Care Study Guidelines

TABLE OF CONTENTS

I. INTRODUCTION…………………………………………………………………………… (page no.)

II. GENERAL DATA…………………………………………………………………………….. (page no.)

III. HISTORY OF PRESENT ILLNESS……………………………………………………... (page no.)

 The reason the client seeks health; it should be quoted in the client’s own
word; include documentation of the history of the chief complaint such as
onset, location, duration, quality, alleviating and aggravating factors and
associated symptoms.
IV. PAST HEALTH HISTORY…………………………………………………………………. (page no.)

V. CLIENT’S CLINICAL COURSE IN THE UNIT……………………………………….. (page no.)

VI. GORDON’S HEALTH PATTERN………………………………………………………… (page no.)

1. Health Perception- Health Management Pattern

2. Nutritional- Metabolic Pattern
3. Elimination Pattern
4. Activity- Exercise Pattern
5. Sleep- Rest Pattern
6. Cognitive- Perception Pattern
7. Self-Perception and Self-Concept Pattern
8. Role Relationship Pattern
Genogram…………………………………………………………………………. (page no.)
9. Sexuality- Reproductive Pattern
10. Coping- Stress Tolerance Pattern
11. Value- Belief Pattern
VII. ENVIRONMENTAL HISTORY…………………………………………………………… (page no.)

VIII. PHYSICAL ASSESSMENT………………………………………………………………… (page no.)

IX. DEVELOPMENTAL DATA……………………………………………………………...... (page no.)

X. ANATOMY, PHYSIOLOGY AND RELATED PATHOPHYSIOLOGY

A. Anatomy and Physiology of the Systems Involve…………………….. (page no.)

B. Concept Framework on the Pathophysiology…………………………. (page no.)
C. Discussion of the Pathophysiology……………………………………….. (page no.)
D. Symptomatology………………………………………………………………… (page no.)

Clinical Manifestations Signs and Symptoms Present

in Patient

XI. MEDICAL MANAGEMENT………………………………………………………………… (page no.)

A. Diagnostic Studies

Diagnostic Studies Ordered Diagnostic Rationale

Studies

B. Results and Findings (present the laboratory tests)

C. Treatment and Procedures

Treatment and Performed to the Rationale

Procedures Patient

D. Medications

List of Medications Prescribed to the Indication

and IVF Patient

E. Diet

Diet Ordered Diet Rationale

XII. NURSING MANAGEMENT

A. Goal of Care………………………………………………………………………. (page no.)

Assessment
Diagnoses
Planning
B. Actual Care Given……………………………………………………………….. (page no.)
Interventions
C. Problems encountered during the Implementation of Nursing Care… (page no.)
D. Restorative Measures Used………………………………………………….. (page no.)
E. Evaluation……………………………………………………………………………… (page no.)
F. Patient Teaching…………………………………………………………………….. (page no.)
XIII. CONCLUSION AND RECOMMENDATION………………………………………….. (page no.)

XIV. IMPLICATION OF THE STUDY…………………………………………………………. (page no.)

A. Nursing Education- Knowledge or Information

B. Nursing Practice- Skills
C. Nursing Research- For baseline information for future study

APPENDICES

Appendix A: Permit Letter

Appendix B: NCP
Appendix C: Discharge Plan (M E T H O D S)
Appendix D: Drug Study
Appendix E: IVF Study

REFERENCES
Specifics: Alphabetical order, single space
Books:
Citing a book in print APA format structure:
Author, A.A.. (Year of Publication). Title of work. Publisher City, State: Publisher.
 EXAMPLE:
Finney, J. (1970). Time and again. New York, NY: Simon and Schuster.
 Citing an e-book from an e-reader
Author, A.A.. (Year of Publication). Title of work [E-Reader Version]. Retrieved from
http://xxxx or doi:xxxx
 EXAMPLE:
Eggers, D. (2008). The circle [Kindle Version]. Retrieved from http://www.amazon.com/

Journal:
Citing a journal article in print
Author, A.A.. (Year of Publication). Article title. Periodical Title, Volume (Issue), pp.- pp.
 EXAMPLE
Nevin, A. (1990). The changing of teacher education special education. Teacher Education
and Special Education: The Journal of the Teacher Education Division of the Council for
Exceptional Children, 13 (3-4), 147-148.

Citing a journal article found online

Author, A.A.. (Year of Publication). Article title. Periodical Title, Volume (Issue), pp.- pp.
doi: XX.XXXXX or Retrieved from journal URL
 EXAMPLE
Jameson, J. (2013). E-Leadership in higher education: The fifth “age” of educational
technology research. British Journal of Education technology, 44 (6), 889-915.
doi:10.1111/bjet.12103

Internet Sources
Citing a general website article with an author
Author, A.A.. (Year, Month Date of Publication). Article title. Retrieved from URL
 EXAMPLE:
Simmons, B. (2015, January 9). The tale of two Flaccos. Retrieved from
http://grantland.com/the-triangle/the-tale-of-two-flaccos/
 Citing a general website without an author
Author, A.A.. (Year, Month Date of Publication). Retrieved from URL
 EXAMPLE
Teen posed of doctor at West Palm Beach hospital: police. (2015, January 16). Retrieved
from http://www.ncbmiami.com/news/local/Teen-Posed-as-Doctor-at-West-Palm-Beach-
Hospital-Police-288810831.html

Citing a photograph retrieved online

Photographer, A.A.. (Photgrapher). (Year, Month Date of Publication). Title of photograph
[digital image]. Retrieved from http://xxxx
 EXAMPLE
Ferraro, A. (Photographer). (2014, April 28). Liberty enlightening the world [digital image].
Retrieved from https://www.flickr.com/photos/afer92/14278571753/in/set-
72157644617030616

*DOI (digital object identifier)

GENERAL GUIDELINES:

1. Observe proper margin

a. Portrait: left 1.5 in, right 1 in., top 1 in., bottom 1 in.
b. Landscape: left 1 in, right 1 in., top 1.5 in., bottom 1 in.
2. Use font style: Tahoma, font size: 11
3. Use double space except for tables and references
4. Use 6 spaces (1 tab) for indention
5. Observe footnoting (example: Black and Hawks, 2015)
6. Page number should be placed on the upper right-hand corner
7. Refences should be within 5 years from present year
8. Be guided with the correct format of references