Title of Case
CASE PRESENTATION
SPEAKER’S NAME
ENTER THE DATE OF PRESENTATION HERE
Outline:
Introduction of the case
Demographic Data
Health History and Physical Exam
Medical Diagnosis
Laboratory, Diagnostic and Imaging tests
Nursing Care Plan
Discharge Plan
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INTRODUCTION
Purpose/ Reason for selecting the case:
Main Goal:
Objectives:
3
Health Assessment
4
HEALTH HISTORY
File No :
Department :
Dates: From To
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Admission Data
Date and Time of Arrival in ER:
Date and Time of Admission:
Department Admitted to:
Source of Admission:
Mode of Transport:
Complaint:
Diagnosis:
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Complaint Data
Time:
Duration:
Location:
Quality:
Associated Factors:
Signs and Symptoms:
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Personal/Social Data
Age :
Gender :
Marital Status :
No. of Children:
Nationality :
Language :
Religion :
Educational Level:
Occupation :
Residence :
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Family History
NO FAMILY MEMBERS AGE EDUCATIONAL OCCUPATIONAL HEALTH STATUS
STATUS STATUS
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Activities of Daily Living
Independent:
Dependent:
Assistance:
Using Aids:
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Previous Health History
Mental/Physical Illness:
Medications:
Accidents:
Surgery/Procedures:
Allergies:
Immunization:
Screen Test:
Menstrual and Obstetric History:
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Habits
Drugs:
Alcohol:
Smoking:
Caffeine consumption:
_____ per day X _____ years
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Criminal/Accident Events (if any)
Source of Information:
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Physical Examination
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General Survey and Behaviour
Apparent Health State: Good / Fair / Ill / Poor
Level of Conscious: Fully Conscious/ Semi Conscious/ Unconscious
Signs of Distress: Cardiac/ Respiratory/ Pain/ Anxiety/ Depression
Built and Height: Normal/ Pyknic/ Athletic/ Aesthetic/ Deformed
Nutritional status and weight: Normal/ fat/ thin/ cachectic
Skin: Normal/ Discoloration/ Obvious lesions
Dressing, Grooming & Personal Hygiene: High/ Normal/ Low
Odor of Body and Breath: Yes/ No
Facial Expression, Posture, Gait and motor activity: Normal/ Abnormal
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Vital Signs
Temperature : °C
Pulse rate : bpm
Respiratory rate : cpm
Blood Pressure : mmHg
S
PO2 :
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Abnormal/ Positive Findings of Involved System
Central nervous system:
Integumentary system:
Respiratory system:
Cardio vascular system:
Gastro intestinal system:
Excretory system:
Provisional Diagnosis:
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Diagnostic Procedure
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USG ABDOMEN:
X-RAY:
CT Scan/MRI
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Laboratory
Investigations
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Test: Date:
Parameters Normal range Patient’s Interpretation Indication
value
Red: for abnormal values
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Medical Diagnosis
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Definition
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Causes/Etiology
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Risk Factors
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Clinical Manifestations
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Pathophysiology
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Management
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PHARMACOLOGICA
LMedication Classification Indications Contraindications Dose Adverse Nursing Responsibilities
Name Patient Effects
Received
Generic:
Brand:
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PHARMACOLOGICA
LMedication Classification Indications Contraindications Dose Adverse Nursing Responsibilities
Name Patient Effects
Received
Generic:
Brand:
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NON-PHARMACOLOGICAL MANAGEMENT
Surgery/Therapeutic Procedure:
Diet:
IV Fluid Support:
Oxygen Support:
Physiotherapy:
Respiratory Therapy:
Blood Transfusion:
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Nursing
Management
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ASSESSMENT NURSING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
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ASSESSMENT NURSING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
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Discharge Plan
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Medication:
Exercise:
Treatment:
Health Education:
OPD Follow up:
Diet:
Special Instructions:
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THANK YOU
