Tagum Doctors College, Inc.

Mahogany St., Rabe Subdivision

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 (Saturday Oct.23, 2021)
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

Contents:
a. Front page (sample format below)

Tagum Doctors College, Inc.

Mahogany St., Rabe Subdivision , Tagum City
Nursing Program

Nursing Management of a Patient with

GESTATIONAL DIABETES MELLITUS

A Case Study Presented to the Nursing Clinical Instructors

of Tagum Doctors College, Inc.

In Partial Fulfillment of the Requirements in

NRG 107: Care of Clients with Problems in…

(Names)

(Date)
 Tagum Doctors College, Inc.
Mahogany St. Rabe Subdivision, Tagum City
Nursing Program

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

iii. Family History (with Genogram) – Narrative note: if There is any

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) Note: your diagnosis will be Human
chorionic Gonadotropin.
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 development of the illness being
of the patient) investigated; cite references at the
end of each discussion)

iii. Symptomatology (tabular) Note: S/S of Pregnancy

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. ( note: how PREGNANCY develop)
v. Narrative: Discuss the pathophysiology narratively/in paragraph, using full sentences.
 Tagum Doctors College, Inc.
Mahogany St.,Rabe Subdivision, Tagum City
Nursing Program

vi. Course in the Ward/Treatment/Interventions

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.
Note: get from the previous Module 4

PROCEDURE PURPOSE NORMAL RANGE RESULT NURSING

(include date and (indicate if above MANAGEMENT
time taken/done) or below normal; (discuss what are the
afterwards, things that the nurse has
discuss the to consider when taking
results vis-à-vis care of a patient who is
the condition of to undergo the
the patient; procedure; cite the
DISCUSSION nursing management
SHOULD NOT pre-, intra-, and post-
BE GENERIC) procedure)

3) Pharmacologic Management (Drug Study) – One drug study per student per subgroup (ferrous
So4, Vit. C and Tetatus Toxoid drug)
Date Medication Mode Dosage Indication(s) Contraindication(s) Side Adver Nursing
Ordered of Effects se Responsibilities
Action Effect
s

any Generic

Name

Brand

Name

Classification

🗹 Add picture of the drug; add references at the end of each table
 Tagum Doctors College, Inc.
Mahogany St., Rabe Subdivision, Tagum City

Nursing Program

4) Surgical Management (tabular)

SURGICAL INDICATION RESULT NURSING MANAGEMENT
PROCEDURE (include (indicate the actual (discuss what are the things
date and time 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)

5) Nursing Management

i. Nursing Care Plan (each student must formulate a nursing care plan)note: Each subgroup instead.

Date Cues Nursing Goal & Interventions Rationale Evaluation

/ Diagnosis Objectives
Time

Subjective Nsg Dx: Be SMART; Note: Add Entries in the evaluation section can b
: Cite 1 rationale hypothetical. HOWEVER, you must ma
goal and at for each sure that the information placed here ji
Rationale/ least 3 interventio with the data presented in the
Objective: Scientific objectives in n. module and with the
Basis: this information used by your groupmates.
section
Add citation Add date and time at the beginning;
at the end of Afterwards, state if GOAL
the MET/PARTIALLY MET/UNMET
rationale/scient
ific Go back to your goal and objectives an
discussion see if you have achieved your goals or
(follow APA not.
7th ed
guidelines)

Reference(s): Cite all references that you used in making this care plan. note: You can get in google

ii. Nurse’s Individual) –CHECKLIST + FDAR note: Each subgroup instead.

6) Clinical Reasoning Questions

7). Discharge Plan (METHODS format) – MEDICATIONS, EXERCISE, TREATMENT, HYGIENE,
OUTPATIENT (CHECK-UP), DIET, SPIRITUALITY note:
(Your Health teaching and recommendations Only)
8) References (APA 7th edition guidelines for references must be followed) note: You can get in google.

Excellentia et Servitum Excellence in Service

LEGEND:

1.RED – Omit

2. GREEN - Recommended to do.