Case Analysis Format: Medical-Surgical & Maternal and Child Health Nursing Concepts

Davao Doctors College, Inc.
Gen. Malvar St., Davao City

College of Allied Health Sciences | Nursing Program
NURSING PROGRAM
CASE ANALYSIS FORMAT
MEDICAL-SURGICAL & MATERNAL AND CHILD HEALTH NURSING CONCEPTS
Guidelines for the Case Analysis Manuscript:
1. As an important RLE requisite, each group shall be required to submit a case analysis manuscript per
week. Students shall be assigned with a case which they will analyze as a GROUP. Aside from the
completion of the case analysis manuscript, the students are also expected to prepare PPT presentation
for their case presentations.
2. Submission of the case study output MUST be made within the day of
3. Follow the format below:
Paper size: 8.5 x 11
Font type: Arial
Font size: 12
Spacing: 1.5
Margins: Right: 1 inch; Left: 1.5 inches; Top: 1 inch; Bottom: 1 inch
Content:
a. Front page (sample format below)

General Malvar St., Davao City
Nursing Program
Nursing Management of a Patient with

CORONARY ARTERY SYNDROME
A Case Study Presented to the Nursing Clinical Instructors

of Davao Doctors College, Inc.
In Partial Fulfillment of the Requirements in

NRG304: Care of Clients with Problems in…
(Names)
(Date)
b. Table of Contents
c. Objectives (General and Specific)
d. Introduction
 Introduce the case; Introduce relevant statistics
 Discuss why there is a compelling need to study the case
 Give a brief overview of the subject (patient being studied) of the study
e. Patient’s Profile
i. Biographic Data
ii. Clinical Data
i. Past Health History - Narrative
ii. Present Health History - Narrative
Aestimamus Vitam
We Value Life
iii. Family History (with Genogram) - Narrative

f. Health Assessment (Narrate findings, starting from General Survey then the per-system
discussion, cephalocaudal)
g. Review of Anatomy & Physiology (of the affected organ/system)
h. Pathophysiology
i. Definition of Diagnosis (list three definitions of the diagnosis of the patient; cite references
at the end of each discussion)
ii. Etiology (tabular)
Etiology (indicate if Present Justification

predisposing or (place a check mark if (discuss how can the predisposing or
precipitating) the etiology is precipitating factor influence the
applicable in the case of development of the illness being
the patient) investigated; cite references at the
end of each discussion)
iii. Symptomatology (tabular)

Signs/Symptoms Present Justification
(place a check mark if (discuss how can the sign or
the client has symptom appear in the illness being
manifested the investigated; cite references at the
sign/symptom) end of each discussion)
iv. Schematic Diagram: Present a simple tracing of the illness/condition of the patient,
starting from its causes (etiology), proceeding to how it slowly progresses into a full-
blown illness (with discussions of symptomatology). It ends with the discussion of
prognosis of the patient.
v. Narrative: Discuss the pathophysiology narratively/in paragraph, using full sentences.
i. Course in the Ward/Treatment/Interventions

i. Medical Management
1) Doctor’s Progress Notes
o Orders must be presented CHRONOLOGICALLY
o Aside from the doctor’s orders, take note of the assessment notes made
by the physician(s) of the patient being investigated
2) Laboratory/Diagnostic Examinations (tabular)
o Include implications and relevant nursing considerations
o All laboratory and diagnostic tests performed for the patient must be
included.
PROCEDURE PURPOSE NORMAL RANGE RESULT NURSING MANAGEMENT

(include date and (indicate if above (discuss what are the
time taken/done) or below normal; things that the nurse has
afterwards, to consider when taking
discuss the results care of a patient who is to
vis-à-vis the undergo the procedure;
condition of the cite the nursing
patient; management pre-, intra-,
DISCUSSION and post-procedure)
SHOULD NOT BE
GENERIC)
Aestimamus Vitam
We Value Life
3) Pharmacologic Management (Drug Study) – One drug study per student
Date Medication Mode Dosage Indication(s) Contraindication(s) Side Adverse Nursing

Ordered of Effects Effects Responsibilities
Action
Generic Name
Brand Name
Classification
 Add picture of the drug; add references at the end of each table
4) Surgical Management (tabular)

SURGICAL PROCEDURE INDICATION RESULT NURSING MANAGEMENT
(include date and time (indicate the actual (discuss what are the things
done) result of the surgery that the nurse has to consider
done) when taking care of a patient
who is to undergo the
procedure; cite the nursing
management pre-, intra-, and
post-procedure)
Aestimamus Vitam
We Value Life
h. Nursing Management
i. Nursing Care Plan (each student must formulate a nursing care plan)
Date / Cues Nursing Diagnosis Goal & Objectives Interventions Rationale Evaluation
Time
Subjective: Nsg Dx: Be SMART; Cite 1 Note: Add rationale for Entries in the evaluation
goal and at least 3 each intervention. section can be hypothetical.
objectives in this HOWEVER, you must make
Objective: Rationale/ Scientific section sure that the information
Basis: placed here jive with the
data presented in the
Add citation at the end module and with the
of the information used by your
rationale/scientific groupmates.
discussion (follow APA
7th ed guidelines) Add date and time at the
beginning; Afterwards, state
if GOAL MET/PARTIALLY
MET/UNMET
Go back to your goal and

objectives and see if you
have achieved your goals or
not.
Reference(s): Cite all references that you used in making this care plan.
ii. Nurse’s Notes (Individual) – CHECKLIST + FDAR

iii. Clinical Reasoning Questions
iv. Discharge Plan (METHODS format) – MEDICATIONS, EXERCISE, TREATMENT, HYGIENE, OUTPATIENT (CHECK-UP), DIET,
SPIRITUALITY
i. References (APA 7th edition guidelines for references must be followed)
Prepared by:
BLAISE B. NIEVE, RN (PH, USA-NMI), MAN, PhD (c)

Program Chair - Nursing
Aestimamus Vitam
We Value Life

Case Analysis Format: Medical-Surgical & Maternal and Child Health Nursing Concepts

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Davao Doctors College, Inc.

Gen. Malvar St., Davao City

Guidelines for the Case Analysis Manuscript:

Davao Doctors College, Inc.

Nursing Management of a Patient with

A Case Study Presented to the Nursing Clinical Instructors

In Partial Fulfillment of the Requirements in

iii. Family History (with Genogram) - Narrative

Etiology (indicate if Present Justification

iii. Symptomatology (tabular)

i. Course in the Ward/Treatment/Interventions

PROCEDURE PURPOSE NORMAL RANGE RESULT NURSING MANAGEMENT

3) Pharmacologic Management (Drug Study) – One drug study per student

Date Medication Mode Dosage Indication(s) Contraindication(s) Side Adverse Nursing

4) Surgical Management (tabular)

Go back to your goal and

ii. Nurse’s Notes (Individual) – CHECKLIST + FDAR

i. References (APA 7th edition guidelines for references must be followed)

BLAISE B. NIEVE, RN (PH, USA-NMI), MAN, PhD (c)

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