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.
