Group Leader

__________________
Group Members

Title of the case

CETN batch ____ GROUP ____

__________________ __________________ __________________ __________________ __________________ __________________ __________________

Process flow of discussion

A brief background of the study Scope and limitation of the study Demographic Profile and pertinent Histories Course in the Ward Summary of pertinent diagnostics and treatment Concept Map of the Case:
This will include assessment , pathophysiological concept and plan of care.

Summary of Medication Nursing Care Plan and Discharge Planning Summary, Conclusion , recommendation

BACKGROUND OF THE STUDY

Background of the Study

Should be in bullet form. No paragraph. You use related videos, pictures or any teaching tools

SCOPE and LIMITATION

The studys
SCOPE
Bullet form

LIMITATION
Bullet form

DEMOGRAPHIC PROFILE

Demographic Profile
Name: _______________________________ Age: _______________ Sex: ___________ Birthday:_____________ Address: _____________________________ Occupation:___________________________

You may include other pertinent profile relating to the case

PERTINENT HISTORY

Pertinent History
This must also be in bullet form. Please include ONLY pertinent history relating to the case. You may state normal history in generic and summarized statements

Past Medical History

______________________ ______________________ ______________________

History of Present Illness

Family History
______________________ ______________________ ______________________

COURSE IN THE WARD

Course in the ward

Day 1: (you may put title per day)

Course in the ward

Day 2: (you may put title per day)

Course in the ward

Day 3: (you may put title per day)

Course in the ward

Day 4: (you may put title per day)

Course in the ward

Day 5: (you may put title per day)

Course in the ward

Day 6: (you may put title per day)

DIAGNOSTICS and TREATMENTS

Pertinent Diagnostics
Name of DIAGNOSTICS/ TREATMENT INDICATION to the case:

Pertinent results with interpretation

you include pictures for better understanding and appreciation Place picture/ video here you may copy the table on the left side and have to tables in one slide In case of trending results like monitoring , you may use chart and graphs

Pertinent Diagnostics
COMPLETE BLOOD COUNT 6

INDICATION to the case:

This is used

5 4 3 wbc rbc platelet

Interpretation: The line graph on the righ side shows that in .

2
1 0

Pertinent Diagnostics
Complete Blood Count (CBC) INDICATION to the case: to assess the patients blood component that may reveal signs of Infections

you include pictures for better understanding and appreciation

Pertinent results with interpretation DATE: June 25 2007 WBC: elevated ( result of the diagnostics )

CONCEPT MAP

Concept Map
- Alcohol
Intake - Occupation - Male

You may construct own style of concept map as long as you can present the link of concepts. You may include plans

-affects judgment and reasoning -slowed reaction time -upset sense of coordination -impaired vision and hearing -decreased concentration -drowsiness

Break in the skin integrity secondary to vehicular accident

Nursing diagnosis 1:
The patient was noted to have difficult in deciding on what to wear. She also seems to be confused most of the time

Noxious stimuli

Nursing diagnosis 2:
Assessment findings and must be supported by diagnostics evidences. Ex: impaired skin with yellowish discharges. WBC is elevated (dated: ___).

Probable portal of entry for pathogens

Perception of pain

Localized infection

Nursing diagnosis 4: Infection spread through blood Impaired immune sysrem

Death

Multiple organ failure

Sepsis
Nursing diagnosis3:

Medication

Summary of Medication
Medication Name Indication
Proton Pump Inhibitor:

Nursing remarks

1. Esomeprazole (Nexium) 10mg/ vial

2. Paracetamol (Biogesic) 500mg

This is use as a prophylaxis for patient to have ulcers

must be diluted with 10 ml NSS.

Summary of Medication
Medication Name Indication
Proton Pump Inhibitor:

Nursing remarks

3.Esomeprazole (Nexium) 10mg/ vial

4.Paracetamol (Biogesic) 500mg

This is use as a prophylaxis for patient to have ulcers

must be diluted with 10 ml NSS.

NCP

Nursing Care Plan

Nursing diagnosis 1: Ineffective Airway Clearance Related to ______ as evidenced by_____

ASSESSMENT
Objective: Subjective: Goal

PLAN

Intervention
Independent Dependent

EVALUATION
GOAL met/ Unmet/ partially met

Objective

collaborative

Nursing Care Plan

Nursing diagnosis 2:
ASSESSMENT
Objective: Subjective: Goal Objective

PLAN

Intervention
Independent Dependent

EVALUATION
GOAL met/ Unmet/ partially met

collaborative

Nursing Care Plan

Nursing diagnosis 3:
ASSESSMENT
Objective: Subjective: Goal Objective

PLAN

Intervention
Independent Dependent

EVALUATION
GOAL met/ Unmet/ partially met

collaborative

DISCHARGE Plan

Discharged Planning
You may site specific points to discuss specially health teaching related to the case You may present the doctors discharge instructions

Summary, Conclusion Recommendation

The groups
Conclusion Recommendation

Group Leader

__________________
Group Members

__________________ __________________ __________________ __________________ __________________ __________________ __________________