Format of Case Presentation

A. Introduction - brief description of the disease and disease statistics

B. Client’s Profile - Complete Profile

Biographic Data
Client’s name, address, age, sex, marital status, occupation, religious preference, health care
financing, and usual source of medical care.
Chief Complaint or Reason for Visit
The answer given to the question “What is troubling you?” or “what brought you to the
hospital or clinic?” The chief complaint should be recorded in the client’s own words.
History of Present Illness
• When the symptoms started
• Whether the onset of symptoms was sudden or gradual
• How often the problem occurs
• Exact location of the distress
• Character of the complaint (e.g., intensity of pain or quality of sputum, emesis, or discharge)
• Activity in which the client is involved when the problem occurred
• Phenomena or symptoms associated with the chief complaint
• Factors that aggravate or alleviate the problem
Past History
• Childhood illnesses, such as chickenpox, mumps, measles, rubella (German measles), rubeola
(Red measles), streptococcal infection, scarlet fever, rheumatic fever, and other significant
illnesses
• Childhood immunizations and the date of the last tetanus shot
• Allergies to drugs, animals, insects, or other environmental agents and the type of reaction that
occurs
• Accidents and injuries: how, when and where the accident occurred, type of injury, treatment
received, and any complications
• Hospitalization for serious illnesses: reasons for the hospitalization, dates, surgery performed,
course of recovery, and any complications
• Medications: all currently used prescription and over-the-counter medications, such as aspirin,
nasal spray, vitamins, or laxatives

Family History of Illnesses

To ascertain risk factors for certain diseases, the age of siblings, parents, and grandparents
and their current state of health or, if they are deceased, the cause of death obtained. Particular
attention should be given to disorders such as heart disease, cancer, diabetes, hypertension, obesity,
allergies, arthritis, tuberculosis, bleeding, alcoholism, and any mental health disorders.

Review of Systems
C. Patterns of Functioning by Gordon - Client’s Response, Analysis and Interpretation
Functional-Health Patterns (by Gordon):
1. Health Perception-Health Management Pattern
a. How has general health been?
b. Any colds in the past?
c. Most important things done to keep healthy? You think these things make a
difference to health?
d. In the past, has it been easy to find ways to follow things nurses or doctors suggest?
e. If appropriate: What do you think caused this illness? Actions taken when symptoms
were perceived? Results of actions?
f. If appropriate: Things important to you while you are here? How can we be most
helpful?
2. Nutritional Metabolic Pattern
a. Typical daily food intake? (Describe)
b. Typical daily fluid intake? (Describe)
c. Weight loss/gain? (Amount)
d. Appetite?
e. Food or eating: Discomfort? Diet restrictions?
f. Heal well or poorly?
g. Skin problems, lesions, dryness?

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 h. Dental problems?
3. Elimination Pattern
a. Bowel elimination pattern (Describe). Frequency? Characteristic? Discomfort?
b. Urinary elimination pattern (Describe). Frequency? Characteristic? Discomfort?
Problem in control?
4. Activity-Exercise Pattern
a. Sufficient energy for completing desired/required activities?
b. Exercise pattern? Type? Regularity?
c. Spare time (leisure) activities? Child: Play activities?
d. Perceived ability for: (code for level)
Feeding ________ Grooming ____________
Bathing ________ General mobility ______
Toileting _______ Cooking _____________
Bed mobility ____ Home maintenance ____
Dressing _______ Shopping ____________

Functional levels code:

Level 0: Full self care
Level I: Requires use of equipment or device
Level II: Requires assistance or supervision from another person
Level III: Requires assistance or supervision fro another person or device
Level IV: Is dependent and does not participate
5. Sleep-Rest Pattern
a. usual sleep pattern (Time on bed and time awaken)
b. Sleep aids (If any)
c. Quality of Sleep (Describe)
6. Cognitive-Perceptual Pattern
a. Hearing difficulty? Aid?
b. Vision? Wear eyeglasses? Last checked?
c. Any change in memory lately?
d. Easiest way for you to learn things? Any difficulty learning?
e. Any discomfort? Pain/ How do you manage it?
7. Self-Perception-Self-Concept Pattern
a. How do you describe yourself? Most of time, feel good (not so good) about
yourself?
b. Changes in your body or things you cannot do? Is that a problem to you?
c. Changes in way you feel about yourself or your body? (since illness started?)
d. Find things frequently make you angry? Annoyed? Fearful? Anxious? Depressed?
What helps?
8. Role Relationship Pattern
a. Live alone? Family? Family structure (diagram)
b. Any family problems you have difficulty handling?
c. How does family usually handle problems?
d. Family depend on you for things? If appropriate: How is the managing?
e. If appropriate: How family/others feel about your illness/hospitalization?
f. If appropriate: Problems with children? Difficulty? Handling?
g. Belong to social groups? Close friends? Feel lonely (frequency)
h. Things generally do well with you at work (school/college) If appropriate: Income
sufficient for needs?
i. Feel part of (or isolated in) neighborhood where living?
9. Sexuality-Reproductive Pattern
a. If appropriate: Any changes or problems in sexual relations?
b. If appropriate; Use of contraceptives? Problems?
c. Female: When menstruation started? Last menstrual period? Menstrual problems? Para?
Gravida?

10. Coping-Stress Tolerance Pattern

a. Tense most of the time? What helps? Use any medicine, drug, alcohol?
b. Who’s mot helpful in talking things over? Available to you now?
c. Any big chances in your life in the last year or two?
d. When (if) have big problems in your life, how do you handle them?
e. Most of the time, is these ways successful?

11. Value-Belief Pattern

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 a. Generally get things you like out of life? Most important thing?
b. Religion important in your life? If appropriate: Does this help when difficulties
arise?
c. If appropriate: Will being here interfere with any religious practices?

D. Complete Physical Assessment - Cephalocaudal Pattern

Actual Findings and Interpretation

E. Growth and Development Pattern - base on the client’s age

Client’s Stage, Analysis and Interpretation

F. Course in the Ward

Client’s day to day activities while admitted - in a narrative format
Doctor’s order aligned to nursing interventions

G. Review of Anatomy and Physiology - identification of the parts and functions of the organ/s affected
H. Ecologic Model - Epidemiologic Triad

I. Pathophysiology - describe the conditions observed during the disease state showing the client’s presenting
signs and symptoms
- Diagram Format

J. Laboratory and Diagnostic Exams - Date of Laboratory Exam, Purpose and Interpretation

K. Drug Study - 6 Columns

1 2 3 4 5 6
Generic Name / Mechanism of / Indication / Contraindication / Side Effects / Nursing
Brand Name Action Adverse Effects Responsibility
- All relevant to client

L. List of Prioritize Nursing Problems

# 1 as top priority

M. Top 3 NCP - ADPIRE

Assessment ( Subjective, Objective, Measurements)
Diagnosis (PES format)
Planning ( Goals and Objectives)
Implementation (Independent, Dependent, Collaborative)
Rationale
Evaluation
N. Discharge Plan - The students can use their own mnemonic.
M.O.D.E. - Medications, symptoms to Observe, Diet, Exercise
M.E.T.H.O.D. S. - Medications, Exercise, Treatment, Health Teachings, what to Observe, Diet,
Spirituality, Sexuality

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 CASE PRESENTATION GRADING and RUBRICS
Each item is rated on the following rubric. SCORE: _____________
1= Poor
2 = Fair Total Score = _______ X 75 + 25 = %
3 = Adequate 100
4 = Good
5 = Excellent Panel: _________________________
Signature Over Printed Name
A. Introduction - brief description of the disease and disease statistics.
A description of the client’s case as well as a brief overview of the research literature is
presented. ________
B. Client’s Profile - Complete Profile
Completeness - a comprehensive amount of information was provided. ______
C. Patterns of Functioning by Gordon
Insightful and thorough analysis of the client’s response. ______
D. Complete Physical Assessment
Sufficient amount of data were gathered from physical examination. _______
E. Growth and Development Pattern
Integrates growth and development pattern based on the client’s adaptation. ______
F. Course in the Ward
Identifies the important role of nurse’s in the day to day activities in the ward. ______
G. Review of Anatomy and Physiology
Anatomy and physiology were carefully examined in significance to the main problems
presented._______
H. Ecologic Model
Thorough analysis of most of the problems causing the disease progression. _______
I. Pathophysiology
Format is appropriate and enhances the understanding of the manner throughout the
development of the signs and symptoms presented by the client. ______
J. Laboratory and Diagnostic Exams
Identification, analysis and interpretation of the laboratory and diagnostic exams and its significance
on the client’s condition. ________
K. Drug Study
Accurate medication administration, its nursing implications and client teaching. ________

L. List of Prioritize Nursing Problems

Nursing Problems were prioritized. _______

M. Top 3 NCP
Identifies & understands the steps of the nursing process and how to write an
individualized Nursing Care Plan.
1. ________ 2. ________ 3. __________
N. Discharge Plan
Makes realistic and appropriate health teachings. ______
O. Presentation
The way of delivery - very clear and concise. _________
The use of visuals and pictures to augment the presentation. ________
P. Question and Answer
Questions were answered and salient points were discussed.________
Q. Time

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Time management. (45 minutes - presentation, 45 minutes - question and answer)._______