CASE STUDY FORMAT

Adapted from University of Pangasinan, and St. Lukes College of Nursing and modified for Capitol University College of Nursing use, November 02, 2011 Prepared by: Friday B. Laas
TITLE & AUTHORS ABSTRACT 5%

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TABLE OF CONTENTS:
ACKNOWLEDGEMENT INTRODUCTION-Discuss the disease condition (client centered) -Rationale of the study SIGNIFICANCE OF THE STUDY TO THE: -----------------------------------------------------------------10% -Nursing Education -Nursing Practice -Nursing Research OBJECTIVES OF THE STUDY: -General -Specific PATIENTS PROFILE -------------------------------------------------------------------------------------- 15% -Nursing Health History -Physical Assessment -Developmental Data (Choose 1 Theory) ANATOMY AND PHYSIOLOGY PATHOPHYSIOLOGY -------------------------------------------------------------------------------------- 10% DIAGNOSTIC TESTS --------------------------------------------------------------------------10% MEDICAL AND SURGICAL MANAGEMENT ------------------------------------------------------ 10% -Drug study NURSING MANAGEMENT --------------------------------------------------------------------------20% -Nursing Care Plan (maximum of 5 problems) EVALUATION, RESULTS & DISCUSSION ------------------------------------------------------ 15% DEFINITION OF TERMS BIBLIOGRAPY -----------------------------------------------------------------------------------------------5%

TOTAL -----------------

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IMPORTANT NOTE: Case study should be started the first week of duty to have ample time to assess, analyze, manage and study the case and to avoid unnecessary overnight which cannot help in managing a patients case.

CASE STUDY FORMAT

Adapted from University of Pangasinan, and St. Lukes College of Nursing and modified for Capitol University College of Nursing use, November 02, 2011. Prepared by: Friday B. Laas
TITLE & AUTHORS 1. It may include the following: a. Nursing intervention b. Outcome of intervention c. Population under study d. The condition of interest 2. The title of the paper should be in capital letters and Arial font size 14. Limit your title to 20 words or less. 3. Name/s of the author/s (given name, middle initial and last name) should be Arial font size 12. 4. Indicate the affiliated institution/s of the author/s with the complete name of the department, institution and its physical address in italicized, Arial font size 12. ABSTRACT 1. The abstract of the manuscript should be limited to 200 words or fewer. 2. It should contain brief information and includes the following components:

a. Brief Introduction b. Case Report as Methodology

c. Results and Discussion

3. It should be in single space. 4. Provide at least 5 keywords. Keywords are words that may be used to identify
the study. They help in indexing or categorizing the study as well.

TABLE OF CONTENTS:
ACKNOWLEDGEMENT INTRODUCTION - Discuss the disease condition (client centered) 1. Background information should be provided to demonstrate how the case contributes to the literature. Please limit the amount of information adequate to familiarize the readers with the topic. (one page only, in single space) 2. Clearly state the objectives or rationale why you chose this case as your focus of study. 3. Clearly state the significance of the case study in relation to the theme. 4. Indicate limitations of the case study. 5. Please include also the following: a. Theoretical framework or nursing theory (which was utilized in the plan of care) SIGNIFICANCE OF THE STUDY TO THE: -Nursing Education -Nursing Practice

-Nursing Research OBJECTIVES of the study: -General -Specific PATIENTS PROFILE - Nursing Health History - Physical Assessment - Developmental Data (Choose 1 Theory) to include the expected and the actual developmental tasks to identify signs of possible fixation or developmental delays. ANATOMY AND PHYSIOLOGY PATHOPHYSIOLOGY - Need to be able to differentiate precipitating from predisposing factors DIAGNOSTIC TESTS (both actual and ideal) MEDICAL AND SURGICAL MANAGEMENT Both actual and ideal Include indication and rationale of the management Drug study with due consideration to drug interactions NURSING MANAGEMENT -Nursing Care Plan (3 to 5 PRIORITY problems) EVALUATION, RESULTS & DISCUSSION 1. Do not summarize or repeat from the previous sections of the abstract. 2. Briefly summarize the results or outcomes of care, including changes in the primary outcome measures. a. NCP / Nurses notes / progress notes (maximum of 5 problems) 3. It should discuss (briefly) the relevant literature of the ideal management and expected outcome or prognosis in the context of the current case. 4. It should include a brief summary, conclusion, discharge plan and recommendations. a. Summary and conclusion b. Discharge Plan

Medication Economy/Exercise Treatment/Therapy Health Teaching/Hygiene Consultation Diet Sex c. Recommendation includes the following Based on the difference between the ideal and actual management.
Can also include recent evidence of a more effective management 5. Lessons the student nurse learned from caring for this patient should be described. DEFINITION OF TERMS / KEY WORDS (for indexing) BIBLIOGRAPY Must be recent from 2005 and up Follow the APA format

IMPORTANT NOTE:
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- Revised copy in a CD to be submitted 2 days after defense. - Everything should be in narrative form. Tables and charts if any will be placed in the appendix.
NURSING HEALTH HISTORY 1. BIOGRAPHICAL DATA - Names, address, age, Birth-date, Sex, Race, Marital status, Occupation, Religion, Health Care financing and usual source of Medical Care 2. CHIEF COMPLAINT What Brought you to the Hospital What is Troubling you Current physical assessment findings 3. HISTORY OF PRESENT ILLNESS Ask the Chronological Sequence of the events in reference to the clients Chief Complaints. Which Should follow the Period duration PRIOR TO ADMISSION When did the symptom started? Follow the PQRST format. How often Type of activity prior to the problem was consultation sought Medications used including maintenance if any How the Problem interfered/Disrupted Activities of daily living PAST HISTORY Childhood Diseases Immunizations Allergies Accident and injuries Hospitalizations-When and Why Medications? 3.1 FAMILY HISTORY OF ILLNESS Health and ages of patients siblings, children, or ages at death and causes Illness of family members similar to the patient Familial incidence of RH fever, HPN, PTB, DM, Mental Illness, and others as suggested by the present illness 3.2 FUNCTIONAL HEALTH PATTERN Health perception and health management How has the general health been? Any colds in the past? Most Important things done to keep or maintain health. You Think this things make a Difference to health(include Family, Folk, Remedies if appropriate) Use of cigarettes, alcohol, Drugs? (Perform Breast Exam) In the past, has it been easy to find ways to follow things nurses/Doctors suggestions. If Appropriate: What do you think caused the illness? actions taken when symptoms were perceived?(Results of action) If Appropriate: things important to you while you are in the hospital or clinic? How can we be most helpful?

Traditional concepts of health and illness? Beliefs and practices?(classify what illness model is being used by the patient) NUTRITIONAL AND METABOLIC PATTERN 1. Typical daily food intake (Specify), Supplements? 2. Typical daily fluid intake/(Specify) 3. Weight loss/gain/Amount? 4. Appetite? 5. Food or Eating discomfort? Diet restriction? 6. Wound Healing? 7. Skin problems? Lesions? Dryness? 8. Dental problems? ELIMINATION PATTERN 1. Describe the Bowel elimination pattern? The CFAC? Discomfort? 2. Urinary elimination pattern (describe) frequency, Discomfort? problem in control? 3. Excessive perspiration? Odor problems? ACTIVITY -EXERCISE PATTERN 1. Sufficient energy for completing desired required activities? 2. Exercise pattern? Types? Regularity? 3. Spare Time: Leisure activities? child: activities? 4. Perceived ability for (Code Level) -Feeding - Bed Mobility -General mobility -Bathing -Dressing -Cooking -Toileting -Grooming -Home Maintenance -Shopping Level (0) - Full Self care Level (1) - Requires use of equipment or device Level (2) - Requires assistance or supervision from another person Level (3) - Requires assistance or supervision from another person or device Level (4) - dependent and does not participate SLEEP-REST PATTERN 1. Approximately how many hours do you sleep at night? 2. Any problem falling asleep? Do you take any sleep medications? 3. Is your sleep continuous? Tired? 4. Take naps? when?(Morning/Afternoon) 5. What do you do for Relaxation?(Watch TV, Listen to radio, read, dance, shopping) COGNITIVE-PERCEPTUAL PATTERN 1. Hearing difficulty? Hearing Aid? 2. Vision/wear eyeglasses? 3. Any change in memory lately? 4. Easiest way to remember/learn things? Difficulties? 5. Any Discomfort? pain? how do you manage it? self- perception and self concept pattern 1. how do you describe yourself? Most of the time, feel good (not so good) about yourself? 2. changes in your body or the things you can do? Problem to you? 3. Changes in way you feel about yourself/of your body?(since illness started) 4. Find things frequently make you angrily? Annoyed? Tearful? Anxious? Depressed? What helps?

ROLE-RELATIONSHIP PATTERN 1. Live alone? Family? Family Structure(Diagram) 2. any Family problems you have difficulty handling?(Nuclear/Extended) 3. How does Family usually handle problems? 4. Family depends on you for things? If appropriate: how are they managing? 5. If appropriate: how Family/others feel about your illness/hospitalization? 6. If appropriate: problem with children? Difficulty handling? 7. Belong to social groups? Close friends? Feel lonely frequently? 8. Things generally go well with you at work? (school / College)? If appropriate income sufficient to needs? 9. Feel part of (or isolated in) neighbourhood where you are living? SEXUALITY-REPRODUCTIVE PATTERN 1. If appropriate: any changes or problems in sexual relations? 2. If appropriate: use of contraceptives? Problems? 3. Female; when menstruation started? Last menstrual period? Menstrual problems? Para? Gravida? COPING-STRESS TOLERANCE PATTERN 1. Tense a lot of time? What Helps? Use of any Medicines, Drugs, alcohol? 2. What is most helpful in taking things over? Available to you now? 3. Any big changes in your life in the past year or two? 4. When you have big problems (any problems) in your life, how do you handle them?

Case presentation and defense 1. Present the most salient parts of the case in 10 to 15 minutes only. 2. Present only the following:
a. Introduction: what the case study is all about and the objectives of the study b. Chief Complaints, History of present illness c. Significant assessment findings to include abnormal lab and diagnostic findings. d. Past medical history (if necessary) e. Pathophysiology f. Summary of medical and surgical management: like medication (name of drugs only), and or surgical intervention if done. g. NCP present only the salient points but still need to include all NCPs in the power-point slides. h. Evaluation of overall patient outcome and recommendation 3. Critiquing and defense in one hour 4. No reading during the presentation