NCM 107 RLE

INDIVIDUAL AND GROUP CASE STUDY

PREPARED BY:
NCM 107 Instructors
 Guidelines
Individual Case Study
- You will be given a case scenario, pregnant or
postpartum client.
- Develop a protocol type individual case study
based from the scenario that will be given to
you.
 Guidelines
Individual Case Study
- Follow the format.
- Submission of case study will be on Oct.30,
2021.
- Long bond Paper, Times new roman,Font 12
- Margins : Left – 1, Right,top,bottom- .5
 Guidelines
Group Case Study/Case Presentation
- Protocol (Pregnant and Postpartum).
- Assign each member of the group their respective parts in the
group case study.
- The one assigned in the Personal profile and history will
conduct the initial interview, but make sure to observe the
minimum health protocol and stay safe.
- Strictly NO face to face interview, please conduct via call or
text, or zoom, gmeet or any online platform possible.
- Should there be any difficulty in the case finding, then the
group can work on a protocol type of group case study.
 Guidelines
Group Case Study/Case Presentation
- Follow the format.
- Submission of group case study will be on______.
- Long bond Paper, Times new roman, Font 12
- Margins : Left – 1, Right,top,bottom- .5
- Submission of final group output will be on_____.
- Soft copies will be given to your respective CI and to
your other CI’c in your section
- Your case presentation is scheduled on ________.
 Guidelines
Group Case Study/Case Presentation
- During case presentation, make sure to
document your presentation.
- Assign a facilitator in the group.
- Take down notes during the giving of comments
and recommendation. For final revision of output
- Submission of final revised output will be on Oct.
15, 2021
Individual and Group Case
Study
FORMAT
 Individual/Group Case Study
• Is one among the main requirements of the
course.

• Focus : Pregnant or Postpartum Client

 PARTS
I. Front Page
II. Table of Contents
III. Body of the Case Study
IV. References- APA format
Body of the Case Study
I. PERSONAL PROFILE
• This part presents the basic information of the
client
• Name : Initials only
• Age:15y/o
• Marital Status: Single
• Occupation: xerox copier staff…
• Religion
• Educational Attainment
 PERSONAL PROFILE
• Name of SO : Initials
• Age
• Gender
• Marital Status
• Religion
• Educational Attainment
• Relationship to the client
 Personal Profile
• Attending OB
• Source of Health Information

• Patient Case: G2P0, (TPAL)20tk weeks AOG

• G2P1 ( 1011) 3 days PP
• Date of Admission
• Date of Discharge
• No. of Hosp Days
• This part is for hospital based cases
 Personal Profiles
• Based from the data gathered ,identify factors that
contributes to the current condition of patient

• Discussion: Based from…

• Age
• Marital Status-
• Occupation-
* w/ lit. And ref..
 II. Health History
A. Present OB History – this consist of the LMP,EDC,
confirmed preg by _____
•  current signs of pregnancy
• GP (TPAL/M)
• Prenatal check-up
• TT vaccine

B. Past OB History - Previous Deliveries,Family

Planning
Name ( Initials) Age Gender Mode of Del Place Complications
1. Baby X none Abortion
 Health History Example
A. Present OB Hx
Mrs. Xy, a pregnant with OB score of G2P0(0010) .She
is in her 20th week gestation…she experienced …
- Date of visit (Further discussion in Course of Visit)

• Note : You need to insert your discussions…

emphasize nursing implications
• Chronologically arranged- start 1st time to confirm
preg..
II. Health History
C. Gyne History – menarche, coitarche, and no.
of sexual partners , any current reproductive
health conditions.
Explain..identify nursing implications..
II. Health History
D. History of Past Illness – it consists of the past
medical history of previous hospitalization,
diagnostic examinations, familial history of
diseases.
Note: This refers to past illness /condition not
related to pregnancy or postpartum

* Explain,analyze..nsg implications
 Other History
• Relevant to client condition
• Social
• Environmental
 Brief Description or Background of Patient’s Condition

- it includes the description of condition

Eg. G1 P0 ,36 weeks gestation
G1P1, 3 days postpartum
- Signs of Pregnancy/ BUBBLEEH for postpartum
- Probable/Positive-

Note:
1. Highlight- what is present to your patient only
2. You need insert discussion
 Brief Description or Background of Patient’s Condition

- Lab/diagnostic procedure (definition or

purpose, how it is done, nursing
considerations before, during and after the
procedure)
- Nursing Management- priority w/ rationale

Note: Explain, relate to patient case, discuss

nursing implication
 Anatomy and Physiology
–include only the involved areas or organs
- Reproductive Organs- Eg. vagina-changes
- Menstrual Cycle- reg/irreg
- Fertilization Process
- Fetal and Maternal Circulation- Eg. 36th weeks
- Milestone of Fetal Development- it depends on the AOG
Note:
1. may use Videos, video clips, picture/figures- parts
2. Dissect- present smallest parts..eg. Uterus
3. Discuss parts related to client’s case
Laboratory Results and Diagnostic Studies

• it must include the dates in chronological

order, the actual results against the normal,
the significance of the results and the nursing
implications that should be based on the
scientific explanation on your case.
• Eg. UTZ results- TVS and abdominal UTZ, lab.
Results
Note : Tabular
Lab Date: March Date: June 18 Interpretation
Test/Dxtics 18
UTZ- TVS Impression Impression discuss
Physical Assessment and Its Physiological Basis

-use person format and include the data when the

patient was assessed
- identify only those appropriate to the patient condition
or identify the data needed for specific problem and
indicate the scientific explanation or reason behind
such signs and symptoms.
- Eg. Nausea and vomiting
- Pls refer to your prenatal
assessment/postpartum assessment
 Physical Assessment and Its Physiological Basis
Date/Time of Assessment

Assessment Assessment Findings Analysis/Interpretation

Psychosocial
Elimination
 Drug Study
- it should be in order and it must include the generic
name, trade name and classification, complete
doctor’s order, date ordered, date given and
discontinued/shifted/increased or decreased eg.
dosage, indication to the patient, action of the drug,
side effects, adverse effects and important nursing
considerations and implications
- Eg. Iron So4 w/ folic acid Amoxicillin, Celecoxib
Calcium
- Present in tabular format
 Drug Study
Medication Action Contraindica Side Effects Adverse Nursing
tion Effect Consideration
Brand Name Discuss
Generic action using
Name the anatomy
Classification: and
physiology
Complete
Drs. Order

Date Ordered
Date Started
Date
Discontinued
/Shifted
 Course of Visit (ICS)
–it should give a complete picture of what
happened during the course of visit and it must
include the progress notes starts at 1st visit, data
will be taken from the mother’s interview,
prenatal book/record, laboratory examinations,
diagnostic test results if available, vital signs
records and physical examinations or
assessment records.
Note: paragraph, discuss data,implications
 Course in the Ward( GCS )
• Admission to discharge (FDAR Format)
Date:
Time:
Focus: FDAR format
Data: Assessment
Admission Action : vital signs taken
-Hooked with an 18 an ivf of d5lrs 1L @___site
at
-Cbc , ua done
-Transfer OB ward
Response:

Health Data: primigravida

teaching Sub: hindi
A:
R:

Labor pains Data:

PQRST
Action:
 Nursing Care Plan
– all data should be based on the Assessment
and Course of visit and all nursing problems
must be addressed accordingly
- Identify at least 3 priority problem (GCS / ICS)
- Present in a tabular format
ASSEESSM Nursing Scientific Planning Interventi Rationale Evaluation
ENT diagnosis explanati on
on
Subjective Short Health on
data: After 3
Madalas hours of
akong appropria
naduduwa yte
l at nursing
nasusuka interventi
on
Objective: -identified
the ways
to
decrease
the feeling
being
n

Long term
Thank you!