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New Era University

College of Nursing

CASE STUDY FORMAT

I. INTRODUCTION
A. Background of the study
B. Objective (general & specific showing Knowledge, Skills & Attitude)
C. Scope and Delimitation
D. Theoretical Framework

I. BIOGRAPHIC DATA
Name
Address
Age
Gender
Race
Marital Status
Occupation
Religious orientation
Health care financing and usual source of medical care

II. CHIEF COMPLAINT OR REASON FOR VISIT

III. NURSING HISTORY (with guide questionnaire)


A. History of Present Illness
B. Past Medical History
a) Childhood diseases
b) Immunizations
c) Allergies
d) Accidents and injuries
e) Hospitalization
f) Medication
A. Family History of Illness (use Genogram)
B. Obstetric History (for OB cases only; with Assessment Guide)
C. Developmental History (for Pediatric cases only; with Assessment Guide)
Note: Assessment guide used should be attached as annexes at the back of the case study report.

I. FUNCTIONAL HEALTH PATTERN (with guide questionnaire)


1. Health Perception and Health Management Pattern
2. Nutrition and Metabolic Pattern
3. Elimination Pattern
4. Activity-Exercised Pattern (use Barthel index)
5. Sleep-rest Pattern
6. Cognitive-perceptual Pattern
7. Self-perception and self-control Pattern
8. Role-relationship Pattern
9. Sexuality-reproductive Pattern
10. Coping-stress tolerance Pattern
11. Value-belief Pattern

Interpretation:
Analysis: (with reference)

I. REVIEW OF SYSTEM (all subjective complaints)

II. PHYSICAL ASSESSMENT (all objective findings; indicate date performed; Head to Toe Assessment; follow IPPA
sequence)
1. General Survey (Short Paragraph)
2. Vital Signs

BODY PART (Technique used) NORMAL FINDINGS ACTUAL FINDINGS INTERPRETATION / ANALYSIS

w/ Reference

I. ANATOMY & PHYSIOLOGY


II. DIAGNOSTIC / LABORATORY STUDIES (Table)

INDICATION FOR SIGNIFICANCE


NAME OF TEST / ACTUAL RESULT
DATE DONE THE TEST / NORMAL VALUE OF THE RESULT /
PROCEDURE / FINDINGS
PROCEDURE FINDINGS

III. SURGICAL PROCEDURE (Operative worksheet, if any)

IV. PATHOPHYSIOLOGY (Present in Schematic Diagram; Mind Mapping)

V. DRUG STUDY / IV INFUSIONS, BLOOD TRANFUSIONS, TREAMENTS GIVEN

Drug Study
DRUG TRADE / PHARMACOLOGIC INDICATION AND ADVERSE DESIRED NURSING
ORDER BRAND ACTION OF DRUG CONTRAINDICATIONS EFFECTS ACTION RESPONSIBILITIES
NAME OF THE ON YOUR / PRECAUTIONS
(Generic, DRUG CLIENT
name,
dosage,
route,
frequency)

Treatments Given
TREATMENT / CLASSIFICATION INDICATION CONTRAINDICATION NURSING
INFUSION RESPONSIBILITIES /
PRECAUTIONS

VI. COURSE IN THE WARD (narrative form)

• Summary of day to day medical/nursing management from the date of admission up to the time case study was done
• Patient’s Status:
a. General condition of the client (ex. LOC, VS, and other Subjective & Objective, complaint during the day)
b. 4 D’s with inference / analysis:
○ Diet
○ Drugs/IVF
○ Lab/Diagnostics procedure
○ Disposition
I. PRIORITIZED LIST OF NURSING PROBLEMS (Table)
• Prioritized using ABC’s and Maslow’s Hierarchy of Needs

DATE NURSING PROBLEMS IDENTIFIED CUES JUSTIFICATION

I. NURSING CARE PLAN

CUES (Defining NURSING BACKGROUND GOALS AND NURSING EVALUATION


Characteristics of DIAGNOSIS KNOWLEDGE OBJECTIVES INTERVENTION
Nursing Diagnosis) (Problem & (Pathophysiology/psychosocial (include long S AND
Etiology) explanation or consequences of and short term RATIONALE
the nursing diagnosis) objectives)

II. PROPOSED / DISCHARGE PLAN (to be submitted by students whose patients are for discharge)

• M - Medications to take at home


• E - Exercises
• T - Treatment
• H - Health Teachings
• O - Out - patient follow-up
• D - Diet
• S - Spiritual / Sexual activity (optional)