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Case Study Format

This document outlines the typical format for a case study report, including 12 sections: 1) Introduction, 2) Objectives, 3) Anatomy and Physiology, 4) Pathophysiology, 5) Nursing History, 6) Physical Assessment, 7) Course in the Ward, 8) Diagnostics/Laboratories, 9) Drug Study, 10) Nursing Care Plan, 11) Health Teaching, and 12) Evaluation. Each section contains specific elements to include, such as signs and symptoms in the Introduction or assessment findings over multiple days in the Physical Assessment. The Nursing Care Plan section describes the assessment, planning, intervention, rationale, and evaluation for each nursing diagnosis.

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Luiezt Bernardo
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111 views4 pages

Case Study Format

This document outlines the typical format for a case study report, including 12 sections: 1) Introduction, 2) Objectives, 3) Anatomy and Physiology, 4) Pathophysiology, 5) Nursing History, 6) Physical Assessment, 7) Course in the Ward, 8) Diagnostics/Laboratories, 9) Drug Study, 10) Nursing Care Plan, 11) Health Teaching, and 12) Evaluation. Each section contains specific elements to include, such as signs and symptoms in the Introduction or assessment findings over multiple days in the Physical Assessment. The Nursing Care Plan section describes the assessment, planning, intervention, rationale, and evaluation for each nursing diagnosis.

Uploaded by

Luiezt Bernardo
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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CASE STUDY FORMAT

I. INTRODUCTION
a. Definition
b. Types if applicable
c. Signs and symptoms
d. Risk factors/etiology
e. Laboratories
f. Management (medical and Nursing)
g. Reference
II. OBJECTIVE
General (SKA)
Specific
student-centered
patient-centered
III. ANATOMY AND PHYSIOLOGY
IV. PATHOPHYSIOLOGY

V. NURSING HISTORY

1. Personal Data
a. Biographical – all information must complete – paragraph form
b. Date & time of admission
c. Chief Complaint

2. Present Health History


-chronological sequence
-signs and symptoms must be included
-intervention that has been done during the occurrence of the signs and symptoms
-evaluation to interventions/result of the interventions done

3. Past Health History


-this includes all hospitalization and other illnesses that have occurred on the patient including date and
length of occurrence/hospitalization
-if female include OB-GYNE history- all about reproductive system
-growth and development for pediatric patients (mile stone)

4. Family health History


-includes genogram of hereditary diseases that runs on the family

5. Social and Economic History


-ADL, leisure time of the patient on the first paragraph
-source of income and support system on the 2 nd paragraph

6. Nutrition and Metabolic Pattern


-usual diet
-24-hour diet recall before admission in table
7. Elimination Pattern
-specify pattern, character, frequency, amount of bowel and bladder elimination

8. Home and Environment


-describe the house the material used, the surroundings, sewage, water supply
-describe the locale of their community

VI. PHYSICAL ASSESSMENT


a. General Survey
- Includes contraption,, grooming, vital statistic (general impression) in paragraph form
b. Review of System
- Each finding must have clinical significance, which explains the abnormalities of the assessment
- Comparison of the first day, in between and last day on the course of duty
FORMAT

PARTS METHOD NORMAL ACTUAL FINDINGS ACTUAL FINDINGS CLINICAL


FINDINGS DAY___DATE____ DAY___DATE____ SIGNIFICANCE
HEAD
To
TOE
Including
genitals

VII. COURSE IN THE WARD

- Narrative form
- Includes the treatment done and other plan of treatment
- All courses of stay in the hospital
- Also the pending diagnostics and laboratories of the patient

VIII. DIAGNOSTICS/LABORATORIES (TABLE)


- WITH CLINICAL SIGNIFICANCE

(SURGERY)- OPERATIVE PROCEDURE, nature and effect of anesthesia used

IX. DRUG STUDY

- ALL RELATED DRUGS/MEDICINES


Generic Brand Classification Actual Mechanism Indication Contraindication Adverse Nursing
Name Name Dosage of Action Effect Responsibilities

X. NURSING CARE PLAN


ASSESSMENT PLANNING INTERVENTION RATIONALE EVALUATION
Subjective Data: Short term Wholly Reason of the Patient’s condition:
Data from the compensatory- intervention done =improved
patient or as 100% of the care =maintained
verbalized by the comes from the =prevented
patient Long term nurse (potential problems)
Partially
SMART compensatory
-50-50
Objective Data:
-Observed data from Supportive-
the pt Educative—the
-Diagnostics that nurse serves as
relates with the guide, educator
problem
-v/s relevant to Independent nursing
illness intervention= may
perform with or
without the doctor’s
knowledge or
Nursing Diagnosis notification/order
(refer to NANDA)
Dependent= needs
doctor’s order
(SPECIFY MEDS)

XI. HEALTH TEACHING-- mam Frocie


M -MEDICATION

E -ENVIRONMENT

T -TREATMENT

H -HYGIENE

O -OUT PATIENT

D -DIET

S -
SAFETY/SPIRITUAL/SEXUA
L
(Case-Based)

XII. EVALUATION – K S A
- Evaluation for the specific objectives
- Apply nursing theories related to the studies

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