SCHOOL OF HEALTH SCIENCES, NGEE ANN POLYTECHNIC

Diploma in Health Sciences (Nursing)

CLINICAL ATTACHMENT MODULE

CASE-STUDY: Standard Template for Year 1, 2 & 3

INSTRUCTIONS:
1. You are required to do ONE case-study on a patient during:
a. CA 1.2a, 1.2b
b. CA 2.1a, 2.1b
c. CA 2.2a, 2.2b
d. CA 3.2a, 3.2b
e. PRCP

2. Your CF/CI will advise you regarding presentation/submission of the case-study.

3. You will be assessed under Assessment components:

a. No 7: Displays critical thinking & clinical reasoning

b. No. 14: Reflects on learning experiences & applies theoretical knowledge to clinical
practice.

4. In addition to the Case-Study Standard Template, use the following documents under the Appendix
to complete your case-study:

a. Appendix A: Medication Information & Management

b. Appendix B: List of Nursing Diagnosis

c. Appendix C: Nursing Care Plan

d. Appendix D: GIBBS Reflective Cycle

5. Select patient type as indicated below for your case-study:

a. CA 1.2a: Select any patient under your charge. Focus: Introduction to doing case-study &
fulfill medication information for Pharmacology 1.

b. CA 1.2b: Select an elderly patient age 65 & above. Focus: Fulfill gerontology component
learnt in FON 2.

c. CA 2.1b: Select a patient with specific disease process learnt at Level 2.1. Focus: fulfill
medication information & management for Pharmacology 2.

d. CA 2.2a & 2.2b: Select a patient with the different needs learnt at Level 2.2: Paediatrics,
Obstetrics/Gynaecology and Mental Health. Focus: fulfill Ethics, Law & Healthcare module.

e. CA 3.2a & 3.2b: Select any patient under your charge. Focus: holistic patient care &
management

f. PRCP: Select any patient under your charge. Focus: holistic patient care & management

Note: Submit case study with documents in the Appendix(s) for relevant modules, as advised by your Lecturer.

CA_Case-Study_Dec09
 1. PATIENT’S DEMOGRAPHIC DATA
Name (initials): Date of Admission:
Date of Birth: Age:
Gender: Race:
Marital Status: Religion:
Main Language of Communication: Occupation:

2. PAST HISTORY
Medical: Surgical (nature & date of operation if applicable):

Family: Social:

3. CURRENT HOSPITALIZATION
Reason for Hospitalization: Pathophysiology (applicable to Level 2 & 3)

Medical Diagnosis: Medical Treatment Plan (see Dr’s orders):

Investigations (lab, radiological etc): Drug Allergy (type & allergy symptoms if applicable):

4. MEDICATION LIST
(To record medication information & management – use template in Appendix A)
Medication(s) Indications:
1
2
3
4
5
6

5. ASSESSMENT DATA (Review of Systems)

1 Neurosensory (cognitive function, memory & reasoning):

2 Respiration (rate, patterns, normal/abnormal breath sounds, SPO2):

CA_Case-Study_Dec09
 3 Circulation (pulse rate, blood pressure, apex beat):

4 Gastrointestinal (abdominal assessment – palpation, percussion):

5 Skin (includes hair & nails; color, texture, lesions, integrity):

6 Mouth & Throat (include lips & tongue – moist/dry, condition of teeth, dentures):

7 Nutrition (eating patterns, appetite):

8 Elimination: Urinary (patterns, incontinence, dribbling):

9 Elimination: Bowels (patters, incontinence):

10 Comfort (pain assessment – use OLDCART, pain score):

11 Sleep (patterns):

12 Mobility & Activity (gait, balance, joints):

13 Psychosocial & economic ((housing, education):

14 Spirituality (religion, religious practices):

15 Risk Assessment (fall & pressure ulcer risk):

16 Others:

6. MASTER PROBLEM LIST (NURSING)

(List in order of priority – at least 3 nursing diagnoses – select from list of Nursing Diagnoses in Appendix B)
CA_Case-Study_Dec09
 Nursing Diagnosis: Actual Nursing Diagnosis: Potential
1

7. NURSING CARE PLAN

(Develop 4 nursing care plans from the master problem list – use template in Appendix C)

8. DISCHARGE PLANNING
Main Caregiver: Home equipment/consumables (specify, if required):

Discharge Placement (home, community hospital etc): Discharge Needs/Concerns (financial, psychosocial
etc):

Caregiver Training/Teaching (specify, if required):

9. SELF EVALUATION
(Reflect on how you have cared for the patient & areas where you can improve – use GIBBS cycle in Appendix D)

CA_Case-Study_Dec09