ST. TONIS COLLEGECollege of NursingBulanao, Tabuk City

GRAND CASE PRESENTATION EVALUATION FORM

INSTRUCTION : Evaluate the case presented according to the scale in each criteria of standards provided in this form. Mark 1 as the lowest score and 5 as the highest score.

Area of Case Presented 1 2 3 4 5Biographical Data of the patientAdmission DataMedical Prognosis

1. History of Present Illness2. Past Medical History3. Family History & Genogram

Patterns of Health Functioning1. Health Perception & Health Management2. Nutritional & Metabolic 3. Elimination4. Activity-Exercise5. Sleep-Rest6. Cognitive-Perceptual7. Self-Perception-Self-Concept8. Role-Relationship9. Sexuality-Reproductive10. Coping-Stress Tolerance11. Values-Belief

Activities of Daily Living1. Nutrition2. Elimination3. Activity & Exercise4. Sleep & Rest5. Hygiene6. Substance Abuse

Physical Assessment1. Review of System

a. Cardiovascular Systemb. Respiratory Systemc. Integumentary Systemd. Musculoskeletal Systeme. Genitourinary Systemf. Gastrointestinal Systemg. Nervous Systemh. Special Senses

2. Physical Examinationa. Vital Signsb. General Appearancec. Skind. Heade. Facef. Neck

g. Thoraxh. Breast & Axillae (for female patient)i. Abdomenj. Male Inguinal Area (for alteration in genitourinary alteration)k. Female Inguinal Area (for alteration in genitourinary alteration)l. Upper Extremitiesm. Lower Extremitiesn. Cranial Senses

Diagnostic Procedures & Medical Management1. Diagnostic Procedures2. Drug Study

Ecologic ModelEvidenced-Based Nursing Practice & Theoretical Paradigm

1. Evidenced-Based Nursing Practice2. Theoretical Paradigm

Anatomy & Physiology with PathologyNursing Care Management

1. Cues2. Analysis & Health Implication3. Nursing Diagnosis4. Goals & Objectives5. Nursing Interventions w/ Rationale6. Evaluation

Discharge Plan1. Medications2. Environment3. Treatment4. Health Education5. Observable S/Sx6. Diet

Grand Total

Comments/Suggestions:

Instructor’s Name & Signature: Date:

Student’s Name & Signature: Date:

*Any alterations and unnecessary markings on the total score will nullify the form.*