CASE PRESENTATION FORMAT

A CASE STUDY OF AN ADULT PATIENT WITH

(DIAGNOSIS of the PATIENT)

a. TABLE OF CONTENTS
b. GLOSSARY/DEFINITION of TERMS
– alphabetical
- not less than thirty (30) words
I. INTRODUCTION
- Definition of the disease
- Statistics on the disease
- Current trends on the disease
III. NURSING ASSESSMENT
a. Personal history (demographics, educational
attainment, occupation, religion)
b. Socioeconomic
c. Environment
d. Activities of daily living (diet and nutrition,
habits/vices, etc.)
f. Family health history with pedigree
g. Physical Assessment (IPPA-Cephalocaudal
approach)
II. PATHOPHYSIOLOGY
(Book and Patient-centered)
- Synthesis of the disease
- Signs and symptoms with rationale
- Diagram
IV. Health history (past and present illness)
V. LABORATORY PROCEDURES
Procedure Date Purpose of the Normal Results Actual Results Analysis and
Requested/Date procedure Interpretation of
Results In (patient results
centered)
VI. DIAGNOSTIC PROCEDURES
Procedure Date Purpose of the Normal Results Actual Results Analysis and
Requested/Date procedure Interpretation of
Results In (patient results
centered)
VII. MEDICAL MANAGEMENT (includes IVF,
NGT, medications etc.)
Treatment or General action Purpose Date ordered Response of the Nursing
medication (patient- patient responsibilities
(generic and centered)
brand name)
VIII. SURGICAL MANAGEMENT

- Description of the Surgical Procedure

- Nursing responsibilities (before, during
and after surgery)
IX. NURSING CARE PLANS
- Five (5) Care Plan
- Prioritization (First 3 NCP) and Justify
- Include at not less than 10 nursing
interventions (IMPORTANT and RELATED to
the PATIENT)
X. REFERENCES