GUIDE FOR NURSING CASE ANALYSIS

PARTS OF THE NURSING CASE ANALYSIS

I. ASSESSMENT

A. Personal Data. This part contains the name, hospital number, sex, age, date of
birth, place of birth, civil status, religion, educational attainment, occupation,
address, chief complaints, admitting diagnosis, date and time of admission,
attending physician, final diagnosis (if available), and date and time of discharge (if
available).

B. Pathophysiology. This part includes a discussion of the anatomy and physiology of

the system/organ affected by the disorder, readings related to the disease, and a
schematic diagram of disease development.

C. Family Background. This part encompasses the data about the client’s family. The
socio-demographic profile of immediate family members living and not living with
the client and relatives living with the client is included.

D. Health History. This part contains the family health history and personal health
history (past and present health history).

E. Developmental Data. This part involves the discussion of the developmental tasks
expected of and attained by the client based on two theories, particularly the
Developmental Task Theory (Biopsychosocial Model of Development) by Robert
Havighurst and Moral Development Theory by Lawrence Kohlberg.

F. Patterns of Functioning and Levels of Competencies. This part contains data

concerning patterns of eating, drinking, bladder and bowel elimination, sleeping and
bathing ( patterns of functioning ), and levels of competencies as to physical,
emotional, social, intellectual, and spiritual aspects (levels of competencies).

G. Physical Assessment. This part includes the information reflective of the client's
general health condition and, more importantly, the data obtained through the head
to toe assessment.

H. On-going Appraisal. This part involves discussions on the progression of the

client’s condition during hospitalization. The primary basis of which is the client's
chief complaint at the time of consultation or admission to the hospital.

I. Medical Management. This part contains the data regarding the laboratory exams
and diagnostic procedures done to the client. It also includes the treatments and
medications administered to the client during hospitalization.

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II. NURSING CARE PLAN

This part is the blueprint of nursing care. All abnormal assessment findings
are addressed in this segment of the nursing case analysis. The nursing care plan
contains a nursing diagnosis, nursing inference, nursing goal, nursing interventions,
and nursing evaluation.

III. GENERAL EVALUATION

This part presents a concise discussion about the client's condition from
admission to discharge, reflective of the outcomes of management. This part's
primary focus is the description of the client’s condition on the day of discharge.

IV. REFERENCES

HOW TO PREPARE A NURSING CASE ANALYSIS

Preparation of nursing case analysis entails hard work, critical thinking, and
integration of previously learned concepts. The following discussion provides
detailed information that guides students in coming up with quality output.

The selection of a client for nursing case analysis is very crucial. Hence, to
facilitate its preparation and promote more meaningful learning experience of the
students during the activity, the following points are suggested:

1. Choose a client whose admitting diagnosis is supported by findings through

laboratory examinations and or diagnostic procedures. This ensures that the
discussions are centered on the theoretical concepts which are being correlated.
2. The client taken as a case should be thoroughly assessed on the day or the time
closest to admission when typical manifestations are evident. This enables the
students to gain a better appreciation of the manifestations of the disease.
3. The client for the case analysis is attended to from initial contact to discharge. This
allows the students to have “hands-on” on the case, which promotes optimum
learning. If prevailing conditions do not allow the students to render actual care to
the client, the client can still be taken as a case provided comprehensive descriptions
of his or her condition are reflected in the on-going appraisal through optimum use
of secondary sources of data.

Note: If a case is not available in the hospital, a case can be taken from the
community provided the medical diagnosis has been established and as much as
possible supported by recent laboratory or diagnostic findings.

4. Prepare very well before doing the assessment. Read about the concept/condition
since it is vital to come up with organized, relevant, and complete assessment data.

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Note: Follow the institutional protocol (e.g., letter addressed to the Chief of the
Hospital thru the Chief Nurse, noted by the Instructor and the Program Coordinator;
and written informed consent) on the involvement of clients for case analyses.

The students need to employ various techniques to gather relevant and

complete data during the assessment. These include observation, interview, the use
of secondary sources of data (e.g., documents in the client’s chart, significant
others/watchers), and physical assessment techniques such as inspection, palpation,
percussion, and auscultation.

The nursing case analysis should be accomplished in consideration of the

important points presented in the ensuing discussions.

I. ASSESSMENT

Personal Data

The chief complaint must be consistent with the recorded data during
admission. If there are discrepancies in data indicated in the clinical face sheet and
present health history, the students will be asked to state the chief complaint
considering the information gathered through history taking during the case
presentation.

Pathophysiology

Anatomy and physiology. Indicate in the manuscript a brief overview of the

system involved and thoroughly discuss the organ's anatomy and physiology affected
by the disease. Discussions should be logically sequenced to promote a thorough
understanding of the pathophysiology. (Sources of information should be
appropriately acknowledged using APA format (7th ed) in in-text citations and
references.)

Readings. Include in this part related facts and or updates regarding the
disease. It should contain discussions about the definition, incidence, risk
factors/etiologies (classified as to modifiability), how the disease develops, and its
manifestations. Information should be presented comprehensively and logically. This
part should substantiate the schematic diagram of disease development.
(Acknowledge properly the sources used, which should be of recent edition, using
APA format (7th ed) in in-text citations and references.)

Schematic diagram of the pathophysiology. Develop this part by integrating

the information contained in the readings. Make general pathophysiology, which
clearly illustrates how the disease develops. Start from the risk factors/etiologies and
end with the signs and symptoms (alterations in structure and function that can be
determined through physical assessment, interview, laboratory exams, and
diagnostic procedures), including the possible complications. Highlight the risk

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factors, manifestations, and complications pertinent to the client. In here arrows,
straight/broken lines are used to depict relationships of pathophysiological events.

If the students took a case with multiple conditions (with co-morbidities), the
pathophysiology must include all the diseases using a pattern depicting how these
conditions relate to one another. If it is impossible to consider all the medical
conditions, the students will focus on the disorder related to the assigned concept.
However, the disease not included in the pathophysiology must be considered in the
other parts of the case analysis (e.g., medical management, nursing care plan) to
exemplify comprehensive care.

Family Background

Present a data summary following the format indicated in the table below.

Family Civil Relationship Educational Place of

Members Sex Age Status to the Client Attainment Occupation Religion Residence

In this part, include immediate family members (parents, siblings, and

children who are living and not living with the client) and relatives living with the
client, using pseudonyms. In the narrative presentation, include discussions about
the family monthly income, sources of income, member/s of the family who decide/s
in the allocation of the budget including the budget for health services, adequacy of
budget to meet the needs of the family, quality of the relationship that prevails
among the family members, and social activities as a family that promotes bonding
among members. The family (monthly or quarterly or semiannually or yearly) income
should be the actual earnings of the household members. In case that the household
is composed of two or more families whose incomes are independent of the other,
include only the income of the family where the client belongs. In instances that
there are financial aids received by the family (for example, from relatives), it should
be presented separately with the family's actual earnings and explain how they
utilize that money. Budget allocation should be presented using a pie graph
(percentage) followed by a narrative description (inclusive of the amount). In case
the family has financial difficulties, particularly in meeting the basic needs and or
monetary demands of disease management and problems on interpersonal
relationships among the members, include the coping strategies the family employs
and its outcomes. As the last paragraph, it may be necessary to include the
implications of the assessment findings, which will serve as a basis in formulating
appropriate nursing problems/interventions reflected in the nursing care plan.

Note: The patient is included in the list of family members. However, the
word“patient” must be placed under the fifth column (relationship to the client).
Sometimes, patients are reluctant to share information pertinent to their
socioeconomic status. In this case, the students must respect the patient ’s right to

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privacy. The students need to include in the case analysis manuscript descriptions
related to their inability to gather all pertinent data in this part.

Health History

Family health history

In here, make use of the genogram to present the hereditary and familial
diseases that prevail in the client’s family. For the hereditary diseases, include up to
the third generation (generation of the client) while for familial diseases, include the
household members. Besides, indicate the causes of morbidity and mortality within
the family, emphasizing diseases similar to or related to the client's condition. Also
include information about the use of health facilities (primary, secondary, or tertiary)
and the management received, including laboratory exams/diagnostic procedures,
surgery, and treatments/medications, and the findings/outcomes. If the family
members’ illnesses were managed through consultation with indigenous health
workers or self-medication, describe thoroughly the management done by indicating
how it was done, what was used and the outcomes. Include the reasons for the
family’s utilization of such health services. (Note: In the manuscript, the points of
discussion are the causes of morbidity and mortality of the family, NOT the individual
member of each generation/household.)

Another data that should be included in this part are the immunizations
received by the family members indicating the type of vaccine/immunization and the
number of doses received by the family's concerned member/s. Further, information
about the lifestyle (vices, patterns of activities and rest, and diet) of the household
members should be included. Data about the client's immunization and lifestyle are
mentioned but should be exhaustively described in the personal health history.
The information obtained in this part indicates the diseases that prevail in the family
and the family’s health beliefs and practices. These may be significant to consider in
the formulation of nursing problems/interventions.

Personal Health History (past and present health history)

Past health history. In this part, include all the disorders suffered by the client
from the time he or she was born except those related to the present condition.
Describe these disorders by indicating the manifestations experienced by the client
and the management done and its outcomes. All surgical procedures done to the
client except those used to manage the current condition should be described.
Relevant data should be presented in chronological order. Also, include discussions
of the client's health habits and practices (e.g., lifestyle), which are not related to the
current illness. Further, indicate the immunizations received by the client specifying
the type and the number of doses.

Present health history. In here, describe the course of the client’s current
illness. Integrate the discussion of factors such as lifestyle that possibly contributed

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to client’s illness development. Account for the manifestations from the time the
client started to experience signs and symptoms close to the disease. Describe the
manifestations as to the onset, location, quality (intensity, and other characteristics),
quantity, precipitating factor, relieving factor, and aggravating factor. Also, integrate
into the discussion previous consultation/admission of the client to health care
facilities (primary, secondary, or tertiary), and the management received including
the results/outcomes of laboratory exams/diagnostic procedures, surgery,
treatments, and medications. In case the client’s illness was managed through
consultation with indigenous health workers or self-medication, describe the
management employed by indicating how it was done, what was used and the
outcomes. Clearly describe in this part exacerbation and or remission of the signs
and symptoms with the associated factors. Relevant events or data should be
presented in chronological order. This part ends with the client's chief complaints at
the time of current admission in the health care facility and the admitting diagnosis;
thus, management done to the client at the emergency room is no longer included.

In case that the client’s condition involves the reproductive system, the
following data should be integrated into the present health history.

For a female client:

a. onset of menstruation and last menstrual period

b. the usual length of a menstrual period in days and the usual amount of
bleeding/number of sanitary pads used per day and whether these are partially,
moderately, or thoroughly soaked
c. concerns on the amount and regularity of menstrual flow; pain experienced during
menstruation
d. management done to address the irregularities or problems related to
menstruation
e. number and outcome of pregnancies, including miscarriages and abortions, and
manner of deliveries
f. ages on the birth of firstborn and last-born children
g. problems related to pregnancy and delivery and their management
h. problems like burning with urination, vaginal itching or discharge, mid-cycle
spotting, pain with intercourse, or any other problem
i. frequency of doing a breast self-examination
j. frequency/schedule of pap smear and mammogram
k. family history of cancer involving the reproductive organs
l. sexual history and practices

For a male client:

a. problems like difficulty in initiating urination, urinary frequency, or frequent

urination at night
b. the onset of itching or presence of penile discharges/lesions, or any other
problems
c. frequency of doing testicular examination

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d. family history of cancer involving the reproductive organs
e. sexual history and practices

Developmental Data

In this part, there is a need to identify the developmental stage where the
client belongs. Then identify the area of resolution, the developmental tasks
expected of the client to achieve, and the developmental hazards based on two
theories, Developmental Task Theory (Biopsychosocial Model of Development) by
Robert Havighurst and Moral Development Theory by Lawrence Kohlberg. This is
followed by the discussion of data that reflects the client’s performance along each
of the expected tasks. Include in the discussion, the ability of the client to master the
expected tasks. Then formulate the analysis and implications. In the analysis, point
out if the client achieves the tasks typically or is lagging in mastering the expected
tasks. Also, explain the possible reasons for the client's ability or inability to attain
the developmental tasks on time. Make an overall conclusion regarding the findings
based on the two theories used. Lastly, in the implications, determine the client's
relevant needs, which should be addressed by nursing interventions.

Patterns of Functioning and Levels of Competencies

Patterns of functioning. This part includes data regarding the patterns of

eating, drinking, bladder and bowel elimination, sleeping, and bathing. The data that
should be included in each of these aspects are indicated below.

Eating pattern. Indicate the food preferences and preparation, dislikes,

allergy-causing foods, amount of food intake, and usual time of eating. Data
obtained in this part should serve as cues in the formulation of nursing problems
related to nutrition.

Drinking pattern. Specify the drinks/beverages preferred, dislikes, allergy-

causing drinks/beverages, amount of intake, and usual time or frequency of intake.
Data obtained in this part should serve as cues in the formulation of nursing
problems regarding fluid imbalances.

Bladder and bowel elimination pattern. Indicate the usual amount of urine
passed per voiding/per day, frequency of urination, characteristics of urine (clarity,
color, odor); the usual amount of stool passed per defecation, frequency of
defecation, characteristics of stool (color, consistency, shape, odor), and rituals. The
data for bladder elimination must be clustered separately from the assessment
findings for bowel elimination. Data obtained in this part should serve as cues in the
formulation of nursing problems associated with elimination.

Sleeping pattern. Specify the usual time of going to sleep at night/ naps/rest
periods during the day, the usual duration of sleep, sleep aids, and rituals. If sleep
interruptions, particularly at night, are experienced by the client, provide clear
descriptions to include the number of times and duration of sleep interruptions, and

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if there is difficulty going back to sleep. Likewise, oversleeping should be clearly
described. Include data describing the quality of rest derived from sleep. Data
obtained in this part should serve as cues in the formulation of nursing problems on
sleep disturbances.

Bathing pattern. Indicate the usual time of taking a bath, frequency of

bathing, bath aids, and rituals. Data obtained in this part should serve as a basis in
the formulation of nursing problems such as self-care deficit.

The abovementioned data should be presented by following the format shown

below.

For a client with acute or chronic condition:

Patterns of Functioning Before Illness During Illness

(specify the time frame)
Eating

Under the column before illness, include data that apply before the client
started to manifest signs and symptoms close to the disease. On the other hand,
data that apply from the time the client started to manifest signs and symptoms
related to the disease up to the time of admission are included under the column
during illness. Data for each function (eating, drinking, etc.) should be presented in
the table in bullets. Below each table, analyze by briefly stating the alteration/s in
each function and explaining the reason/s behind it. Reasons regarding the
alterations are not mentioned along with the tabular data, only in the analysis. The
reasons behind the alterations, which are usually based on the pathophysiology,
serve as guides in identifying relevant nursing diagnoses' etiologies.

For a client with congenital condition:

Patterns of During Illness

Functioning
Eating and so on

Under the column during illness, include all relevant data from birth or
several years or months before the current hospitalization. The primary basis of the
time frame is the ability to present relevant data that could clearly describe
alterations of functions concerning the client’s condition. Data for each function
(eating, drinking, and so on) should be presented in the table in bullets. Below each
table, analyze by briefly stating the deviations in each function and explaining the
reason/s behind it. Reasons regarding the alterations are not mentioned along with
the data in the table, only in the analysis. The reasons behind the alterations, which
are usually based on the pathophysiology, serve as guides in the identification of the
etiologies of relevant nursing diagnoses.

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Levels of Competencies. This part contains data regarding the client's ability to
perform activities/tasks related to physical, emotional, social, intellectual, and
spiritual aspects. The data that should be included in each of these aspects are
indicated below.

Physical competency. Describe in this part the client's ability to carry out
activities such as ADL and other physical activities, which are usually done. The use
of assistive devices should be described. If involvement with physical activities is
associated with discomforts, it should be objectively depicted. Describe the level of
activity and the client's discomforts as physical activities are performed. Data here
should serve as a basis in the formulation of relevant nursing problems such as
decreased activity tolerance and impaired physical mobility.

Emotional competency. In this part, describe the client's emotional status, the
ability to express emotions, and the ability to control feelings. Also, identify if the
client's emotions are appropriate to stimuli because emotional changes do not
necessarily mean alterations in this competency. Data obtained in this part serve as a
basis in the formulation of nursing problems centered on the psychosocial aspect.

Social competency. Describe in this part the quality of the client’s

interpersonal relationships. Include data that reflect the client’s ability to interact
and or relate with other people. Limitations about the frequency of interaction with
other people and the groups of people the client interacts with as imposed by the
disease do not necessarily mean alterations in this competency. Data obtained in this
part serve as a basis in the formulation of nursing problems focused on the social
aspect.

Intellectual competency. In this part, discuss the ability of the client to

perform mental activities. Describe the ability to make decisions, comprehend, and
retain information. Also, the ability for calculation, orientation to time, place, and
person should be included. Further, the level of knowledge of the client regarding his
condition is also described. Data obtained in this part serves as a basis for the
formulation of nursing problems related to cognition and knowledge about the
condition.

Spiritual competency. Describe in this part the client’s faith, religious beliefs,
and practices/activities. Changes or limitations regarding the type of and frequency
of doing religious activities as imposed by the disease do not necessarily mean
significant alterations in this competency. Data obtained in this part serve as a basis
in the formulation of nursing problems centered on spirituality.

The abovementioned data should be presented by following the format

indicated below.

Levels of Competencies Before Illness During Illness

Physical competency

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 Under the column for before illness, include data that apply before the client
started to manifest signs and symptoms close to the disease. On the other hand,
data that apply from the time the client started to manifest signs and symptoms
related to the disease up to the time of admission are included under the column
during illness. Data for each competency (physical, emotional, and so on) should be
presented in the table in bullets. Below each table, analyze by briefly stating the
alteration/s in each competency and explaining the reason/s behind it. Reasons
regarding the alterations are not mentioned along with the tabular data, only in the
analysis. The reasons behind the alterations, which are usually based on the
pathophysiology, serve as a guide in the identification of the etiologies of relevant
nursing diagnoses.

Physical Assessment

Physical assessment should be done during the initial contact with the client
closest to the time of admission. It should be focused on the organ/s or system/s
affected by the disease. It should contain data primarily about the general health
condition of the client and head to toe assessment. The place, date, and time of
physical assessment should be included in the written output.

General health condition. This part includes a description of the appearance

of the client. Describe the client’s body built, grooming, the color of the skin/lips
(e.g., pale or cyanotic), the appearance that reflects the degree of strength (e.g.,
appears weak or strong), position or activity, and gadgets connected to the client
(e.g., IVF, IFC, NGT). Also, describe the client’s behavior (e.g., restless, irritable) and
level of consciousness (e.g., disoriented, stuporous, unconscious). Further, include
the client’s height, weight, and BMI, which serve as the basis for the nursing
problems related to nutrition. The client’s vital signs are likewise included since they
signify the overall health condition.

Head to toe assessment. In this part include data gathered through inspection,
palpation, percussion, and auscultation. The assessment methods appropriate for
the client’s condition should be utilized to ensure a thorough assessment. For
example, in assessing the thoracic and abdominal regions, assessment findings that
provide clues on the involvement of the internal organs should be included. Outline
assessment findings using bullets. For each body part, do not put indicators (for
example, eyes – color, shape, etc.), describe it in detail (for example, eyes – with a
white sclera, pinkish conjunctiva, etc.). The primary focus of assessment is the body
part affected by the disease. If a particular assessment finding is expected in a typical
case but not present in the client, the absence of such data must be reflected. Both
normal and abnormal assessment findings should be included in the manuscript. The
following body parts must be assessed:

Head
Eyes
Ears
Nose

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 Mouth
Neck
Chest
Abdomen
Perineum
Upper extremities
Lower extremities

Note: Significant data between the time of physical assessment and on-going
appraisal should be reflected in the initial part of the latter.

On-going Appraisal

In this part, include discussions regarding day to day (for acute conditions) or
weekly (for chronic conditions) evaluation of the client’s condition during
hospitalization. The primary basis of which is the client's chief complaint at the time
of consultation or admission in the hospital. However, in some instances, other
health problems arise and should also be reflected in this part. The ongoing appraisal
should start the day after the physical assessment was conducted. The data within
24 - hour period, from 7:00 am to 7:00 am the next day should be included in day to
day appraisal. For weekly appraisal, essential data, including changes in the clients’
condition from day 1 to day 7, should be reflected. Although the nurse’s notes can
serve as a secondary source of data, the ongoing appraisal should not be made
similar to the charting. It should contain the assessment findings such as complaints
or needs of the client and objective data which are also reflected in the previous
parts of the case analysis; management done (for example, orders for a new drug,
administration of IVF, insertion of tubes, diagnostic procedures, independent nursing
interventions, etc.); and the response of the client towards the management of the
complaints or needs or the effects of interventions. Since the ongoing appraisal
contains various information related to the other parts of the nursing case analysis,
sometimes students are challenged to accomplish this part. To ensure completeness
and consistency of information, initially, make a summary of data that will serve as
the basis for discussion. Refer to the table below.

Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7

Need/problem

Management

Response/Effect

Through this table, improvement and/or deterioration of the client’s

condition are easily traced. However, in the final written output, the ongoing
appraisal is presented in narrative form.

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Note: If the students took a case who was confined in the ICU and had the initial
contact with the patient in the regular ward, relevant information from the time of
admission and confinement in the ICU must be accounted for as the first part of the
On-going Appraisal and labeled as “Course of Confinement.” This requirement also
applies when the students get a case several days after admission.

Medical Management

Laboratory examinations and diagnostic procedures. In this part, include a

brief description of the examination or procedure. This is followed by the statement
of the purpose of the examination/procedure in relation to the client’s case. The
information regarding laboratory examinations must be presented as follows:

If the laboratory exam was done once:

Date ordered:
Date performed/of specimen collection:
Date of release:

Laboratory Examination Found Value Normal Value Significance

If the laboratory exam was done more than once:

Date ordered:
Date performed/of specimen collection:

Note: Multiple columns are created under the date where the found values are
written.

Laboratory Date Normal Significance

Examination Value
>
>
>

For the column on significance, identify whether the result is normal,

increased, or decreased, and its implications. Below the table, place the analysis,
which clearly explains the reason/s for the abnormal findings. Acknowledge properly
the references (APA 7th ed.) used in the explanation of abnormal findings. The
analysis is followed by the nursing responsibilities arranged chronologically, including
measures that could help normalize the results. Relevant nursing interventions
should be clearly rationalized.

Note: For the diagnostic procedures (e.g. ECG, Chest X-ray), the data presentation
does not involve the use of a table.

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 Treatments. This part includes the special diet, oxygen therapy, suctioning,
nebulization, IVF therapy, blood transfusion, insertion of IFC, NGT, and others. In
here, provide a brief description of the treatment, and state its purpose in relation to
the client’s case. This is followed by logically arranged appropriate nursing
responsibilities with a clear rationale.

Drug study

In this part, include all the medications given to the client throughout
hospitalization. Indicate the date and time when the drug was ordered, discontinued,
or changed (as to dosage, route & frequency). For each drug, place the generic name,
brand name, classification, dosage and frequency, route of administration,
mechanism of action, desired effect, and nursing responsibilities with rationale. In
case it is a generic drug, disregard the brand name. In the mechanism of action,
explain how the drug exerts its therapeutic effect while in the desired effect, explain
the reason why the drug is given to the client. The explanation about the desired
effect relates the drug to the client’s condition. This is followed by a list of
appropriate nursing responsibilities with rationale. Include nursing interventions that
could potentiate, enhance, and ensure the drug's safe use. Hence, there is a need to
integrate the 12 Rs, contraindications, side effects, and adverse effects in the nursing
interventions.

Also, include the computation of the drug dosage for the patient, which is
placed before the nursing responsibilities. The nursing responsibilities in medical
management should be presented following the format shown below.

Nursing Responsibilities Rationale

1. 

II. NURSING CARE PLAN

The relevance of the nursing care plan primarily depends on accurate and
reliable assessment. Also, abnormal assessment findings become worthwhile only
when addressed in the nursing care plan. A thorough analysis of assessment findings
should be done to develop a viable and relevant nursing care plan. The type and
number of nursing diagnoses included in the nursing care plan depend on what could
be derived from the assessment. The nursing care plan is composed of the nursing
diagnosis, nursing inference, nursing goal, nursing interventions, and nursing
evaluation.

Nursing diagnosis. Several types of nursing diagnoses can be formulated.

Nursing diagnoses can be actual (validated by the presence of major defining
characteristics), potential/risk (with high probability to occur with the existence of
the actual problem), possible (with a suspected problem for which additional data
are needed), wellness (clinical judgment about the client in transition from a specific
level of wellness to a higher level of wellness), or syndrome diagnoses (a cluster of

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actual or risk nursing diagnoses that are predicted to be present because of certain
event or situation). Nursing diagnoses should be stated following the PES (P-
problem, E-etiology, and S-signs and symptoms) format. If it is an actual nursing
diagnosis, it should be stated reflecting the P, E, and S. On the other hand, a
potential/risk nursing diagnosis is stated with the P and E. Statement of a possible
nursing diagnosis only contains the P. A wellness or health promotion nursing
diagnosis contains the label “Readiness for Enhanced,” followed by the desired
higher-level wellness (P), related factors are not included but with two cues (S) to
make a wellness diagnosis valid: (1) a desire for a higher level of wellness and (2)
effective present state or function. A syndrome nursing diagnosis statement consists
of the P, E, and S. A nursing diagnosis may have more than one (1) etiologies
depending on the client's condition or assessment findings. Use the NANDA-
Approved Nursing Diagnoses as a basis in the formulation of nursing diagnoses.

Nursing inference. This explains how the problem is formulated. It clearly

states how the etiology brings about the problem. The primary basis of the nursing
inference is the pathophysiology.

Nursing goal. This part of the nursing care plan provides direction to what is
expected to be achieved. Long-term (usually requires weeks) and/or short term
(usually requires hours or several days) goals can be formulated depending on the
type of nursing problem. It should be specific, measurable, attainable, realistic, and
time-bound. The nursing goal is composed of the following:

a. time frame – time needed for the attainment of the desired outcome
b. the condition under which the desired outcome is achieved
c. subject - client
d. desired outcome – what is expected to be achieved
e. parameters – criteria that determine whether the desired outcome is met or not

Nursing interventions. Appropriate nursing measures should be included.

Nursing interventions are most appropriate when the etiology is addressed. In order
to come up with such type of nursing interventions, the following are suggested:
a. ensure that the identified etiology is fully understood, and
b. consider the time frame (adequacy of time to carry out the intervention
and to bring about the preferred effects) and the desired outcome of the
nursing goal.

In some instances, however, supportive nursing interventions that do not directly

attack the etiology are included. The nursing interventions must be sequenced based
on their degree of relevance (with the highest to the lowest degree of significance)
to the etiology. Further, nursing interventions should be rationalized. The rationale
should clearly state how the intervention attacks or eradicates the etiology, thereby
solving the problem. If the administration of a specific drug is included as one of the
nursing interventions, specify the drug, dosage, route, and frequency of
administration and derive the rationale from the mechanism of action and the

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desired effect. The nursing interventions should be presented following the format
below.

Nursing Interventions Rationale

1. 

Nursing evaluation. This is based on the set nursing goal. This determines the
effects or outcomes of the nursing interventions rendered. It can be stated similarly
with the nursing goal, although it denotes achievement or non-achievement of the
desired outcome.

The nursing diagnoses should be presented chronologically, from the client’s

admission to discharge from the hospital. The initial set of nursing diagnoses should
be arranged according to priority (actual, potential/risk, possible, and wellness
problems ). The nursing diagnoses that arise later during hospitalization are
presented in chronological order. Justify the prioritization of nursing problems based
on the principles of ABCs and Maslow’s Hierarchy of Needs.

III. GENERAL EVALUATION

In this part, describe briefly the condition of the client from admission to
discharge. The discussion on this part highlights the description of the client’s
condition on the day of discharge, which signifies improvement or deterioration of
condition as outcomes of management done throughout hospitalization. Also,
indicate the date and time of discharge and mode of transportation from the ward.

IV. REFERENCES

All references must be included. Use the APA Format 7th edition.

HOW TO PRESENT A NURSING CASE ANALYSIS

1. During the presentation

a. Data should be presented logically and comprehensively. Be ready for any

questions that could be asked by the audience and exert extra effort to provide
relevant answers.
b. Ideas/suggestions that could enrich the nursing case analysis should be accurately
and wholly noted and integrated into the final written output.
c. Considerations in the presentation of the specific parts of the nursing case analysis:
i.Personal Data: Personal data should be presented in narrative form. Use an
acceptable pseudonym, which is easy to recall. Use the pseudonym consistently.
ii. Pathophysiology: Make use of illustrations of the organ/s affected in the
discussion of anatomy and physiology. Also, the readings should be integrated into
the presentation of the schematic diagram of disease development. The readings

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should not be presented separately with the schematic diagram of the
pathophysiology. The risk factors/etiologies and the manifestations true to the client
should be identified/emphasized.
iii. Family background: Present the table of the family's socio-demographic profile
and the budget allocation and expenditures through a pie graph. Other significant
data should be outlined in the visual aid.
iv. Family health history: A diagram of the genogram should be shown concurrently
with the narrative presentation.
v. Developmental data, patterns of functioning, and levels of competencies: Present
the tables and analysis in the visual aid and discuss thoroughly.
vi. Physical assessment: Present through the visual aid an outline of the assessment
findings and explain it very well. Highlight abnormal findings.
vii. Ongoing appraisal: Present an outline (in table form) of the significant events
that happened to the client daily/weekly, which serve as the basis of discussion. The
presentation should promote a clear understanding of the improvement or
deterioration of the client’s condition by the audience.
viii. Medical management: Present the findings of laboratory
examinations/diagnostic procedures through the visual aid outlined and in tabular
form and provide a thorough discussion. All the treatments and medications
included in the drug study should be shown through the visual aid completely.
ix. Nursing care plan: All parts of the NCP should be presented through the visual
aid.
x. General evaluation: Only the outline of data should be presented through the
visual aid, which serves as a basis for a thorough discussion.
xi. Implications: The salient points must be presented through the visual aid as a
basis for discussion.
e. All class members are expected to demonstrate an interest in participating
throughout the case presentation to ensure optimum learning on the related
concept.

2. After the presentation

a. Refine the manuscript by integrating all the suggestions made during the
presentation of the case.
b. Submit the final manuscript one to two weeks following the case presentation.

The panel members may require students to redo their case analysis and
presentation. The primary grounds for such decision include the following:
1. plagiarism
2. extremely poor assessment
3. numerous data inconsistency

Prepared by:
Gemma D. Galutira
Faculty member
CHS, Department of Nursing

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