Saint Francis of Assisi College COLLEGE OF NURSING 045 Admiral Village, Talon III, Las Pinas City FORMAT

FOR CASE STUDY I. INTRODUCTION a. Rationale for choosing the case (briefly give an overview of the case study and explain the reason why the clients case was chosen) b. Objectives ASSESSMENT a. Client Profile b. Chief Complaint c. History of Present Illness d. Past Medical History e. Family History of Illness f. Gordons Functional Assessment g. Physical Examination h. Laboratory and Diagnostic Study Description Indication and Contraindication Client Preparation and Post-Procedure Instructions Normal Values Actual Result Clinical Interpretation Briefly explain the significance of the results to the clients condition and to the treatment modalities III. PROBLEM IDENTIFICATION a. Review of Anatomy and Physiology (briefly discuss the anatomy and physiology of the body system or organs affected by the disease) b. Pathophysiology (in a paradigm or narrative format, explain the disease process from the risk/predisposing factor then the mechanism of the disease until the appearance of the signs and symptoms present in the patient) c. Problems List (list all the problems/nursing diagnoses identified on the patient and justify based on the assessment findings) IV. PLANNING a. Problem Prioritization (Briefly explain the basis of prioritization) b. Nursing Care Plans Nursing Scientific Goal and Expected Cues Diagnosis Explanation Outcomes Subjective: Briefly explain Goals: why the Objective: nursing Expected Outcomes: diagnosis is identified on the patient and relate to the disease process of the patient. Include reference materials used. c. Discharge Plan i. Home Medications ii. Exercises and Activity Restrictions iii. Treatment Modalities iv. Health Teaching v. Out-Patient Department Visit/Follow-Up Visit vi. Diet vii. Special Orders/Signs and Symptoms to Report

II.

Nursing Interventions Please include the independent, dependent and collaborative nursing interventions

Rationale

Evaluation

V.

IMPLEMENTATION a. Drug Study Drug Name Generic Name: Brand Name: Classification: Dosage Just include the actual dosage ordered for the patient Drug Action Indication Just write the indication specific to your clients case Contraindication Adverse Effects Nursing Responsibilities Just include the special considerations or instructions applicable to your clients case

b.

Treatment Modalities (This refers to nursing or medical procedures being done to your patient such as IV Therapy, nebulization, NGT feeding, chest physiotherapy, suctioning, CBG monitoring, Oxygen therapy etc.) Description Indication Contraindication Nursing Responsibilities Name of the Treatment: Brief Description:

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c.

Course in the Ward (Using the format below, briefly explain the day to day progress of the client and its response to the medical management and treatment modalities implemented) Day Assessment Data Doctors Orders Nursing Interventions Client Response Start from the day Include significant Reflect the List down all the nursing Include the response client was met and assessment data orders of the interventions carried out on of the client to the handled until the indicating the health doctor pertinent that same day treatments and day that the student status and progress to the interventions nurse-patient of the client on that management of implemented relationship has particular day the client ended

VI. EVALUATION a. Summary of the study b. Conclusion (please evaluate effectiveness of nursing care base on the goals of care and expected outcomes. You may also include your insights on your nursing experience) VII. References (List down all the textbooks, journals and other reference materials used in the conduct of the case study. Please follow proper documentation format as given below) Example: Kozier, et. al. (2008). Kozier and Erbs Fundamentals of Nursing: Concepts, Process and Practice. (8th ed.) New Jersey: Pearson Prentice Hall, 160-244

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