Case Study Guide for Level IV Students

8/4/2019 Case Study Guide for Level IV Students

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LEVEL 4

GENERAL NURSING UNIT



EMILIO AGUINALDO COLLEGE1113-1117 San Marcelino St., cor. Gonzales St. Ermita, Manila

School of Nursing

A Case Presentation on(case title)

In partial fulfillment of the requirements in(subject title)

Submitted to:(Full name of C.I./area of affiliation)

Submitted by:(year & section/group#/members full name-alphabetical order)

Date Submitted



ACKNOWLEDGEMENT

We would like to thank the people who have been part of thiscase presentation:

For the Lord Almighty who has given us strength and courageto fulfill this requirement despite our hectic schedules.

for our teacher, Sir/Mam, who guided us in our clinical duties.

For our families who have been very supportive in achievingour goals.

For our patient who has been cooperative during our interview with him/her.

For Dr. Dinah Fojas who made our topic for the caseunderstandable at our level.



Table of Contents(sample only)• INTRODUCTION PAGE/S #• OBJECTIVES PAGE/S #• DEMOGRAPHIC PROFILE PAGE/S #• HISTORY OF PRESENT ILLNESS PAGE/S #• PATTERNS OF FUNCTIONING (PHYSICAL ASSESSMENT) PAGE/S #•

ANATOMY & PHYSIOLOGY PAGE/S #• PATHOPHYSIOLOGY PAGE/S #• DRUG STUDY PAGE/S #• PARENTERAL THERAPIES PAGE/S #• DIAGNOSTIC EXAMS PAGE/S #• LABORATORY EXAMS PAGE/S #•

COURSE IN THE WARDS PAGE/S #• PROBLEM IDENTIFICATION / PRIORITIZATION PAGE/S #• NURSING CARE PLAN PAGE/S #• DISCHARGE SUMMARY / PLAN PAGE/S #• REFERENCES PAGE/S #



INTRODUCTION(sample only)

• Inguinal Hernia

• Types:

•

Who are at risk?• What are the symptoms?

• How is it diagnosed?

• Herniorraphy

• Recovering from surgery • Preventive measures that can be done

• Note: this is an overview of the entire disease condition of the patient (summarized), written on a 1-page only



PATIENT’S DEMOGRAPHIC PROFILE

• HOSPITAL #:• WARD/ROOM/BED #:• DATE OF ADMISSION/CONFINEMENT:• TYPE OF ADMISSION: EMERGENCY • NAME:• ADDRESS (CITY/PROVINCE):• AGE:• SEX:• BIRTHDATE:•

BIRTHPLACE:• WEIGHT:• RELIGION:• NATIONALITY:• CIVIL STATUS:

• OCCUPATION:



(continuation)

Chief Complaint/s:

ATTENDING PHYSICIAN:

INITIAL/ADMITTING/TENTATIVE/WORKINGDIAGNOSIS:

FINAL DIAGNOSIS:



HISTORY OF PRESENT ILLNESS

A. Present Illness

This is a case of Mr. JTB….. who came in due to…..

B. Chronological History

2 years PTA, patient noted…..

3 months PTA, after carrying a 100 kg transmission of atruck, patient noted that….



C. Past Medical History

• Patient has no hypertension, diabetes mellitus, andasthma. Has allergies to some foods like eggplant,

sardines, and bagoong. (elaborate more)

D. Family History

•

His mother is known to be hypertensive. No knownhistory of cardiac disease, cancer, tuberculosis, kidney problem and diabetes.(elaborate more)

• May use diagram & legend for visual explanation to show

relatedness of the disease to the patient’s history.



(Continuation)

E. Personal and Social History

Patient is a non-smoker but occasional alcoholic drinker.He is a mechanic operator who usually carries heavy load.(elaborate more)

(Note: must identify significant data related to patientcondition)



(Physical Assessment Tool)

PATTERNS OF FUNCTIONINGGORDON’S FUNCTIONAL HEALTH PATTERN GENERAL SURVEY • HEALTH PERCEPTION – HEALTH MNGT PATTERN• NUTRITIONAL – METABOLIC PATTERN•

ELIMINATION PATTERN• ACTIVITY – EXERCISE PATTERN• SLEEP –REST PATTERN• COGNITIVE – PERCEPTUAL PATTERN• SELF-PERCEPTION – SELF-CONCEPT PATTERN• ROLE – RELATIONSHIP PATTERN• SEXUALITY – REPRODUCTIVE PATTERN• COPING – STRESS – TOLERANCE PATTERN• VALUE- BELIEF PATTERN



NUTRITIONAL – METABOLIC

PATTERN(sample only)

SUBJECTIVE DATA: the patient stated that she only drinks 2-3 glasses/day. She also stated that she had aloss of appetite due to discomfort in swallowing of food.

OBJECTIVE DATA: facial grimacing when swallowing.Swelling and redness of tonsils. Weight: 38 kg, height:4’9”

BMI: 19 (acceptable)



(sample only)

NORMS / STANDARDS

Intake of 1200-1500 ML OR 8-10 GLASSES OF WATER/DAY for an adult

BMI: <18.5 – underweight

18.5 – 24.9 – normal

25 – 29.9 – overweight30 – 39.9 – obese

> 40 – extremely obese



General Survey Include DATE OF ASSESSMENT

General appearance

Level of consciousness Vital signs

Body built

Language



Sample chart for physical

assessment (GORDON’s)

Nutritional – Metabolic Pattern

BEFOREHOSPITALIZATIO

N

SUBJECTIVECUES:

OBJECTIVE CUES:

DURINGHOSPITALIZATIO

N

SUBJECTIVECUES:

OBJECTIVE CUES:

NORMS/STANDARDS

(BOOKBASED/IDENTIF Y REFERENCE)

ANALYSIS

(DESCRIBE YOUR OWNSIGNIFICANTINTERPRETATION)



ANATOMY / PHYSIOLOGY Textbook discussion (focus on the involved body organ

and its normal function)

Can add pictures (download in the internet) &references (new edition)

May include Diagrams & charts



PATHOPHYSIOLOGY PATIENT-BASED

PREDISPOSING / PRECIPITATING FACTORS

MODIFIABLE & NON-MODIFIABLE FACTORS PROCESS (PATHOGENESIS) TO PRESENTING

SIGNS/SYMPTOMS TO DEVT OF COMPLICATIONS

USE OF ARROWS / SYMBOLS



Pathophysiology of CVA(sample only)

Predisposing factors

Precipitating factor

Non-modif iable

modif iable

Process of pathogenesis/sequela

Appearance of presenting signs / symptoms



DRUG STUDY

> GENERIC> BRANDNAME

PATIENT’

S DOSAGEFREQUENCY DISCONTINUATIO

NROUTE ACCEPTA BLETHER APEUTICPLASMA LEVEL SHIFTEDOF DRUGS

DRUGCLASSIFIC ATION(chooseonly applicable

to yourpatientcondition)

INDICATION>CONTRAINDICATION(chooseonly

applicable to your patientcondition)

>DRUG ACTION> (bookbased)

>SIDE-EFFECTS>ADVERSEEFFECTS

>NURSINGCONSIDER ATION/S(INDEPENDENT/DEPENDENT

ACTIONS)



DRUG STUDY• Generic and brand name

• Patients dosage/frequency/route/date of discontinuation/route/therapeutic plasma level

• Drug classification

• Mechanism of action

• Indications / contraindications

• Side effects / adverse effects

• Nursing considerations (independent/dependent)



PARENTERAL THERAPIES IVF (Identify the type of solution/flow rate/ amount of

solution/# of bottles consumed/drug incorporation/identify the significance of parenteral solution to the

condition of the patient)

COLLOID SOLUTIONS and others

Use chart format if more than 1 IVF solution is used



DIAGNOSTIC EXAM X-RAYS / CT SCAN / MRI /ENDOSCOPY

LAPAROSCOPIC /VISUALIZATION EXAMS

ECG / EEG SHOW ACTUAL / ROENTGENOLOGICAL FINDINGS

INTERPRETATION / IMPRESSION OF RESULTS

DATE TAKEN (PREVIOUS TO CURRENT)



LABORATORY EXAMS URINE / FECAL / HEMATOLOGY / BACTERIOLOGY

/ BLOOD CHEMISTRY

PRESENTED IN A DIAGRAM (include date taken(previous to current)/normal values/highlight actualabnormal findings/remarks/ significance of the exam& interpretation of results



Course in the Wards• Narrate pertinent significant changes on the patients’

condition; new doctors’ order; put your nursing action(if any); new diagnostic or laboratory exams ordered;

changes in medication

• Done at the end of your shift/daily with the patient orevery RLE duty

•

Include date/time• Must be presented in a narrative/descriptive format



PROBLEM

IDENTIFICATION/PRIORITIZATION Identify all significant HEALTH PROBLEMS seen in

the patient

Identify at least 3 ACTUAL and 2 POTENTIALprioritized health problems

THEN RANK IT ACCORDING TO PRIORITY

JUSTIFICATION FOR EACH IDENTIFIED HEALTH

PROBLEM AS TO WHY IT IS OF HIGH PRIORITY



Nursing Care PlanNote: (Make also a Pre-op/Post-op NCP for your patient if undergone anoperation)

• Make NCP for each HEALTH PROBLEM identified• CUES/ CLUSTERED DATA /ASSESSMENT (SUBJ/OBJ)

• NURSING DIAGNOSIS & ETIOLOGY (1 ONLY PER CARE PLAN)• INFERENCES / SCIENTIFIC ANALYSIS• OBJECTIVE (S-M-A-R-T)• INTERVENTIONS (Independent-Dependent-Collaborative actions)• RATIONALE•

EVALUATION• Note: present NCP in a chart form (Cues;Nsg

Dx;Inference;objective;interventions;rationale;evaluation)



DISCHARGE SUMMARY / PLAN• NARRATE THE STATUS OF THE PATIENT (ACTUAL

CONTACT WITH THE PATIENT ON THE LAST DAY OFDUTY)

•

Use M-E-T-H-O-D-S• M – medications

• E – exercise

• T – treatment

•

H – health teachings• O – outpatient follow-up

• D – diet of patient

• S – sexual / spiritual



DISCHARGE SUMMARYNutritional therapy • Patient was advised to have regular diet, can have intake of fruits &

vegetables with high fiber so as not to strain during bowel movt.Maintenance of daily activities

• Avoid tub baths for at least 5 days after the operation, because soaking will separate the skin tapes and the would might get infectedMedical mngt• Instructed patient to frequently checked for signs of infection (fever,

swelling, discharges)(Note: use past tense, make instructions clear as if u were talking to the

patient, avoid medical jargons)



REFERENCES Include textbook title, edition, volume, pages,

Include all textbook & references used in during theconduct of study

May include significant websites / internet references/addresses

ona n orma on or



ona n orma on orStudents

•

Make 3 NCP for ACTUAL health problem & 2 NCP forPOTENTIAL health problem

• Submit a copy of the Case Presentation to the panelist 3days before the actual oral defense for the Grandpresentation

• A Criteria for Grading the case presentation is given to you in advance for review of your case.

• Use legal size paper for your case study

•

This is a group work, thus a group grade is given to allmembers of the group.

Case Study Guide for Level IV Students

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