Thanks to visit codestin.com
Credit goes to www.scribd.com

Scribd
Upload
132 views6 pages

Case Study Format

This document outlines a case study template for nursing students, including sections for patient demographic information, health history, current health profile, and the nursing process. The health history section collects information on past medical issues, immunizations, hospitalizations, injuries, family history, social history including habits, and a review of systems. The current health profile focuses on presenting complaints, medical diagnosis, and prior interventions. The nursing process section includes assessment findings, laboratory results, nursing diagnosis, expected outcomes, interventions, and evaluation. This template provides a standardized way for nursing students to document, assess, plan, implement, and evaluate a patient case study.

Uploaded by

Christian Llerin
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
132 views6 pages

Case Study Format

This document outlines a case study template for nursing students, including sections for patient demographic information, health history, current health profile, and the nursing process. The health history section collects information on past medical issues, immunizations, hospitalizations, injuries, family history, social history including habits, and a review of systems. The current health profile focuses on presenting complaints, medical diagnosis, and prior interventions. The nursing process section includes assessment findings, laboratory results, nursing diagnosis, expected outcomes, interventions, and evaluation. This template provides a standardized way for nursing students to document, assess, plan, implement, and evaluate a patient case study.

Uploaded by

Christian Llerin
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
You are on page 1/ 6

University of San Carlos

School of Health Care Profession


Department of Nursing
Cebu City

CASE STUDY

I. PATIENT DEMOGRAPHIC PROFILE


Name: Age: Status:
Religion: Occupation:
Nationality: Gender:
Home Address:

II. HEALTH HISTORY PROFILE


A. Past Medical History (include dates, severity, complications if any)
1. Pediatric and Adult Illness
Date Illness Medication Remarks

2. Immunization
Immunization Doses Dates Remarks

3. Hospitalization
Date/Year Hospital Diagnosis Duration

4. Injuries and Accidents

5. Transfusions
6. Allergies

B. Family History (Support with a genogram and limit to two (2) generation if patient can recall)

C. Social and Personal History


1. Occupation

2. Number of Children

3. Foreign travel

4. Habits (tobacco, alcohol, non-prescription drugs, others)

5. Diet

6. Type of Family

7. Cultural and Religious Beliefs

8. Brief Description of Average Day


D. Review of System (for the past 6 months). Physical Assessment

General Weight loss Fatigue Anorexia Night Sweats


Chills Fever Weakness

Skin Itch Rash Lesions Bruising


Bleeding Color Change

Eyes Pain Discharges Itch Vision Loss Diplopia


Excessive tearing Glasses/Contact Lens Date of Last Exam

Ears Earaches Discharges Tinnitus Hearing Loss

Nose Obstruction Discharges Epistaxis

Throat and Mouth Sore Throat Bleeding Gums Toothache Dentures

Neck and Head Swelling Dysphagia Hoarseness

Chest Cough Sputum: Amount and Character Hemoptysis


Wheeze Pain on respiration Dyspnea

Cardiovascular Precordial pain Palpation Dyspnea on Exertion Orthopnea


Paroxysmal nocturnal Dyspnea Edema
Heart murmur Thrombophlebitis Claudication

Gastrointestinal Heart Burn Nausea Vomiting Diarrhea food intolerance


Excessive gas or indication Constipation Jaundice
Change in Bowel Movement Bloating Melena
Hemorrhoids Hernia
Genitourinary Heart Burn Nausea Vomiting Diarrhea food intolerance
Excessive gas or indication Constipation Jaundice
Change in Bowel Movement Bloating Melena
Hemorrhoids Hernia

Extremities Joint Pains Varicose Veins Claudication


Back pains Edema Stiffness Deformities

Endocrine Hot flashes Hair loss Temperature Intolerance


Polydipsia Goiter

Neurology Numbness Tingling Tremor Fainting Headaches


Muscle Weakness Ataxia Unconsciousness Paralysis
Memory loss Dizziness Seizure

Psych Anxiety Depression Sexual Problems Insomnia


Nightmares

Others

III. CURRENT HEALTH PROFILE


A. Presenting complaints and medical diagnosis to include interventions done prior to
hospitalization.
B. Application of the Nursing Process
1. Assessment Findings (Head to Toe)
2. Laboratory/Diagnostic Results

Date Lab Exam Patient Results Normal Findings Interpretations/


Significant

You might also like