CENTRAL MINDANAO UNIVERSITY

COLLEGE OF NURSING
MUSUAN, MARAMAG, BUKIDNON

Title of the study: MEDICAL SURGICAL CASE STUDY

Researchers:

Name: Abila, Louie John Level III Phone: 09096627605

Name: Acabal, Ruena C. Level III Phone: 09451555992
Name: Acut, Charyl Jane Level III Phone: 09355106953
Name: Acut, Cyril Jane Level III Phone: 09750446592
Name: Alen, Gwynette Kaye Level III Phone: 09551393218
Name: Mangubat, Rubie John Level III Phone: 09352551636
Name: Mejos, Mary Grace Level III Phone: 09265072861
Name: Segovia, Rogen Khyla Level III Phone: 09186359925
Name: Ubanan, Jescirelle Level III Phone: 09773069073
Name: Ybut, Keith Wesley Level III Phone: 09558506806

You are being asked to be in a research study of Central Mindanao University, College of
Nursing. You were selected as a possible participant mainly because your case, which is
Congestive Heart Failure Class IV, Chronic Kidney Disease: 1. Chronic Kidney Disease 2.
Cardiogenic Shock 3. T/C Ischemic Heart Disease in Congestive Heart Failure Class IV 4.
Community Acquired Pneumonia High Risk T/C Chronic Kidney Disease. This will help us
better understand its management and we will be able to provide safe and quality nursing
care to clients with the same diagnosis/case. We ask that you read this form and ask any
questions that you may have before agreeing to be in the study.

The purpose of the study is to have a detailed understanding of the disease process you have
undergone. Ultimately, this research will be presented in front of clinical instructors. All data
about the current condition will be scrutinized and presented.

If you agree to be the participant of this study, you will be asked to answer all possible
questions that will be given by the researchers. Moreover, we will be conducting physical
assessment and interview to complete the needed information. There are no reasonable
foreseeable risks that underlies this study. There may be unknown risks but the team will do
their best to provide optimum safety for both parties involved.

Rest assured that anonymity and confidentiality will be observed through the course of our
study. We will not be collecting or retaining any information about your identity. We will not
include any information in any report we may publish that would make it possible to identify
you. Your identity will be disclosed in the material that is published. However, you will be
given the opportunity to review and approve any material that is published about you.
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 The decision to participate in this study is entirely up to you. You may refuse to take part in
the study at any time without affecting your relationship with the investigators of this study.
You have the right not to answer any single question, as well as to withdraw completely from
the interview at any point during the process; additionally, you have the right to request that
the interviewer not use any of your interview material.

You have the right to ask questions about this case study and to have those questions answered
by me before, during or after the research. If you have any further questions about the study, at
any time feel free to contact any of the researchers. If you like, a summary of the results of the
study will be sent to you. If you have any other concerns about your rights as a research
participant that have not been answered by the researchers, please feel free to contact any of
the numbers given.

Your signature below indicates that you have decided and voluntarily given your consent as a
participant for this study, and that you have read and understood the information provided
above. You will be given a signed and dated copy of this form to keep, along with any other
printed materials deemed necessary by the researchers.

Subject's Name (print):

Subject's Signature: Date:

Research Participants Date:

Signature over printed
name:

Witness’ Signature
over printed name:

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 CENTRAL MINDANAO UNIVERSITY
COLLEGE OF NURSING
MUSUAN, MARAMAG, BUKIDNON

Title of Study:
Researchers:
Name
: Level Phone:
Name
: Level Phone:
Name
: Level Phone:
Name
: Level Phone:
Name
: Level Phone:
Name
: Level Phone:
Name
: Level Phone:
Name
: Level Phone:
Name
: Level Phone:

Ikaw gina awhag nga maga ambit niining pag istudyo sa Central Mindanao University,
College of Nursing. Ikaw napili nga possible nga participante tungod kay ikaw adunay
talagsaong kaso nga mao ang “Congestive Heart Failure Class IV, Chronic Kidney Disease:
1. Chronic Kidney Disease 2. Cardiogenic Shock 3. T/C Ischemic Heart Disease in
Congestive Heart Failure Class IV 4. Community Acquired Pneumonia High Risk T/C
Chronic Kidney Disease”, kini magatabang kanamo nga padayon pang masabtan ang pag
tambal ug pag hatag ug saktong interbensyon sa mga susamang kaso o sakit. Kami
nagahangyo nga imo kining basahon ug kung mag hatag ug mga pangutana kung adunay may
nalibugan usa ka mo musugot nga mulambigit niinini nga pag istudyo.

Ang tumong niini nga pag istudyo mao ang pagtuki sa mas lalom pang mga detalye sa maong
sakit nga nabatian. Kini usab ipresentar sa mga clinical instructors. Tanan nga detalye sa
maong papel kay pagatukion ug ipresenta.

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 Kung ikaw musugot sa pagpartisipar niining papela, ikaw pagapangutan.on sa mga mag
istudyo. Sila usab maga-eksamin ug magakalap ug mga impormasyon nga kinahanglan para sa
maong pag tuki-tuki. Wala’y angay kabalak-an kung maga partisipar niiini. Buhaton sa grupo
ang tanan nga ilang makaya para makahatag ug seguridad sa mga tao nga mag apil niini nga
buluhaton.

Salig nga ang adunay “confidentiality” o ang tanang butang nga magahatag ug pag-ila sa mga
nakilambigit niini kay itago para ma preserbar ang identipikasyon sa maong mga tawo. Dili
namo iapil ang unsa o kinsa mang ngalan sa papel nga pagasulaton kundili ang mga resulta
lamang sa pag-eksamin. Pero, ikaw tagaan ug opurtunidad nga ma tan-aw ang maong
material.

Ang desisyon sa pakig-lambigit niini nga buluhaton kay anaa ra saimong pagbuot. Ikaw
pwede mu undang sa pagpartisipar nga dili gaka apektuhan ang imong relasyon sa mga
imbetigador.

Aduna kay katungdanan nga mu dili sa kung unsa mang gi pangayo sa mga nag hatag niini
kanimo. Pwede usab ka mangutana sa maong pagtuki. Kung aduna kay dugang nga mga
pangutana pwede nimo makontakt palihug ayaw ka ulaw ug tawag sa mga numero nga
nakasulat sa ibabaw.

Imong pirma magasimbolo nga ikaw mihatag sa pagsugot ang kini imong kaugalingong
pagbuot nga mulambigit niini nga buluhaton ang kini usab magasimbolo nga adunay pag
sabot sa mga impormasyong nabasa sa ibabaw. Ikaw pagahatagan ug napirmahan nga kopya
sa susamang dukomento kauban ang uban pang mga papel nga kinahanglan sa mubasa.

Ngalan sa partisipante
(print):

Pirma: Date:

Research Participants Date:

Signature over printed
name:

Witness Signature
over printed name:

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