PRIVATE UNIVERSITY SAN JUAN BAUTISTA

Nursing Care II Subject

GUIDE FOR THE PRESENTATION OF THE PROCESS OF

Nursing Care

OBJECTIVES

❖ Apply the Nursing Care process in all its stages.

❖ Develop experiences in presenting academic work.
❖ Presentation
❖ The case study will be developed by applying the Nursing Care Process.
at all stages, in the patient assigned to the student during the rotation of the
hospital practice.
The content of the work will be as follows:

❖ Cover
❖ Presentation (similar to the introduction)
❖ Index (with page numbering)
Chapter I Valuation

❖ I a. Problem situation
I. VALUATION PHASE

Case Election

Affiliation data.
Nombre:

Sexo:

Life stage:

Chronological age:

Place of birth:

Date of birth:

Level of education:

Occupation:

Marital status:

Número de hijos:

Religion:

Address:
 Reason for admission.
Medical history.
Medical diagnosis.
Medical treatment.

Data collection.
Subjective data
Interview (Nursing assessment according to functional patterns).

Objective data
Observation (Head-to-toe physical examination or by systems)

Documents or measurement
Clinical History (Laboratory tests and ultrasound results)
and X-rays)

Interconsultation report.

2. Data organization. (Domain model)

3. Analysis and interpretation of data: (Confrontation with the literature)

Data Domain/ Base Problem/ Factor

relevant Class Theoretical Code related

CAP II. NURSING DIAGNOSIS

-Priorización de diagnóstico (Mínimo 6 diagnósticos enumerados)

Data Domain/ Problem Related factor

Deduction
relevant Class Conditional Determinant Real Potential

CHAPTER III. PLANNING

1. Priorización de los diagnósticos enfermero. (mínimo 6 diagnósticos)

2. Scheme of Didactic Care Plan
Implementation of the Plan

Result
Diagnosis Intervention of Foundation
Objectives expected
Nurse Nursing Inter. Inf.
Evaluation

CHAPTER IV. EXECUTION

Documentation and nursing record (SOAPIE)

CHAPTER V. EVALUATION

Evaluation of achievement of objectives and attention.

Evaluation of the process.

❖ Chapter V Conclusions and Recommendations

❖ Conclusions
❖ Recommendations
❖ Annexes
❖ Bibliography

❖ The specific content according to each chapter of the work is the

next:
❖ Cover: According to the following sheet
SAN JUAN BAUTISTA PRIVATE UNIVERSITY

FACULTY OF HEALTH SCIENCES

PROFESSIONAL NURSING SCHOOL

Nursing Care Subject II

CASE STUDY

Nursing Care Process

PRESENTED BY

LAST NAMES AND FIRST NAMES

THE PERU

2022 - II
❖ Valuation:
❖ Situación problema: describir la primera observación realizada al paciente durante
the rotation of clinical practice.
❖ Data collection: mention the data collected considering all the
primary and secondary sources.
❖ Describe the data obtained from the observation: interview, physical examination,
include an interview with the closest family member or the person responsible for the patient's care,
home visit report (Not applicable) (conditions of the housing, environment
familiar, social situation, economic, spiritual of the family, support networks,
housing location, number of household members, patient position
in the home, perception of the family, in relation to the patient's illness
review of the medical history (anamnesis, physical examination, diagnoses, tests
laboratory, evolution, treatments, notes and work plan or kárdex of
Nursing.
❖ Organize the data by listing the problematic data.
❖ Analyzing and interpreting the identified problem data previously refers to the
justification and explanation of each data according to theory, review of bibliography or
professional experience.
❖ Nursing diagnosis, concluding with the patient's issues, considering
the real and potential problems with their causes.
❖ Planning: develop the care plan according to priorities
❖ Present the Functional Care Plan:
PROBLEMAS Y OBJETIVOS ACCIONES CRITERIOS DE EVALUACIÓN

❖ Implementación del plan: describir los recursos que requeriría para la ejecución del
plan, incluir necesidades del personal.
❖ Intervention: describe the actions taken during the care I provided to the
patient during the internship period, detail those that were considered
in the care plan.
❖ Evaluation: describe your opinion regarding the formulation of the stages of
Process that you have developed, if you believe that it reflects the needs of
, or if you think some aspects are missing, also describe your opinion with
regarding the nursing care provided, the nursing care was
completed or some were missing, the priority was appropriate, if it had the
necessary resources.
❖ The work will be submitted typed and bound after the presentation.

❖ Evaluation
❖ The presentation and exposition of the case study is part of clinical practice.
❖ The evaluation criteria will be as follows:
❖ Work:
❖ Timeliness of delivery
❖ Presentation Quality
❖ Content
❖ Scientific Foundation
❖ Exposition:
❖ Attendance and punctuality
❖ Use of audiovisual aids
❖ Characteristics of the exhibition
❖ The student who does not present on the scheduled dates will receive a grade of 05.
❖ All the professors of the subjects will attend the exhibition.
clinical practices.
 INTERVIEW GUIDE

1. START OR ORIENTATION
Student Presentation (BEGINNING OF THE THERAPEUTIC RELATIONSHIP)

Address the patient with respect and warmth

A. Affiliation Details
• NAMES:...
• DATE OF BIRTH:...................................................
• LUGAR DE NACIMIENTO:…………………………………………………….
• EDAD: ……………………………………………………………………………
• GENDER: ……………………………………………………………………………
• MARITAL STATUS: ...
• LEVEL OF EDUCATION: __________________________________
• OCCUPATION:.......................................................................
• ADDRESS: …………………………………………………………………….

2. BODY OR WORK
B. HOSPITALIZATION DATA

• HOSPITAL: ……………………………………………………………………..
• SERVICE: ..........................................................
• NRO. [Link].:..........................................................
• DATE OF ENTRY:........................................................
• NRO. CAMA:……………………………………………………………………
• MEDICAL DX: ...........................................................................
C. PERSONAL BACKGROUND

Childhood diseases

Received medical treatment and evolution

Surgical interventions

• ACCIDENTS: ………………………………………………………………
• ALERGIAS: …………………………………………………………………….
D. BIOLOGICAL FUNCTIONS

• FOOD: ……………………………………………………………….
• DELETION: ………………………………………………………………….
• REST - SLEEP: ……………………………………………………………
• SED: ………………………………………………………………………………
• ACTIVITY: ……………………………………………………………………..
E. HARMFUL HABITS

• TOBACCO: ………………………………………………………………………..
• ALCOHOL: ………………………………………………………………………
• CAFÉ: …………………………………………………………………………….
• TE:………………………………………………………………………………
• DRUGS: ...
 F. FAMILY HISTORY

• PARENTS: ………………………………………………………………………
• BROTHERS: ………………………………………………………………….
• CHILDREN: ………………………………………………………………………….

G. SOCIO-CULTURAL ECONOMIC BACKGROUND

• INTERPERSONAL RELATIONS: ……………………………………..

• ECONOMIC DEPENDENCY: ___________________________________
• WORK DONE: ..................................................
• EDUCACIÓN: ………………………………………………………………….
• ENVIRONMENT WHERE LIVES: ……………………………………………………
• RELIGIÓN: ……………………………………………………………………..
• HOBBIE: ………………………………………………………………………..

H. PSYCHOLOGICAL BACKGROUND

• ANXIETY: …………………………………………………………………….
• FEAR: ...
• FEAR: …………………………………………………………………………
• ANGUISH: …………………………………………………………………….

I. Nutritional Background

• TIPO DEALIMENTACIÓN: ………………………………………………….

• DIET: ………………………………………………………………………….

J. MOTIVO DE CONSULTA

• CAUSES OF HOSPITAL ATTENDANCE: ...........................

3. FINAL OR CLOSURE
Inform the client that the interview is coming to an end.

Thanks for your collaboration

Say goodbye kindly