CASE STUDY FORMAT

I. INTRODUCTION
A. Background of the study
1. Patient Case Description
2. Micro Case Situation
3. Macro Case Situation
B. Objective (general & specific showing Knowledge, Skills & Attitude)
C. Scope and Delimitation
D. Theoretical Framework

II. BIOGRAPHIC DATA

Patients’ initial
Address
Age
Sex
Race
Marital Status
Occupation
Religion
Health care financing/source of medical care
Date of Admission

III. CHIEF COMPLAINT OR REASON FOR VISIT

Clinical diagnosis upon admission:

IV. NURSING HISTORY (with guide questionnaire)

A. History of Present Illness
B. Past Medical History
C. Family History of Illness (Genogram-both grandfather/mother {until 3rd generation})
D. Developmental History (for Pediatric cases only; with Assessment Guide)
E. Psychiatric History for Mental Health
F. Obstetric History (for OB cases only; with Assessment Guide)
Note: Assessment guide used should be attached at the back of the case study report.

V. FUNCTIONAL HEALTH PATTERN (with guide questionnaire)

1. Health Perception and Health Management Pattern
2. Nutrition and Metabolic Pattern
3. Elimination Pattern
4. Activity-Exercised Pattern (use Barthel index)
5. Sleep-rest Pattern
6. Cognitive-perceptual Pattern
7. Self-perception and self-control Pattern
8. Role-relationship Pattern
9. Sexuality-reproductive Pattern
10. Coping-stress tolerance Pattern
11. Value-belief Pattern
12. Emotional Pattern
13. Cultural Pattern
14. Recreation Pattern
15. Environment
16. Hygiene
17. Substance Used
Interpretation:
Analysis: (Provide end note Ex. Lana, 2019)
NOTE: Applied in each health pattern

NOTE: The following data must be presented in a tabulated format:

a. Nutrition & metabolic pattern
b. Elimination Pattern
c. Activity-Exercise Patterns
d. Sleep – rest pattern
e. Substance use/use of medications

Before Hospitalization During Hospitalization Analysis/inference References

VI. REVIEW OF SYSTEM (subjective complaints)

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 VII. PHYSICAL ASSESSMENT (all objective findings; indicate date performed; Head to Toe assessment
follow
IPPA sequence)
General Survey (Short Paragraph)
Vital Signs
BODY PART (Technique NORMAL ACTUAL INTERPRETATION/ ANALYSIS
used) FINDINGS FINDINGS With reference
Based on the pathophysiologic
analysis of the patients’ disease
process.

VIII. ANATOMY & PHYSIOLOGY

A. With anatomical figure
B. Include structure description

IX. DIAGNOSTIC/LABORATORY PROCEDURES

Date INDICATION NSG.CONSIDERATI NORMAL ACTUAL ANALYSIS/
(chronological) FOR THE ON VALUE/ RESULT/ INTERPRETATION
TEST/ BEFORE & AFTER FINDINGS/ FINDINGS/ (with Reference;
NAME OF TEST/ PROCEDUR THE PROCEDURE IMPRESSIO with pathophysiologic
PROCEDURE E N relevance)

X. SURGICAL PROCEDURE (Refer to Operative worksheet if applicable)

XI. PATHOPHYSIOLOGY (Present in Schematic Diagram; Concept/Mind mapping/ Obstetric Physiology
Analysis)
XII. DRUG STUDY/ IV INFUSIONS/ BLOOD TRANSFUSIONS, AND TREATMENTS

DATE TRADE/ PHARMA INDICATIO ADVERSE DESIRED NURSING

ORDERED/ BRAND COLOGI N AND EFFECTS ACTION ON RESPONSIBILITIES/PRE
STARTED NAME C CONTRAI OF THE CLIENT CAUTIONS
DRUG ORDER ACTION NDICATIO DRUG
(Generic name, OF NS (disease related)
dosage, route, DRUG
frequency) (disease
related)

INFUSION/ CLASSIFICATION INDICATION CONTRAINDICATIO NURSING RESPONSIBILITIES/

TREATMEN N PRECAUTIONS
T

XIII. COURSE IN THE WARD (narrative form)

 Summary of day to day medical/nursing management from the date of admission up to the time
case study was done
 Patient’s Status:
General condition of the client (LOC, VS, Subjective & Objective, complaint during the day)
Patient Condition & 4 D’s with inference/analysis:
o Drugs/IVF
o Diagnostics/Lab. Procedure
o Diet
o Disposition (special order, instruction)
XIV. PRIORITIZED LIST OF NURSING DIAGNOSES (Table)
 Prioritized using ABC’s , Actual or Potential Problem, Maslow’s Hierarchy of Needs
 Include 1st three priority diagnoses only
DATE NURSING PROBLEMS CUES JUSTIFICATION
IDENTIFIED

XV . NURSING CARE PLAN

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ASSESSME NURSING BACKGROUND GOALS AND NURSING EVALUATION
NT DIAGNOSI KNOWLEDGE/ OBJECTIVES INTERVENTION (narrative form)
S (Problem ANALYSIS(Pathophys (include long and S AND
Subjective & Etiology) iology/ psychosocial short term RATIONALE Efficiency
Objective explanation or objectives) (with reference) Accuracy
Measureme consequences of the Is the problem:
nt nursing diagnosis) Independent met?
Dependent partially met?
Collaborative not met?

XVI. FINAL DIAGNOSIS (if for discharge)

XVII. PROPOSED/DISCHARGE PLAN (to be submitted by students whose patients are for discharge)

 M – Medications to take at home

 E – Exercises
 T – Treatment
 H – Health Teachings
 O – Out - patient follow-up
 D – Diet
 S – Spiritual/Sexual activity (optional)

Writing Style & Format

1. Cover Page (see attachment)
2. Table of contents (small Roman Numeral pagination)
3. References (APA Format)
4. Legal Size
5. Page margination 1.5x1x1x1
6. Font Arial
7. Font Size 12
8. Double spaced (except for cover page, table of contents, references, NCP, Drug Study, and all in
tabular form).
9. Pagination – upper right
Prepare 4 sets of the manuscript (for panelist only).

10. Submit the manuscript to your adviser for proof reading 3 days before the schedule presentation.

End Stage Renal Disease

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 A case study
Presented to the faculty of Nursing
New Era University

In Partial fulfillment of the requirement for the Course _______, Concept of _________

Presented by:

BSN Level II, Group ____

Name of members

Date of Exposure
__________ Semester, AY ________________

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