Nursing case presentation by student nurses is an effective tool in acquiring knowledge about diseases, enhances critical thinking, practices their ability to apply the nursing process and improves their communication skills.
A very important component of a nursing case presentation is the collection of data about the client both subjective and objective. This means a thorough Nursing Health history, physical assessment and the results of laboratory test and diagnostic procedures.
Here is an outline on how to go about your nursing case presentation.
- Biographic Data
- Chief Complaint (Chief Complaint may be different from reason for visit) Reason for Visit (reason the patient states for seeking care)
- History of the Present Illness
- Past history
- General state of health
- childhood illnesses
- Immunizations
- adult illnesses
- psychiatric illness
- operations
- injuries
- hospitalizations
- current medications
- Allergies
- Family History of Illness
- the age and health or age and cause of death of each immediate family member
- the occurrence within the family of any of the following conditions ( diabetes, TB. heart disease, high blood pressure, stroke, kidney disease, cancer arthritis, anemia, mental patient
- Menstrual and Obstetric History (if applicable)
- Lifestyle/ Activities of Daily Living
- Social Data
- Psychological Data
II. Patterns of Functioning /Gordon’s Functional Health Pattern
III. Physical Assessment
IV. Laboratory/ Diagnostic Examination Results
V. Medications. IV infusions, Blood Transfusions, treatments given
VI. Review of Systems
VII. Anatomy and Physiology
Review of the organ system and its function related to illness of the client
VIII. Pathophysiology of the disease
IX. Prioritized List of Nursing problems
X. Nursing Care Plan
XI. Discharge Plan
If you need help about your nursing case presentation, you can leave a comment on this blog. Hope this guide will help you my dear students!
{ 12 comments… read them below or add one }
besides head to toe examination,what all would be included under physical assessment?
@ irene: Physical examination means using inspection, palpation, percussion and auscultation techniques. It should also include, neurological, reflexes, muscle strength and mental status assessment. You can refer to Kozier’s book (fundamentals of nursing) for more about physical assessment. Thanks for visiting the site
hi dra! i just want to verify f the case presentation of midwives are the same with the nurses? thanks
@riza: more or less the same except in the latter part which is the nursing care plan. I’m not sure also if midwives do use the Gordon’s health pattern.From the biographic profile up to physical examination, more or less they are the same.
its hard. . i had difficulties making such..
@ kylia: yes its hard for newbies, but its a part of the learning process. Good luck!
For infection Control what are the possible case presentations
@Ajaz: IN any nursing case presentation, the client is the focus of the case presentation. Any infectious disease can do as case presentation. Infection control should be based on the Isolation precautions in a hospital setting at the same time knowing the chain of infection.
this was really helpfull, i wish that my instructors would give a more in-depth discussion such as this
@ don: thank you. glad i was of help to fellow nurses here and abroad.
i need help……. we dont have enough data regarding our case because our patient had been transferred to another hospital before they even tell us that our case will that of the patient who was transferred….do you think we have a higher chance to survive this case???? im nervous the panel(hehehe) might ask things outside the data we just gathered from the chart…… wahhh scarcity
@ alfred: how will you be able to properly diagnose if you have not assessed your client properly? As I always tell my students a good case presentation depends on the data you have collected. Good luck!