CETN Case Study Standard Template

8/2/2019 CETN Case Study Standard Template

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Title of the case

Group Leader

__________________

Group Members

__________________

__________________

____________________________________

__________________

__________________

__________________

CETN batch ____GROUP ____


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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


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BACKGROUND

OF THE STUDY


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Background of the Study

Should be in bullet form. No paragraph. You

use related videos, pictures or any teaching

tools


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SCOPE and

LIMITATION


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The studys

SCOPE Bullet form

LIMITATION Bullet form


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DEMOGRAPHIC

PROFILE


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Demographic Profile

Name: _______________________________

Age: _______________ Sex: ___________

Birthday:_____________ Address: _____________________________

Occupation:___________________________ You may include other pertinent profile relating to the case


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PERTINENT

HISTORY


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Pertinent History

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

Past Medical History

______________________

______________________

______________________

Family History

______________________

______________________

______________________

History of Present Illness


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COURSE IN THE

WARD


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Course in the ward

Day 1: (you may put title per day)


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Course in the ward



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Course in the ward



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Course in the ward



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Course in the ward



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Course in the ward



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DIAGNOSTICS

and

TREATMENTS


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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 oneslide

In case of trending results like

monitoring , you may use chart

and graphs


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COMPLETE BLOOD COUNT


This is used

Interpretation:

The line graph on the righ side shows

that in .

0

1

2

3

4

5

6

wbc

rbc

platelet


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Complete Blood Count (CBC)


to assess the patients blood component

that may reveal signs of Infections

Pertinent results with interpretation

DATE: June 25 2007

WBC: elevated ( result of the

diagnostics )

you include pictures for

better understanding

and appreciation


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CONCEPT

MAP


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Concept Map

Break in the skin

integrity secondary tovehicular accident

- AlcoholIntake- Occupation- Male

-affects judgment and reasoning

-slowed reaction time

-upset sense of coordination

-impaired vision and hearing

-decreased concentration

-drowsiness

Probable portal

of entry for

pathogensNoxious stimuli

Perception of

painLocalized

infection

Infection spread

through bloodSepsisMultipleorgan failureDeath

Impaired immunesysrem

Nursing diagnosis 1:Nursing diagnosis 2:

Nursing diagnosis3:

Nursing diagnosis 4:

Assessment findings and must be supported by

diagnostics evidences. Ex: impaired skin with

yellowish discharges. WBC is elevated (dated:

___).

The patient was noted to

have difficult in deciding on

what to wear. She also seems

to be confused most of the

time

You may construct own style of concept map as

long as you can present the link of concepts.

You may include plans


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Medication


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Medication Name Indication Nursing remarks

1. Esomeprazole

(Nexium)

10mg/ vial

Proton Pump Inhibitor:

This is use as a

prophylaxis for

patient to haveulcers

must be diluted

with 10 ml NSS.

2. Paracetamol

(Biogesic) 500mg


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Medication Name Indication Nursing remarks

3.Esomeprazole

(Nexium)

10mg/ vial

Proton Pump Inhibitor:

This is use as a

prophylaxis for

patient to haveulcers

must be diluted

with 10 ml NSS.

4.Paracetamol

(Biogesic) 500mg


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NCP


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

by_____

ASSESSMENT PLAN Intervention EVALUATION

Objective:

Subjective:

Goal

Objective

Independent

Dependent

collaborative

GOAL met/ Unmet/

partially met


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Nursing Care Plan

Nursing diagnosis 2:ASSESSMENT PLAN Intervention EVALUATION

Objective:

Subjective:

Goal

Objective

Independent

Dependent

collaborative

GOAL met/ Unmet/

partially met


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Nursing Care Plan

Nursing diagnosis 3:ASSESSMENT PLAN Intervention EVALUATION

Objective:

Subjective:

Goal

Objective

Independent

Dependent

collaborative

GOAL met/ Unmet/

partially met


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DISCHARGE

Plan


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Discharged Planning

You may site specific points to discuss specially

health teaching related to the case

You may present the doctors discharge

instructions


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Summary,

Conclusion

Recommendation


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The groups

Conclusion Recommendation


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Group Leader

__________________ Group Members

__________________

__________________

__________________

__________________

__________________

__________________

__________________

Documents

CETN Case Study Standard Template