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COLLEGE OF NURSING
A GUIDE TO CLINICAL CASE STUDY AND ITS PRESENTATION
I. Table of Contents
II. Preliminaries
A. Introduction
The case should begin with a brief passage presenting the patient
by his or her initials, age, medical diagnosis and other related information,
whenever applicable. It then shall document a description of the medical
condition or disease in general that continues and ends up with other
information, such as manifestations, diagnostics and managements, as to
provide readers or listeners a wider understanding and knowledge about
the disease. The body of introduction discusses the information below:
1. Clinical manifestations
2. Diagnostic procedures
3. Medical management (it may include any surgical, pharmacological,
nursing approaches that applies to the study)
4. Evaluation and Prognosis
Lastly, it is also vital that presenters include the disease
epidemiology which denotes local and foreign statistics of disease
occurrence within the last 5 years.
B. Case Objectives
1. General Objective
A. Biographic Data
1. Name (initials only)
2. Address
3. Age
4. Sex
5. Race
6. Marital Status
7. Occupation
8. Religious Orientation
9. Source of Income (Healthcare Financing and usual source of medical
care)
This initial part of history-taking may have additional information
whenever necessary and applicable. (E.g. pregnancy-related cases are expected
to notate of LMP, AOG, EDC and GPTPAL accordingly; admitting and final
diagnosis may also be included)
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1. Childhood diseases
2. Immunizations
3. Allergies
4. Accident and Injuries
5. Hospitalizations (This must include any surgical procedures
encountered or previous hospitalizations related to the case being
presented. Preferably, the year patient was hospitalized should be
noted.)
6. Medications (This should state medications the patient have been
prescribed oftentimes and/or any OTC drugs commonly taken for
illnesses)
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? age 80 79 77
(Cancer) Hypothyroidism (Heart Failure) Smoker
Obese Type II DM Lumbar disk
disease
58 54 60
65 60 60 Migraines Grave’s disease A&W
HTN MVP Smoker Myopia Hypercholesterolemia
Arthritis HTN
37 32 30
Tyoe II A&W HTN
DM
Genogram Key:
= Female
= Male
= Deceased
A & W = Alive and Well
Reference: ( ) = Cause of death
Weber, J. R. and Kelley, J. H. (2014). Health Assessment in
= Adoption
Nursing, Fifth Edition. C & E Publishing Inc. p. 23
= Client
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Development
al Stage
Definition
Findings
Analyis
VII. Pathophysiology
This segment of the study briefly defines the disease process the client has
encountered. Following a sentence or passage of description, it will discuss
the entire mechanism of the disorder using a schematic diagram that begins
with risk factors contributing to the occurrence of a disease – modifiable and
non-modifiable causative factors. Sometimes the identification of one or two
risk factors as either modifiable or non-modifiable may vary from one patient
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Insulin
Insufficiency
Hyperglycemia
Thirst sensation
Poor wound healing Poor O2 and nutrient
Osmotic diuresis supply of the body cells
↓Immunity
Polydipsia
Polyuria Cell starvation
Glycosuria
Polyphagia
Weight loss
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X. Medical-Surgical Management
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Gentle reminder, contents of the table above for presentation must deliver
data that directly relates to the patient only. Likewise, each procedure done
must be arranged chronologically according to the date it was ordered.
B. Surgical Management
Surgical Procedures Date General Client’s Nursing
Performed Description Response Responsibilities
and
Purpose
1. Appendectomy Prior:
(sample only) During:
After:
C. Drugs
Medicat Date Route of Mechan Indicatio Contrai Client’s Nursing
ion Ordere Admini ism of n ndicatio Response Responsibi
d/ stration/ Action n lities
Given/ Dosage/
Taken Frequen
cy
Generic: [This Prior:
column
Brand: shall During:
discuss
Classific both After:
ation: desired
and
untoward
(side and
adverse
effects)
reactions
on drugs]
Gentle reminder, contents of the table above for presentation must deliver
data that directly applies or relates to the patient only. Likewise, each
medication must be arranged according to the date it was ordered, i.e. in
chronological order.
D. Diet
Type of General Indication/ Specific Client’s Nursing
Diet Description Purpose Foods Response Responsibilitie
Taken s
Prior:
During:
After:
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E. Exercise
Type of General Indication/ Client’s Nursing
Exercise Description Purpose response Responsibilities
Prior:
During:
After:
Objective:
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XIII. Conclusion
XIV. Bibliography
Since clinical case study serves as one of the prime examples of nursing
researches, students must narrate their study using third person point of view. (E.g.
“Nursing students” or “researchers” as sentence subjects, instead of saying “I” or
“We”)
For typing and printing concerns, please observe the following:
Font Style: Times New Roman
Font Size: 12
Margins: 1 inch in all borders
Front Page: (See samples attached)
Header: (Title of the Clinical Case Study) + BulSU – CON
Place at right top corner
E.g. Lobar Pneumonia ║ BulSU – CON
Footer: Page numbers only.
E.g. Page 3 of 38
Binding: Hard – Binding
Color: Royal Blue
Additional sample templates attached herewith
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