CASE STUDY FORMAT
TITLE & AUTHORS
ABSTRACT ----------------------------------------------------------------
- 5%
TABLE OF CONTENTS:
ACKNOWLEDGEMENT
INTRODUCTION-Discuss the disease condition (client –centered)
-Rationale of the study
SIGNIFICANCE OF THE STUDY TO THE:
------------------------------------------------------------------ 10%
-Nursing Education
-Nursing Practice
-Nursing Research
OBJECTIVES OF THE STUDY:
-General
-Specific
PATIENT’S PROFILE
-------------------------------------------------------------------------------------- 15%
-Nursing Health History
-Physical Assessment
-Developmental Data (Choose 1 Theory)
ANATOMY AND PHYSIOLOGY
PATHOPHYSIOLOGY
-------------------------------------------------------------------------------------- 10%
DIAGNOSTIC TESTS
--------------------------------------------------------------------------- 10%
MEDICAL AND SURGICAL MANAGEMENT
------------------------------------------------------ 10%
-Drug study
NURSING MANAGEMENT
--------------------------------------------------------------------------- 20%
-Nursing Care Plan (maximum of 5 problems)
EVALUATION, RESULTS & DISCUSSION
------------------------------------------------------ 15%
DEFINITION OF TERMS
BIBLIOGRAPY --------------------------------------------------------------------------------
----------------- 5%
TOTAL --------------------------------------------------------------------------------
----------------- 100%
1
IMPORTANT NOTE: Case study should be started the first week of duty to have
ample time to assess, analyze, manage, and study the case and
to avoid unnecessary overnight which cannot help in managing a
patient’s case.
CASE STUDY FORMAT
TITLE & AUTHORS
1. It may include the following:
a. Nursing intervention
b. Outcome of intervention
c. Population under study
d. The condition of interest
2. The title of the paper should be in capital letters and Arial font size 14.
Limit your title to 20 words or less.
3. Name/s of the author/s (given name, middle initial and last name) should be
Arial font size 12.
4. Indicate the affiliated institution/s of the author/s with the complete name of the
department, institution and its physical address in italicized, Arial font size
12.
ABSTRACT
1. The abstract of the manuscript should be limited to 200 words or fewer.
2. It should contain brief information and includes the following components:
a. Brief Introduction
b. Case Report as Methodology
c. Results and Discussion
3. It should be in single space.
4. Provide at least 5 keywords. Keywords are words that may be used to
identify the study. They help in indexing or categorizing the study as well.
TABLE OF CONTENTS:
ACKNOWLEDGEMENT
INTRODUCTION - Discuss the disease condition (client –centered)
1. Background information should be provided to demonstrate how the case
contributes to the literature. Please limit the amount of information adequate
to familiarize the readers with the topic. (one page only, in single space)
2. Clearly state the objectives or rationale why you chose this case as your focus
of study.
3. Clearly state the significance of the case study in relation to the theme.
4. Indicate limitations of the case study.
5. Please include also the following:
a. Theoretical framework or nursing theory (which was utilized in the plan
of care)
SIGNIFICANCE OF THE STUDY TO THE:
-Nursing Education
-Nursing Practice
-Nursing Research
2
OBJECTIVES of the study:
-General
-Specific
PATIENT’S PROFILE
- Nursing Health History
- Physical Assessment
- Developmental Data (Choose 1 Theory) – to include the expected and
the actual developmental tasks to identify signs of possible fixation or
developmental delays.
ANATOMY AND PHYSIOLOGY
PATHOPHYSIOLOGY
- Need to be able to differentiate precipitating from predisposing factors
DIAGNOSTIC TESTS (both actual and ideal)
MEDICAL AND SURGICAL MANAGEMENT
Both actual and ideal
Include indication and rationale of the management
Drug study with due consideration to drug interactions
NURSING MANAGEMENT
-Nursing Care Plan (3 to 5 PRIORITY problems)
EVALUATION, RESULTS & DISCUSSION
1. Do not summarize or repeat from the previous sections of the abstract.
2. Briefly summarize the results or outcomes of care, including changes in
the primary outcome measures.
a. NCP / Nurses notes / progress notes (maximum of 5 problems)
3. It should discuss (briefly) the relevant literature of the ideal management
and expected outcome or prognosis in the context of the current case.
4. It should include a summary, conclusion, discharge plan and
recommendations.
a. Summary and conclusion
b. Discharge Plan
Medication
Economy/Exercise
Treatment/Therapy
Health Teaching/Hygiene
Consultation
Die
Sex
c. Recommendation includes the following:
Based on the difference between the ideal and actual management.
Can also include recent evidence of a more effective management
5. Lessons the student nurse learned from caring for this patient should
be described.
DEFINITION OF TERMS / KEY WORDS (for indexing)
BIBLIOGRAPY
Must be recent from 2005 and up
Follow the APA format
IMPORTANT NOTE:
- Revised copy in a CD to be submitted 2 days after defense.
- Everything should be in narrative form. Tables and charts if any
will be placed in the appendix.
3
NURSING HEALTH HISTORY
1. BIOGRAPHICAL DATA
- Names, address, age, Birth-date, Sex, Race, Marital status, Occupation,
Religion, Health Care financing and usual source of Medical Care
2. CHIEF COMPLAINT
What Brought you to the Hospital
What is Troubling you
Current physical assessment findings
3. HISTORY OF PRESENT ILLNESS
Ask the Chronological Sequence of the events in reference to the
client’s Chief Complaints. Which Should follow the Period duration
PRIOR TO ADMISSION
When did the symptom started? Follow the PQRST format.
How often
Type of activity prior to the problem
was consultation sought
Medications used including maintenance if any
How the Problem interfered/Disrupted Activities of daily living
PAST HISTORY
Childhood Diseases
Immunizations
Allergies
Accident and injuries
Hospitalizations-When and Why
Medications?
3.1 FAMILY HISTORY OF ILLNESS
Health and ages of patient’s siblings, children, or ages at death and causes
Illness of family members similar to the patient
Familial incidence of RH fever, HPN, PTB, DM, Mental Illness, and others
as suggested by the present illness
3.2 FUNCTIONAL HEALTH PATTERN
Health perception and health
management
How has the general health been?
Any colds in the past?
Most Important things done to keep or maintain health.
You Think this things make a Difference to health(include Family,
Folk, Remedies if appropriate)
Use of cigarettes, alcohol,
Drugs? (Perform Breast Exam)
In the past, has it been easy to find ways to follow things
nurses/Doctors suggestions.
If Appropriate: What do you think caused the illness? actions taken
when symptoms were perceived?(Results of action)
If Appropriate: things important to you while you are in the hospital or
clinic? How can we be most helpful?
4
Traditional concepts of health and illness? Beliefs and practices?(classify
what illness model is being used by the patient)
NUTRITIONAL AND METABOLIC PATTERN
1. Typical daily food intake (Specify), Supplements?
2. Typical daily fluid intake/(Specify)
3. Weight loss/gain/Amount?
4. Appetite?
5. Food or Eating discomfort? Diet restriction?
6. Wound Healing?
7. Skin problems? Lesions? Dryness?
8. Dental problems?
ELIMINATION PATTERN
1. Describe the Bowel elimination pattern? The CFAC? Discomfort?
2. Urinary elimination pattern (describe) frequency, Discomfort? problem
in control?
3. Excessive perspiration? Odor problems?
ACTIVITY -EXERCISE PATTERN
1. Sufficient energy for completing desired required activities?
2. Exercise pattern? Types? Regularity?
3. Spare Time: Leisure activities? child: activities?
4. Perceived ability for (Code Level)
-Feeding - Bed Mobility -General mobility
-Bathing -Dressing -Cooking
-Toileting -Grooming -Home Maintenance
-Shopping
Level (0) - Full Self care
Level (1) - Requires use of equipment or device
Level (2) - Requires assistance or supervision from another person
Level (3) - Requires assistance or supervision from another person or device
Level (4) - dependent and does not participate
SLEEP-REST PATTERN
1. Approximately how many hours do you sleep at night?
2. Any problem falling asleep? Do you take any sleep medications?
3. Is your sleep continuous? Tired?
4. Take naps? when?(Morning/Afternoon)
5. What do you do for Relaxation?(Watch TV, Listen to radio, read,
dance, shopping)
COGNITIVE-PERCEPTUAL PATTERN
1. Hearing difficulty? Hearing Aid?
2. Vision/wear eyeglasses?
3. Any change in memory lately?
4. Easiest way to remember/learn things? Difficulties?
5. Any Discomfort? pain? how do you manage it?
self- perception and self concept pattern
1. how do you describe yourself? Most of the time, feel good (not so
good) about yourself?
2. changes in your body or the things you can do? Problem to you?
3. Changes in way you feel about yourself/of your body?(since
illness started)
4. Find things frequently make you angrily? Annoyed? Tearful?
Anxious? Depressed? What helps?
5
ROLE-RELATIONSHIP PATTERN
1. Live alone? Family? Family Structure(Diagram)
2. any Family problems you have difficulty handling?(Nuclear/Extended)
3. How does Family usually handle problems?
4. Family depends on you for things? If appropriate: how are
they managing?
5. If appropriate: how Family/others feel about your illness/hospitalization?
6. If appropriate: problem with children? Difficulty handling?
7. Belong to social groups? Close friends? Feel lonely frequently?
8. Things generally go well with you at work? (school / College)?
If appropriate income sufficient to needs?
9. Feel part of (or isolated in) neighborhood where you are living?
SEXUALITY-REPRODUCTIVE PATTERN
1. If appropriate: any changes or problems in sexual relations?
2. If appropriate: use of contraceptives? Problems?
3. Female; when menstruation started? Last menstrual period?
Menstrual problems? Para? Gravida?
COPING-STRESS TOLERANCE PATTERN
1. Tense a lot of time? What Helps? Use of any Medicines, Drugs, alcohol?
2. What is most helpful in taking things over? Available to you now?
3. Any big changes in your life in the past year or two?
4. When you have big problems (any problems) in your life, how do
you handle them?
Case presentation and defense
1. Present the most salient parts of the case in 10 to 15 minutes only.
2. Present only the following:
a. Introduction: what the case study is all about and the objectives of the study
b. Chief Complaints, History of present illness
c. Significant assessment findings to include abnormal lab and diagnostic
findings.
d. Past medical history (if necessary)
e. Pathophysiology
f. Summary of medical and surgical management: like medication (name
of drugs only), and or surgical intervention if done.
g. NCP – present only the salient points but still need to include all NCPs in
the power-point slides.
h. Evaluation of overall patient outcome and recommendation
3. Critiquing and defense in one hour
4. No reading during the presentation
