AL-ISRA-University

Faculty of Nursing

Adult 2 clinical

Case study writing

Student name………………………… Date…………………

Clinical area…………………………. Case name ………….

A- Write a case study according to the form

● Demographic Date
………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………

● Chief Complaint, Sign and Symptoms

………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………

● Medical Diagnosis ……………………………………………………………………………………………

● Medical and surgical history

………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………
● Pathophysiology and definition of the disease
……………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………
……………

Physical Exam

Inspection : He is able to walk, but with the help of his son, and does not exercise
a lot twice a week. He is able to eat well and also does not need help in bathing or wearing
clothes, and he uses crutches to climb up the stairs

Palpation : nothing raises a red flag

Percussion :

Ascultation……………………………………………………………………………………………………………………………………
……………………………………………
 ● Diagnostic Test andProcedure

Lab test Patient result Normal range Interpret result

Diagnostic Procedure (abnormal finding)

………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………

● medical management (medication, IV therapy)

Medication Classification Dose and Route Side effect Nursing

frequency (major) consideration

1-
2-

1-
2-

1-
2-

1-
2-

IV fluid name Type according to Rate /hour Total amount over 24

osmolarity hours

● nursing diagnosis as priority

1………………………………………………………………………………………………………………………………………
 ● goal

1……………………………………………………………………………………………

● nursing intervention

Non – pharmacological intervention Pharmacological intervention

❖ What is the fall risk assessment for your patient …………………………?

Rational …………………………………………………………………

❖ If your patient has a Pain

What is the pain score ……………………………. pain scale that used ………………

❖ If your patient used O2 therapy

What’s the O2 therapy methods ……………………………. Flow rate …………………

Indication of uses…………………………………………………………………………………

Nursingcare…………………………………………………………………………………………………………………………………………………
….
Clinical instructor: Mouna Hamdan