surgical, obstetrical, gynecological and mental health problems, if any)

Client’s lifestyle, diet and activities of daily living (ADL)

V. Developmental Data

Use at least 3 theories (by Erickson, Freud, Havighurst, Piaget) - Task at specific age

VI. Definition of Complete Diagnosis

Define the whole diagnosis (should have at least 3 references from any medical-surgical books)

VII. Definition of Terms

Medical Terms related to your study (should have at least 3 references from any medical-surgical books)
VIII. Physical Assessment

Head to toe/cephalocaudal ( use inspection, palpation, percussion, auscultation)

IX. Anatomy and Physiology

In narrative form. Include picture/s and or illustration.

X. Etiology and Symptomatology

Should be written in tabular form (basic/actual/rationale)

XI. Pathophysiology

Diagram form. Should start with the predisposing and precipitating factors.

All factors must be included and the factors seen on the patient are highlighted.

XII. Doctor’s Order

Should be written in tabular form. (Date ordered/Doctor’s order/rationale/remarks)

XIII. Diagnostic Exam

Should be written in tabular form. (Date ordered/test/normal value/patient’s result/clinical significance/nursing

responsibility

XIIV. Drug Study (Tabular form)

Generic Name/brand name/classification/dosage and frequency/mechanism of

action/indications/contraindications/side effects/adverse reaction/nursing responsibility

XIV. Surgical Procedure (if any)

Tabular form (Date/cues/need/nursing diagnosis/objective of care/nursing intervention/evaluation)

XV. Nursing Theories applicable to the case presented (at least 3)

XVI. Nursing Care Plan

Tabular form (Date/cues/need/nursing diagnosis/objective of care/nursing intervention/evaluation WITH RATIONALE

XVII PROGNOSIS

XVIII. Discharge Plan (M.E.T.H.O.D)

M - Medication

E - Exercise

T - Treatment

H - Health education/Teaching

O - Out-patient Schedule

D - Diet

XIX. SUMMARY, FINDINGS AND Recommendation

XX. References/Bibliography
SHIFTING EXAM (LEVEL 2,3,4)

1. Major exam

2. 50 items

3. Given every after rotation

4. Questions are based on their rotation concepts

5. Test questions will be solicited from the RLE CI’s who handled the students

6. Questions will be collated by the Clinical coordinator

SIMULATION (LEVEL 2)

1. Done at the end of the semester

2. Clinical instructors will handle 8-10 student in a day

3. The student will be picking a random case to analyze and to determine the procedure to be performed

4. He/she is not allowed to bring his/her notes iunside the room

5. The student will be given 30 minutes to finish the procedure

6. The student’s presentation will be one-on-one with the clinical instructor

7. The rubric for return demonstration will be used for grading the student.

ORAL REVALIDA (LEVELS 3, 4)

1. Done at the end of the semester

2. Pointers will be given one month in advance and will be based on the RLR concepts the students had for the semester

3. Clinical instructor will handle 8-10 students in two days

4. The student will be picking a random case/disease to discuss

5. The student should bring manila paper/s and marker. He/she is not allowed to bring his/her notes inside the room.

6. The student will be given 1.5 hours for the presentation:

15 minutes - preparation

1 hour - presentation

15 minutes - discussion/question and answer

7. The student shall discuss the following:

Definition

Anatomy and Physiology (only of the major organ involved)

Etiology

Symptomatology (significant features/manifestations)

General pathophysiology (simplified)

Medical managemnt

Laboratories (2-3)
 Medications (2-3)

Treatment (if applicable, the surgery)

Nursing management (5)

Possible nursing diagnosis (3

Prognosis

8. The student’s presentation will be one-on-one with the clinical instructor

9. The rubric for oral presentation will be used for grading the student.