I. INTRODUCTION A. Brief description of the medical condition B. Statistics (Incidence and Prevalence rate) i. International ii. Local A. General Objective B. Specific Objectives

II. OBJECTIVES (must include the Cognitive, Psychomotor, and Affective Domains)

III. ANATOMY AND PHYSIOLOGY (Brief description of the organ/system affected as to its normal
functioning) IV. VITAL INFORMATION Name (Initials only): Age: Sex: Address: Civil Status: Religion: Occupation: Date & Time admitted: Ward: Chief Complaint: Impression/Admitting Diagnosis: Pre-Op Diagnosis (if applicable): Post-Op Diagnosis (if applicable): Surgical Operation performed: Final Diagnosis: Attending Physician(s): V. CLINICAL ASSESSMENT A. Nursing History  Obtain the patient’s history based on your interview; DO NOT solely rely on the Admitting Notes of the physician.  Write in paragraph form. B. Past Health Problem/Status  Include past illnesses, allergies, previous hospitalization, medications taken. C. Family History of Illness  Heart disease, Cancer, Diabetes, HTN, TB etc.  Indicate from maternal and paternal side  Illustrate in a family genogram o Make use of the Genopro application


A.   Vital Signs First, record the Vitals upon Admission Show then the Vitals taken during your care Height: Weight: BMI*:


*Calculating BMI: (Weight in pounds) divided by( Height in Inches) x(Height in Inches) x 703 Below 18.5 Underweight Normal 25-29.9 Overweight 30 and above Obese


Physical Assessment (Cephalocaudal) Indicate in RED any deviations obtained in the PA I. General Appearance (include posture, gait, overall hygiene and grooming) II. Skin, hair and nails III. Head, face, and lymphatics IV. Eyes, ears, nose, mouth and throat V. Neck and upper extremities VI. Chest, breast and axilla VII. Respiratory system (thorax and lungs) VIII. Cardiovascular system IX. Gastrointestinal system X. Genitor-urinary system XI. Musculoskeletal system I. II. III. IV. General Appraisal Speech (quality, clarity, coherence) Language Hearing Mental status (level of consciousness, attitude, appropriateness of response and relevance) V. Emotional status



LABORATORY AND DIAGNOSTIC DATA (Relate to the disease why are the values increased or decreased; DO NOT only say “Anemia”, “Hyponatremia” etc. There must be a pathophysiological basis for these abnormal values) A. Chemistry Name and Date of Examination Result Normal values Significance of the Abnormal Result

B. Hematology Name and Date of Examination Result Normal values Significance of the Abnormal Result

C. Urinalysis (24 hr. urine collection, etc.) Name and Date of Examination D. Fecalysis (with Occult Blood) Name and Date of Examination Result Normal values Significance of the Abnormal Result Result Normal values Significance of the Abnormal Result

E. Other tests (Xrays, UTZ, CT Scan, Biopsy, ECG, Lumbar Tap, CS/GS, etc.) Name and Date of Examination Result Normal values Significance of the Abnormal Result

IX. PATHOPHYSIOLOGY (Textbook diagram inclusive that of your patient’s case)
    Do this in schematic diagram After collecting all the necessary data, at this point you will be able to pin point and trace the pathogenesis of the medical condition of your patient. When you make the Pathophysiology, be sure that you will include in the diagram the process of disease development of your patient. You can do this by assigning different symbols or colors to the flow chart.

X. MEDICAL MANAGEMENT A. Drug Study (write this in landscape format) Name of Drug with Dosage Generic Name Action Mechanism of Action Indication Side Effects Contraindications Nursing Responsibilities

TAKE NOTE of the following as examples on how to write the Drug Study:  Action of the Drug: ANTIBACTERIAL  Mechanism of Action: It binds to the cellular wall of the bacteria and promotes phagocytosis thus resulting to the death of the microorganism.  Indication: State the reason why this drug is specifically ordered for the patient. You may cite laboratory results to support your reason.  Nursing Responsibilities: Indicate only on the things that you should be watching for and that is relevant to the case of the patient. DO NOT LITERALLY COPY THE WHOLE TEXT ON THE DRUG HANDBOOK.

B. Other Treatments (ordered by the physician)
  Define the treatment or procedure Indicate the rationale for this treatment/procedure that can help in the care of the patient

XI. NURSING MANAGEMENT A. Concept Map of Nursing Problems  Identify the Nursing Problems (Nursing Diagnoses)

Illustrate in a concept map and show interrelationships (if any) of these problems

B. Nursing Care Plan (write this in landscape format)
 In presenting the NCP, arrange the Nursing Problems according to PRIORITY.

XII. DISCHARGE PLANNING  Use this Mnemonic as a guide in making the discharge planning M – edications E – xercise and activity T – reatment H – ome teaching in relation to disease, etiology and hygiene measures O – ut patient follow-up D – iet (what foods are needed and to avoid) S – Spirituality


MY JOURNEY (Learning Experiences)  End with all the learning experiences you have encountered in taking care of your patient and in making this case study (both positive and negative points)

XIV. BIBLIOGRAPHY/REFERENCES  Make use of the APA format ADDITIONAL INFORMATION:  All case studies should be written in long paper, Arial 11, 1.5 spacing, margins: L: 1.5”, 1” on the rest