MINI CASE STUDY

I. HEALTH HISTORY
A. DEMOGRAPHIC (BIOGRAPHICAL) DATA
1. Client’s Name or Initial (Optional) :
2. Gender (Sex) :
3. Age :
4. Race / Nationality:
5. Religion:

B. REASON(S) FOR SEEKING CARE or CHIEF COMPLAINTS

(Problem with duration and accompanying s/s one or more symptoms or concerning using the patient to seek
care or may quote the patient's own words.)
Example:
 “Noticed swelling in hands, feet, and face” 2 days ago
 “Frontal Headache” won’t be relieve with a pain reliever
 “Feeling irritable”
 “Doesn’t want overhead lights on”

C. OB GYNE HISTORY (if applicable)

OB-Gyne History
Menarche (age): When:
Amount ad characteristics
Duration
Associated Symptoms

D. PEDIATRIC HISTORY (if applicable)

Maternal and Birth history

Birthdate : Hospital:
Birth Weight:
Type of Delivery:
Condition After Birth:

Mother:
Complications of Delivery:
Anesthesia during labor:
Exposure to Teratogenic agents during pregnancy:
II. DIAGNOSIS-BASED PATHOPHYSIOLOGY (Narrative Format)
- Include only the system involved in the diagnosis

III. Procedure (USN, Gavage, CTT, Surgery, etc.)

Nursing Responsibilities /
Procedure Indication / Analysis
Implications

IV. NURSING CARE PLAN

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective Short Term: Independent:

data:

Objective data: Long Term: Dependent:

Collaborative:

V. DRUG STUDY

Mechanism of Side effects & Nursing

Drug Name Indication Contraindication
Action Adverse Effects Responsibilities

Generic Name: Side Effects:

Classification:

Dosage: Adverse
Effects:
Frequency: