PAMANTASAN NG LUNGSOD NG PASIG

12-B Alkalde Jose Street, Kapasigan, Pasig City

COLLEGE OF NURSING

CASE PRESENTATION FORMAT

FRONT PAGE:

TABLE OF CONTENTS:

INTRODUCTION:

I. Demographic Data
Name: (Initial name)
Age:
Birthplace:
Birthday:
Civil Status:
Race/Nationality:
Religion:
Educational Background:
Address:
Occupation of Parents:
Usual Source of Income:
Admission Diagnosis:
Final Diagnosis:
Date Admitted:
Time Admitted:
Height:
Weight:
BMI:

II. Information Source and Source of Information

NURSING HISTORY

III. Chief complaint:

IV. Present Health History of Illness (from the start of disease/illness) related to admitting diagnosis

V. Past Medical Health History

VI. Family History: Genogram (3 generation)

VII. Physical Health Assessment

NORMAL CHART BASIS ACTUAL ANALYSIS

Day 1 Day 2
I Initial Nurses
P
P
A
VIII. Menstrual History
iX . Sexual History
X . Obstetrical History
XI. Gynecological History
XII. Developmental and Psychosocial History
- Determine the physical cognitive and psychosocial development of the patient(developmental
History) and describe educational level, family of origin, current household , personal interest and
lifestyle .

Gordon’s Functional Pattern ( At least 1 month of pre diagnose , underlying cause of current case)
Gordon’s Before Confinement During Confinement Identified Nursing
Diagnosis
Health Perception- Health Subj.: Subj.:
Management Pattern
Obj: Obj:

XIII. Anatomy: (normal function only)

PARTS FUNCTION
With picture

XIV. Physiology: (Theoretical based / Client based) diagram form) (Pathophysiology for High -Risk Client)

XV. Laboratory/Diagnostic result: normal values and significance

XVI. Drug study:

Generic GeneraI Dosage Contraindication Side Nursing Patient
name/ Indication/ (Actual/Route/ effects Consideration(include teaching
Brand Time) action effects on Lab
name result)
(Stock)

Prescribed
days/frequency

XVII. Problem Lists:

Actual Problem (At least 2):

Problem Number PROBLEM DATE IDENTIFIED DATE RESOLVED

(Prioritized)

Potential Problem (1: Risk):

XVIII. Nursing Care Plan: ADPIRE