CONTENTS OF CASE PRESENTATION

I. INTRODUCTION
II. GENERAL OBJECTIVE
III. PATIENT’S PROFILE
IV. NURSING HISTORY
a. Past health history
b. Present health history
c. Family health history
V. ACTIVITIES OF DAILY LIVING
VI. PHYSICAL EXAMINATION RESULT
VII. LABORATORY FINDINGS
VIII. ANATOMY AND PHYSIOLOGY OF THE ORGAN INVOLVED
IX. PATHOPHYSIOLOGY
X. DRUG STUDY
XI. NURSING CARE PLAN
XII. DISCHARGE PLAN

EXAMPLE OF PATIENT’S PROFILE

Name: Ms. Q.
Age: 2 y/o
Gender: Female
Address: 33 M. Santos St., Antipolo City
Birth date: December 17, 2006
Birth Place: Antipolo City
Civil Status: Child
Religion: Catholic
Nationality: Filipino
Nearest kin: Mother
Chief Complaint: Vomiting for 2 days
Initial vital signs: RR-22 cpm, PR-94 bpm, BP-NA, T-38°C, Wt-12 kg.
Admitting Diagnosis: Acute Gastroenteritis
Attending Physician: Dra. Manalo

ACTIVITIES OF DAILY LIVING

Activities of Daily Living Before Hospitalization During Hospitalization

Nutrition
Elimination
Hygiene
Rest and Sleep
Exercise
Substance abuse
Sexual activity

PHYSICAL EXAMINATION RESULT

Body Part Technique Used Findings Interpretation and Analysis

PATHOPHYSIOLOGY
(in a diagram format)

Modifiable and Non-modifiable risk factors

Disease process in the body

Signs and Symptoms

DRUG STUDYMETRONIDAZOLE
Generic/ Trade Classification Indications Contra- Dosage and Side Effects Nursing
Name indications Route Responsibilities
Metronidazole Antibiotic Acute infection with Hypersensitivity Available CNS: Headache, Assessment:
susceptible anaerobic to metronidazole; forms: Tablets dizziness, ataxia, History: CNS or hepatic
Antibacterial bacteria pregnancy (do not —250, 500 mg; vertigo, disease; candidiasis
(moniliasis); blood
use for ER tablets—750 incoordination,
Amebicide Acute intestinal amebiasis dyscrasias; pregnancy;
trichomoniasis in mg; capsules— insomnia, seizures, lactation
Amebic liver abscess first trimester). 375 mg;powder peripheral
Antiprotozoal for injection— neuropathy, fatigue Physical: Reflexes,
Trichomoniasis Use cautiously 500 mg; affect; skin lesions,
with CNS injection—500 GI: Unpleasant color (with topical
Preoperative, diseases, hepatic mg/100 mL; metallic taste, application); abdominal
intraoperative, disease, anorexia, nausea, exam, liver palpation;
powder for
postoperative prophylaxis urinalysis, CBC, liver
candidiasis injection—500 vomiting, diarrhea,
for patients undergoing function tests
colorectal surgery (moniliasis), blood mg GI upset, cramps
dyscrasias, Avoid use unless
Topical application in the lactation. GU: Dysuria, necessary.
treatment of inflammatory incontinence, Metronidazole is
papules, pustules, and darkening of the carcinogenic in some
erythema of rosacea urine rodents.

Unlabeled uses: Administer oral doses

Local:
prophylaxis for patients with food.
undergoing gynecologic, Thrombophlebitis
abdominal surgery; hepatic (IV); redness, Apply topically
encephalopathy; Crohn's burning, dryness, (MetroGel,
disease; antibiotic- and skin irritation MetroCream) after
associated (topical) cleansing the area.
pseudomembranous
colitis; treatment of Advise patient that
Other: Severe,
Gardnerella vaginalis, cosmetics may be used
disulfiram-like
giardiasis (use over the area after
recommended by the CDC) interaction with application.
alcohol, candidiasis
(superinfection) Reduce dosage in
hepatic disease.
NURSING CARE PLAN

ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION EVALUATION

Subjective data: Problem related to cause Goal: Include the interventions (what is the outcome of
(what the client says) (should be broader than to solve the problem or the treatment)
(should be based on objective, opposite of the the diagnosis
Objective data: NANDA’s List of problem)
(what you observed Diagnoses) (all possible independent
including what you have Objective: interventions first before
measured) (SMART) dependent and
collaborative
interventions)

DISCHARGE PLAN

Medications (home medications instructions: dosage, route, time, indications, drug to drug and drug to food interactions, precautions)
Exercise (recommended exercise, its benefit for the patient’s condition)
Treatment (drug therapy, hydration therapy, physical therapy, rehabilitative therapy)
Health teaching (self-care activities, hygiene, sleeping pattern and rest periods, disease prevention)
Outpatient Follow up (information for follow up measures)
Diet (recommended diet, proper amount, benefits of the diet and transitions in the diet)