CASE

PRESENTATION
CASE PRESENTATION
I. Title Page
II. Table of Contents
III. Introduction
IV. Nursing theories
V. Patient’s data
VI. History of present illness
VII. Review of systems
VIII. Physical assessment
IX. Course in the ward
X. Review of Related Literature
XI. Anatomy and Physiology
XII. Pathophysiology
XIII. Laboratory and Diagnostic Procedures
XIV. Drug Study
XV. NCP
XVI. Discharge Plan
1. TITLE PAGE

A case of Cholelithiasis
2. TABLE OF CONTENTS

• THE ARRANGEMENT OF CONTENTS AND THE CORRESPONDING

PAGES FROM THE INTRODUCTION TO THE BIBLIOGRAPHY
3. INTRODUCTION:
• WHAT IS THE SIGNIFICANCE OF THE CASE
NURSING THEORIES
• HOW IS IT APPLIED IN YOUR CASE, APPLICATION, SITE EXAMPLES
HOW DID YOU APPLY THE THEORY
• HOW WILL THE THEORY HELP YOUR CLIENT
4. PATIENT’S DATA

• GEN. DATA • REVIEW OF SYSTEM

• CHIEF COMPLAINT • PHYSICAL
EXAMINATION
• HISTORY OF PRESENT
ILLNESS • ADMITTING DIAGNOSIS
• COURSE IN THE WARD
• PAST MEDICAL HISTORY
• FINAL DIAGNOSIS
• FAMILY HISTORY
• PERSONAL AND SOCIAL
HISTORY
GENERAL DATA
• Name
• Age
• Address
• Occupation, work status
• Marital status
• Religion
Note:
IDENTIFICATION, AGE RELATED DISEASES, WORK, DEMOGRAPHICS

8
 CHIEF COMPLAINT HISTORY OF PRESENT
ILLNESS
• Subjective reason for • sequence of events
seeking care • Is it sudden or gradual
• Main reason for • Duration
bringing the pt. to the • Location, quality,
hospital intensity of each
symptoms
• Predisposing and
aggravating factors
• Consultations
• Relief measures
9
5. HPI
• SEQUENTIAL STORY TELLING LEADING TO THE
CHIEF COMPLAINT
• EMPHASIZE ON WHEN IS THE APPEARANCE OF
THE SIGNS AND SYMPTOMS
• PAIN – QUALITY, RADIATION, SITE, TIMING
• DID YOU CONSULT , WHAT IS THE MEDICAL
DIAGNOSIS, MEDICATIONS, RELIEF
• AVOID USING MEDICAL TERMS
 PAST MEDICAL FAMILY HISTORY
HISTORY
• Hospitalizations not • Genetic and familial
related to the case disease
• Surgical operations • Family structures to
not related to the case know the support
• Medication history and structures
compliance

11
PERSONAL AND SOCIAL HISTORY
• Habits
• Lifestyle pattern
• Use of alcohol, tobacco, caffeine, recreational drugs (confidential)
• How many sticks /day = pack years
• How many bottles/session
• For how many years?

12
OBSTETRICAL HISTORY
• Menarche
• Interval of menstruation
• Ob score
• Sexual history if found significant
NOTE: IF YOUR CASE IS OB-GYN, STD

13
ENVIRONMENTAL HISTORY
• Working
• Home
• Exposure to pollutants

NOTE:
YOU WILL INCLUDE THIS DATA IF THE DISEASE IS WORK RELATED,
OCCUPATIONAL

14
Psychosocial history
• Client support system
• Family styles to cope with stress
• Behaviors
• Social life
NOTE:
YOU WILL INCLUDE THIS DATA IF THE PROBLEM IS PSYCHOLOGICAL

15
6. REVIEW OF SYSTEMS-
COLLECTING DATA OF ALL THE
BODY SYSTEMS
General presentation of Skin, Hair, Nails
the signs and symptoms
• Fever, chills, malaise, • itching, color or texture
pain, sleep pattern, change, excessive
fatigability sweating, abnormal
 Diet nail or hair growth
i. Appetite, restrictions,
likes and dislikes
16
MUSCULOSKELETAL
• Joint stiffness
• Pain
• Restricted motion
• Swelling
• Heat
• Deformity

17
HEAD AND NECK
Eyes: Ears:
• Blurring • Hearing loss
• Diplopia • Pain
• Photophobia • Discharge
• Pain • Tinnitus
• recent change in • vertigo
vision

18
HEAD AND NECK
Nose: Throat and Mouth:
• Sense of smell • Hoarseness
• Frequency of colds • Change in voice
• Obstruction • Frequency of sore
• Epistaxis throat
• Sinus pain • Bleeding or swelling
• Post nasal discharge of gums
• Soreness of tongue
and buccal mucosa
19
CHEST AND LUNGS
• Pain related to Respiration
• Dyspnea
• Cough
• sputum

20
Heart and Blood vessel
• Chest pain (timing, duration and relieving factors)
• Dyspnea
• Orthopnea/ can not sleep while in su
• Hypertension
• Easy fatigability

21
Gastrointestinal
• Appetite • Flatulence
• Food intolerance • Hemorrhoids
• Dysphagia
• Heart burn
• Nausea and vomiting
• Bowel regularity
• Change in the color of
the stool
• Constipation
• diarrhea
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Genitourinary
• Dysuria • Sexually transmitted
• Flank or supra pubic disease
pain
• Frequency
• Nocturia
• Hematuria
• Polyuria
• Hesitancy
• Loss in force of stream

23
Endocrine (genital/reproductive)
• Thyroid enlargement Males:
or tenderness • Puberty onset
• Heat or cold • Difficulty with erection
intolerance testicular pain
• Unexplained weight • Libido
change • Infertility
• Distribution of facial
hair

24
Neurological
• Syncope
• Weakness or paralysis
• Abnormalities of sensation
• Coordination
• Tremors
• Loss of memory

25
Psychiatric
• Depression
• Mood changes
• Difficulty of
concentration
• Nervousness
• Tension
• Suicidal thoughts
• Irritability

26
7. Physical Assessment – CEPHALO -CAUDAL
• ADMITTING DIAGNOSIS – is copied from the chart
8. COURSE IN THE WARD
• FINAL DIAGNOSIS – is copied from the chart or you can ask the doctor

27
9. Review of Related Literature
• Literature related to your case
• Statistical data/demographics
FOR THE STUDENTS TO BE THEIR GUIDE IN THE CASE
10. ANATOMY AND PHYSIOLOGY

• ANATOMY OF THE
ORGAN INVOLVED
• NORMAL
PHYSIOLOGY AND
FUNCTION
11. Pathophysiology:
• WRITTEN EXPLANATION
• Diagram of what is happening with
your client, representation of the origin
of the signs and symptoms…
Problem list:
• Impaired breathing pattern
• Risk for Injury
• Impaired tissue perfusion
• Anxiety

LEARN HOW TO PRIORITIZE

12. LABORATORY AND DIAGNOSTIC
PROCEDURE
• DIFFERENT LAB. EXAMS
• INTERPRETATION
• DIAGNOSTICS
• IMPORTANCE OF THE RESULTS
• NURSING IMPLICATIONS
DO NOT MISS ANY LABORATORY SPECIALLY PROCEDURES WHICH ARE
DIAGNOSTIC
13. DRUG STUDY

• NAME OF THE DRUG

• INDICATIONS
• ACTIONS
• CONTRAINDICATION AND PRECAUTION
• ADVERSE REACTION
• ROUTE AND DOSAGE
• AVAILABILITY
• NURSING IMPLICATION
• STARTED AND DISCONTINUED
NAME INDICATION ACTION CONTRAINDI ROUTE AVAILABILIT NSG.
CATION/ AND Y RESPONSI
ADVERSE DOSAGE BILITY
REACTION

GENERIC
BRAND
NAME

DATE
SATRTED
AND
FINISHED
14. NURSING CARE PLAN

• CUES /PROBLEM (SUBJECTIVE & OBJECTIVE CUES)

• NURSING DIAGNOSIS WITH RATIONALE
• PLAN/ GOAL (SMART)- STG or LTG
• INTERVENTION
• RATIONALE
• EVALUATION
5 Steps (ADPIE)
Assessing: collecting, validating and
communicating of patient data
Diagnosing: analyzing patient data to
identify patient strengths and problems
Planning: specifying patient outcomes and
related nursing interventions
Implementing: carrying out plan of care
Evaluating: measuring extent to which
patient achieved outcomes
SAMPLE NCP PATTERN:
CUES/ NURSING PLAN INTERVENTION RATIONALE EVALUATION
PROBLEM DIAGNOSIS GOAL

SUBJECTIVE: DIAGNOSIS SHORT TERM: DIAGNOSTIC EACH RATIONALE

SHOUD BE AT THE
I,D,C LEVEL OF THE SAID
OBJECTIVE: INTERVENTION
RATIONALE LONG TERM: THEARPEUTIC
P. E. I,D,C

EDUCATIVE
LAB. I,D,C
15. DISCHARGE PLAN

• IDENTIFY THE NEEDS OF THE PATIENT AFTER DISCHARGE

• NURSING IMPLICATIONS/ROLES
• SPECIAL PROCEDURES TO TEACH THE CLIENT OR THE NEXT OF KIN
• MEDICATIONS
• NUMBERS TO CALL
• GROUP ASSISSTANCE
16. BIBLIOGRAPHY:
• RESOURCES
• REFERENCES
Thank you and
Good luck!