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Trinity University of Asia

St. Luke’s College of Nursing


275 E.Rodriguez Sr. Ave. Cathedral Hts.
Quezon City

Grand Case Presentation


Format and Rules

Revised by the Faculty of Nursing


June 1,2015
Frequently Asked Questions (FAQ)
Question: What case is the best to present?

Answer:
 Multisystem disorder is challenging to present but a case with one or two
diagnoses will do. What ever the group will agree to choose, the most
important thing is that the group were able to explain and defend the
case very well.
 Choose a case where almost all laboratory and diagnostic procedure are
all done.
 Choose a case where almost all medication and treatment are given.
 Consider the length of hospitalization.Ideally, a minimum of 3 days that
you handle patient. The longer the client will be handled by the group the
more data can be obtained and the group can assess, plan, intervene and
evaluate the care given.

Question: What would be the font and the font size to be used?
What would be the proper spacing?

Answer:
 Font: Calibri
 Font Size 12
 Spacing 1.5

Question: How many copies of ring bind GCP manuscript must be submitted by
the group?

Answer: 3 copies with the assigned color


Question: How many copies of hardbound must be submitted by the group
and
What color?

Answer: 1 copy of hard bound


Color: Royal blue (maltese cross blue)
Letters silver

Take note: The hardbound GCP is only permitted if it is already approved by the
panel. That means the group should see their panel to show the
corrections made. Ask the panel for their schedule and availability
for
consultation. It is important that you bring the old manuscript
where
they wrote their comments, suggestions and corrections.

The title of the case should be formal and base on the actual case or
diagnosis. Do not use a “sub title or quote”.

Example of Subtitle: “Aray,aray ang bato” (it’s a no,no)

Remember that the GCP is also a form of research.

Include the Approval Sheet


Sample Format of Approval Sheet

The Approval Sheet

In partial fulfilment of the requirements of the Degree of Bachelor of Science


in Nursing, the Grand Case Presentation has been prepared and submitted by;
Diño Jason, Doña Annalie, Fernandez Dan, Fernando Remedios Gacuya Rhea.

The aforementioned grand case presentation, (write the title of case here),
which has been checked and satisfactoriy edited, is hereby recommended for
submission.

Approved by the following panellists on (month/day/year):

Signature
Name of panel
_________________
Head Panel

Signature Signature
Name of panel Name of Panel
_____________ _______________
Panel Member Panel Member

Noted by:

Gisela D.A. Luna,RN PhD,SPED


Dean
St. Luke’s College of Nursing
Title page

TITLE OF THE CASE (Font 14)

A Grand Case Presentation (Font 12)

Presented to the Faculty of St. Luke’s College of Nursing

In Partial Fulfillment of the Requirements

In Related Learning Experience for the

Degree of Bachelor of Science in Nursing

Submitted by:

Yr and Section / Group No.

Name of Students

Month and Year


Example

RHEUMATIC HEART DISEASE SECONDARY TO RHEUMATIC FEVER

A Grand Case Presentation

Presented to the Faculty of St. Luke’s College of Nursing

In Partial Fulfillment of the Requirements

In Related Learning Experience for the

Degree of Bachelor of Science in Nursing

Submitted by:

4NU1 Group 1

Diño,Jason
Doña, Annalie
Fernandez,Dan Richard
Gacuya, Rhea
Pacada,Pamela

June 1, 2015
TABLE OF CONTENTS
(Font 14)

(Font 12)

I. Objectives Page No.


A. General
B. Specific

II. Introduction Page No.

III. Patient’s Profile Page No.

A. Demographic Data Page No.


B. Chief Complaint
C. History of Present Illness
D. Maternal History (OB-Gyne /Neonatal Cases)
E. History of Past Illness
F. History of Family Illness
G. Social History
Growth and Development (for Pediatric)
H. Allergies
I. Assessment
1. Physical Assessment
Others: Adult Head to Toe Assessment
Pediatric Assessment ( for Pediatric Cases)
Neonatal Assessment (Newborn Cases)
2. Gordon’s Functional Health Pattern (clients 12 years and above)

IV. Anatomy and Physiology


V. Pathophysiology
Vi. Course in the Ward
VII. Diagnostic Procedure and Laboratory Examinations
Viii. Drug Study
IX. Nursing Theory
X. Nursing Care Management
XI. Discharge Plan
XII. Bibliography
I. Objectives
A. General (1)
B. Specific
 Knowledge (at least 1-3)
 Skills (at least 1-3)
 Attitude (at least 1-3)

Reminders:

 Page layout: Portrait


 Specific objectives are written in BULLETS in the order of K-S-A
 Do not write the word Knowledge – Skills – Attitude as heading
 Learn to write the learning objectives using the BLOOM’s Taxonomy
(if you do not know Bloom’s, you can go to your CI to teach you)

II. Introduction:
Reminders:
 Page layout: Portrait
 Paragraph form and contains the following:
 1st Paragraph - Background of the Study
 2nd Paragraph – Definition of the case
 3rd Paragraph – Etiology
 4th Paragraph – Risk Factors
 5th Paragraph – General Signs and symptoms
 6th Paragraph – Incidence
 Choice and Significance (3-5sentence)
 Definition
 Emphasized etiology, risk factors and general signs and symptoms that
are related to the case by using bold. Italic , underline, highlight, etc.
 Incidence must be presented from macro to micro – International to
local.
 Suggest to use graphical presentation; pie chart, bar graph, etc. On the
hard copy and actual presentation.
III.Patient’s Profile

A. Demographic Data of Patient

Name
Address
Age
Gender
Civil Status
Occupation
Nationality
Religion
Admitting Diagnosis
Date and time of Admission

Reminders:
 Page lay out: Portrait
 Keep patient’s name and address confidential
 E.g Mr. JAR, Quezon City
 Keep physician’s name confidential
 E.g. Dr. HPV
 In the absence of admitting diagnosis, impression or working is accepted.

B. Chief Complaint
Reminder
 Chief complaint is not written exactly what the patient is verbalized
WRONG “ Sumasakit ang dibdib ko”....
RIGHT Chest pain

C. History of the Present Illness


Reminders
 Page layout
 Paragraph form (narrative)
 State what led the client to consult the hospital / emergency department
 Should be hour/hours,day/days,week/weeks,month/months
Guide questions:
o How, when, what
o Manifestation/s
o Signs and symptoms
o Treatment done
o Response to the treatment
o Consultation made: when and where
 DO NOT JUST RELY ONTHE DATA TAKEN FROM THE CHART. Validate the
data
 DO YOUR OWN NURSING HISTORY

D. Maternal History
 for OB-Gyne / Reproductive / for all Female
 Newborn Case
Reminders
 Page layout : Portrait
 Paragraph Form
 Attached is a copy on how to obtain maternal history (sample form
please)

E. History of the Past Illness


Reminders
 Page layout: Portrait
 Paragraph form
 Guide questions:
o Ever been hospitalized before? (when, where, why,etc)
o Do you suffer from any illnesses or conditions?
e.g mental illness
o Have you had any operations or procedure?
e.g. surgery
o Ask specifically about these diseases; another helpful
mnemonic is ; JAM THREADS
J – jaundice
A – anemia and other haematological conditions
M – myocardial infarction
T – tuberculosis
H – hypertension and heart disease
R – rheumatic fever
E – epilepsy/seizure/convulsion
A – asthma and COPD
D – diabetes
S- stroke
 Medications taken (when and why, etc)
(any maintenance)

F. History of Family Illness


Reminders
 Page layout Portrait
 Paragraph Form
 Guide questions:
o Are your family in good health
o Parents - maternal and paternal
- alive and well, or what is the cause of death?
o Grand parents? Children?spouse?
o Some areas of the family history may need detailed
questioning.
- E.g. to determine if there is significant family history of
Heart disease or cancer
o Be tactful when asking about a family history of malignancy
- “ I know this is difficult but it is important for us to have
the correct information.....”
 It may be useful to draw a family pedigree tree

G. Social History
(refer to MIAD/ HA)
Reminders:
 Page layout: Portrait
 Paragraph form
 Probe without prying (?)
 Guide Questions:
o Who else lives with you?
o Occupation
o Marital status
- Spouse’s job and health
o Housing – ( apartment?stairs – how many?
o Who visits – family, neighbours, general practitioners,
nurse?
o Any dependents
o Mobility –walking aids needed?
o Any Activity/ies that the patient can do or can’t do due to
illness?
o Taking alcohol, tobacco and recreation – How much? How
long?When did you stop?
- Quality of alcohol intake in terms of unit
- Smoking in terms of pack years.
 Patient frequently n “underestimate” how much they drink and
smoke , be inclined to double any quantities stated. A helpful for this
psychosocial aspect is SAD LADDERSS;

S - Smoking
A – Alcohol use
D – Drug Use
L – Living Situation
A- Activities of Daily Living
D- Depression
D- Diet
E- Exercise
R- Relationship
S- Sexual history
S- Support

H. Allergies
I. Assessment

1. Physical Assessment (Use Appropriate Assessment tool as indicated)


Example: Adult - Head to Toe Assessment
MIAD
Geriatric Assesment (e.g. CGA)
Pediatric Assessment
Neonatal Assessment
OB-Gyne
- Include sexual history(age, history of STD’s etc)
2. Gordon’s Functional Health Pattern (for clients 18 years old and above)
Reminders:
 Page layout
 No subjective data
 Paragraph Form
 Use a table EXACTLY AS SHOWN BELOW

Date: ____________

Temperature : _______˚C Route : ________


Pulse Rate : _______b.p.m Site : __________
Respiratory Rate : _______c.p.m
Blood Pressure : _______mm Hg
Weight : _______kg
Height :_______feet ____inches

Before Hospitalization During Hospitalization


Gordon’s Functional Health Pattern

 Change in PATTERN must be EVIDENT and CONGRUENT


 It is important and necessary to indicate the DATE OF ASSESSMENT
 Utilize assessment form or tool in obtaining data (see discussion on
Gordon’s Functional Health Assessment)
 Other resources in the HSC library maybe helpful for the Gordon’s
Functional Health Assessment.

IV . Anatomy and Physiology


Reminders
 Page lay out
 Paragraph form
 Focus on the affected organ involved only
Example: Diagnosis: Upper Gastrointestinal Bleeding (UGIB)
Discuss Upper GI only
 Picture/Images maybe useful in the discussion
 You may use VIDEO presentation on the actual day of the
GCP (if you want)

V. Pathophysiology
Reminders
 Page layout: Portrait
 Schematic presentation /page layout: Portrait or landscape (wherever
you can save more space)
 Start with MODIFIABLE FACTORS and NON-MODIFIABLE FACTOR
o Some surgery case may or may not have a modifiable factor or
non modifiable factors;
o Modifiable Factors: Life style Environment ,Diet
o Non Modifiable Factors: Age, gender, hereditary diseases
 Discussion on the DISEASE PROCESS follows
 Finally the signs and symptoms seen on the client.
 Make it concise
Sample: Pathophysiology (Schematic Diagram)

Pathophysiology of _______

Modifiable Non
Modifiable

factorss

factors

FacFactors

Disease Process

Factors

Disease Process

Disease Process

S/SX
Neuro Cardio Pulmo GI GU Integ Endo
      

Pathophysiology:
 Back up the etiology
 Check connections of the case with each other
VI. Course in the Ward

Reminders:
 Page layout: Portrait
 Paragraph form for the days not handled (no duty)
o Make a summary
 Bulleted for the days handled (days of duty)
 Days and date of duty is IMPORTANT
 Take note of the following;
o Current condition and sudden changes in the client’s condition.
Example: High grade fever, increase BP, bleeding, vomiting,
seizure
o Diagnostic procedures:
Example: Endocospic Gastroduodenoscopy (EGD)
o Laboratory procedure: CBC, Serum Na,K,Cl,Lipid profile
Note if laboratory/procedure is requested, done or not
Done
o Intravenous Fluid: Name of IVF, volume (in ml or cc), total
infusion time or flow rate
Example: PNSS 1L X12 hours or PNSS 1L X 20 gtts/min
o Medication: Name of Drug, dosage,dose, route
Example: Kalium durule 2 tabs, three times a day PO
Atenolol 50 mg tab once a day PO
o Treatment: Name of treatment, dosage/dose/route
Example: Salbutamol nebulization, 1 nebule every 6 hours
 NO REDUNDANCY of entry please.
Example: Day 1 – Monday, August 5, 2015
PNSS 1L X 12 hours

Day 2 – Tuesday, August 6, 2015


PNSS 1L X 12 hours

Day 3 – Wednesday, August 7, 2015


PNSS 1L X 12 hours
 Just READ the doctors order. Do not copy exactly what is written in the
chart. Rephrase the statement in the course in the ward but the thought
is still the same.
 Read the NURSES NOTES and get only important data/details. DO NOT
COPY THE ENTIRE NURSES NOTES.

VII. Diagnostic Procedure and Laboratory Examination

Reminders:
 Page layout: Portrait
 Indicate the date
 Retype the result and findings / interpretations
 Include NURSING CONSIDERATIONS: before, during and after applicable
 For series of laboratory examinations, example serum K, organize it in
table to facilitate discussion
 Learn why such diagnostic procedure and laboratory examinations
prescribed
 The interpretation should be related to the case
 You can use a table for this if you want

VIII. Drug Study


 Page layout: Landscape
 ONE DRUG PER PAGE
 Use table with 6 columns (see table)
o 1st Column – DRUG Generic name, Brand Name, Functional
Class, Chemical Class
o 2nd Column – Dosage, including form, frequency and route
o 3rd Column – Mechanism of Action
o 4th Column – Indications , Contraindications
o 5th Column – Side Effects, Adverse Reactions
o 6th Column – Nursing Consideration
 Use Nursing drug handbook,PPD for Nurses Notes, Mosby, Lippincott, etc
as reference
 Drug must focus on the chosen case.
 Indicate when the drug is given
 Type of order (e.g.stat, standing, PRN)
 Indicate the actual dosage or recommended dosage (pedia)

Sample

Drug Mechanism Indication & Side Nursing


Dosage of Action Contraindications Effects & Responsibility
Adverse
Reactions
Generic Name: 10 mg Indication: Side
Amlodipine Tab OD Effects
P.O Contraindication
Brand Name: Adverse
Norvasc Effects

Functional
Class:
Anti-
hypertensive

Chemical Class
Calcium
Channel
Blocker
IX. Nursing Theory

Reminders:
 Page Layout: landscape / portrait
 Paragraph form
 NURSING THEORY will serve as guide in making nursing care plan
 BRIEFLY discuss the chosen theory nursing theory. The use of
CONCEPTUAL FRAMEWORK or PARADIGM will be helpful in the
discussion.
 During the actual day of GCP, the presenter must discuss how the
nursing theory was applied to the case.
 Utilize at least 1 to 2 applicable nursing theories.
 The theory should also be connected to the NCP
X. THE CARE PLAN

Difference of:

NURSING CARE PLAN (NCP) – define


- What want to do for the patient
- Written in future tense
- “plan of care”

NURSING CARE MANAGEMENT (NCM) – define


- care you have rendered to the patient
- written in past tense
Reminders:
 For GCP sake we will use the NCM instead
 Page layout: Landscape
 May utilize 1 or 2 pages for each nursing care management
 PRIORITIZED identified ACTUAL problems
 RISK problems will only be considered in the absence of actual
problems
 Use 2 part nursing diagnosis only (problem and etiology)
 For setting goal, use S-M-A-R-T (specific,
measurable,attainable,results oriented,time bound)
 Interventions include; independent,dependent, collaborative
 Collaborative refers to other member of the health team like the
Physical therapist, ancillary department,dietician,etc
 For goal met and partially met write supporting data
 For Goal not met just write the support data.
e.g. Still have a fever of 39˚C
 Long term Goal (define/explain)
 Short term goal (define/explain)
 If patient died....you can still present it as long as it was handled
XI. Discharge Planning:

Reminders:
 Bulleted / Page layout: Portrait
 The mnemonic M-E-T-H-O-D-S is just a guide in making a good discharge
plan
M – Medications
E - environment
T - treatment
H – health teachings
O – out patient follow up
D – diet
S – social
S – spirit
S- sexual (as indicated /case to case basis)

 It is not necessary that each M-E-T-H-O-D-S must be present in the


discharge plan ONLY IF APPLICABLE

X. Bibliography
 Write all forms of resources
e.g. books, journals, internet ,research ,study
- as much as possible less internet
 Site the references
 Take recognition of the author
TRINITY UNIVERSITY OF ASIA
St. Luke’s College of Nursing

Grand Case Presentation Evaluation Tool

Year / Section/ Group: ____________________________________________

Title of the Case: _________________________________________________

GUIDELINES

1. Each case must be approved by the coordinator / adviser /CI prior to the
presentation.
2. All the presenters must be in the venue 15 minutes before the start of the
presentation. See to it that there is LCD and cord at the venue.
3. Schedule of the presentation will be arranged by the Clinical Coordinator.
4. In the absence of a group member , the other members should assume
responsibility of the missed part.
Absent group member will make an individual case presentation after 1 week
of exposure in the clinical area .
5. No one is allowed to go out of the room while the presentation is on going.
6. Allotted time for the GCP is one hour and 15 minutes. 45 minutes for the
Presentation and 30 minutes for the question and answer or vice versa.
7. Physical setting should be formal and participants are encouraged to speak in
English
8. Criteria for evaluation

AREAS OF EVALUATION RATINGS COMMENTS


I. Format – 15%
A. Relevance of the Objective 5%
B. Organization / Clarity 10%
II. Content 30%
III. Presentation -25%
A. Appeared at Ease 5%
B. Good quality and tone of Voice 5%
C. Choice and quality of media 10%
used/visual impact
D. Adherence to time limit 5%
IV. Question and Answer 30%
TOTAL 100%

Names of Panelists / Signature:


1. _______________________
2. _______________________
3._______________________
Addendum: Comments and Suggestions (by invited panel from SLMC)

Physical Assessment
 Include cranial nerve if needed
 Check papillary reaction
 GCS
 Pressure ulcer grade
 May use BATTELL/BACTELL ADL Scale
 May use MRS Modified Ranking Scale

Diagnostics:
 Brief indication / purpose

GCP
 Case should be most recent and part of the current semester
 Read books at least 5 books
 Community GCP

This Grand case presentation format revision was presented during the faculty meeting in June 1,2015
which was spearheaded by Remedios H. Fernando. All the content is was based on the suggestions,
comments of all the faculty and panel involved during the 1st , 2nd and summer of academic year 2014-
2015.