Angeles University Foundation

Angeles City
NCM 102 - Format Case Study ( Pedia )

I. INTRODUCTION

A. Current trends about the Disease condition

B. Reasons for choosing such case for presentation

II. NURSING ASSESSMENT

1. PERSONAL DATA
(name, age, sex, religion, name of parents, address, date of
birth, place of birth, nationality, date of admission-and discharge)

NOTE: indicate informant and state relationship to client

2. PERTINENT FAMILY HISTORY ( up to 3rd degree relationship

including dates)

a. size of family
b. mother’s previous pregnancies in chronological order and her
attitudes towards them, mode of deliveries
c. living condition including housing and economic status
d. cultural factors affecting the health of the family (superstitious
beliefs, health attitudes)

3. PERSONAL HISTORY

a. Pre-natal –mother’s practices/ habit during pregnancy

b. Birth duration and circumstances of labor, home or hospital
c. C feeding
d. Growth and development (client centered; from infancy to
present age)
- mention month or year when specific development
was achieved
- behavior on reference to the different theories of
growth and development
- Erick Erikson -Sigmund Freud
- Jean Piaget
e. Immunization status

4. HISTORY OF PAST ILLNESS

5. HISTORY OF PRESENT ILLNESS
6. PHYSICAL EXAMINATION (IPPA Cephalocaudal Approach)
 - Note: Initial assessment upon admission and on every
NPI, specific date should also be included

7. DIAGNOSTIC AND LABORATORY PROCEDURES

DIAGNOSTI DATE INDICATION RESULT NORMAL ANALYSIS
ST
C/ ORDERE (S) S( 1 , VALUES AND
LABORATO D PURPOSE(S) 2ND, 3RD ) (UNIT INTERPRETATI
RY DATE USED IN ON OF
PROCEDUR RESULT( THE RESULTS
ES S) HOSPITA (patient-based)
L)

Note : Nursing responsibilities prior to, during and after the procedure
should also be included

III. ANATOMY AND PHYSIOLOGY (with visual aids)

IV. THE PATIENT ILLNESS

A. Schematic Diagram
1. Book Centered
2. Patient-centered
B. Synthesis of the disease

1. definition of the disease

2. Predisposing/ precipitating factors
3. sign and symptoms
4. health promotion and preventive aspects of the disease

V. THE PATIENT AND HIS CARE

A. MEDICAL MANAGEMENT

a. IVFs, BT, NGT feeding, Nebulization, TPN, Oxygen therapy, Etc.

Medical Date ordered General Indications(s) Clients

management/ Date performed Description Or response to
treatment Date changes/ Purpose (s) treatment
d/c (patient-
centered)
NOTE: Nursing responsibilities prior to. During and after the
treatment should also be included

b. DRUGS
Name of Date ordered Route of General Indications(s)Clients
drug(s) Date administration action , Or response
generic Given/taken Dosage and Classification Purpose (s) to
and brand Date frequency of Mechanism of (patient- medication
name changes/ d/c admin action centered) With
actual side
effects
NOTE: Nursing responsibilities prior to. During and after the
treatment should also be included

c. DIET

Type of Diet Date ordered General Indications(s) Clients

Date performed Description Or response and/
Date changes/ Purpose (s) or reaction to
d/c (patient- diet
centered)
NOTE: Nursing responsibilities prior to. During and after the
treatment should also be included

d. Activity and Exercise

Type of Date ordered General Indications(s) Clients

Exercise Date started Description Or response and/
Date changes/ Purpose (s) or reaction to to
d/c (patient- activity/
centered) exercise
NOTE: Nursing responsibilities prior to. During and after the
treatment should also be included

B. SURGICAL MANAGEMENT ( Booked-Based if not yet performed

/ Patiend based – if performed)

a. Brief description
b. Nursing responsibilities prior to, during and after the operation

C. NURSING MANAGEMENT (atleast five problems)

1. Nursing Care Plan

Assessme Nursing Scientific Planning Interventio Rational Evaluatio

nt Diagnosi Explanatio (objective/goa n e n
s n l)
 2. Actual Sopiers

VI. CLIENT’S DAILY PROGRESS IN THE HOSPITAL

1. Client’s daily progress chart (from admission to discharge)

DAYS ADMISSION 2 3 4 5 DISCHARGE

Nursing
Problems

1. Altered…..
2. risk for …
Vital signs (Include
PR,RR,BP,PP, actual
TEMP results)
Lab procedure (Include
actual
results)
DRUGS

DIET
Activity/Exercise

2. DISCHARGE PLANNING
a. General condition of client upon discharge
b. METHOD

VII. CONCLUSION and RECOMMENDATION ( Learning Derived)

VII. BIBLIOGRAPHY