Catanduanes State University

College of health Sciences

Virac, Catanduanes

Format of Case Study:

I. INTRODUCTION
Background of the Study: Reason why you choose this case study.
Significance of the study
Scope and Limitations
Goal
Objectives

Overview of the disease

Signs and symptoms
Anatomy of the affected system (may use pictures from the internet)
Physiology of the affected system
II. BIOGRAPHIC DATA
Name:
Address:
Birthdate:
Civil Status:
Mother’s Name:
Occupation:
Educational attainment:
Father’s Name:
Occupation:
Educational Attainment:
Religion:
III. NURSING HEALTH HISTORY
a. Past Health History
b. Present Health History
c. Chief Complaint:
d. Family health History
IV. ACTIVITIES OF DAILY LIVING

Before hospitalization During hospitalization Interpretation and

analysis
Nutrition
Elimination
Exercise
Rest and Sleep
Hygiene
Substance Use

V. PHYSICAL ASSESSMENT
 1.General Appearance

Normal Findings Actual Findings Interpretation and Analysis

Posture
Skin color
Hygiene
Nutrition
Age-Apprppriateness
Verbal
Non-verbal
2. Vital Signs

Normal Findings Actual Findings Interpretation and Analysis

Temperature
Cardiac Rate
Respiratory Rate
Blood pressure

3. Measurements:

Normal Findings Actual Findings Interpretation and Analysis

Weight
Height

4. Affected Body Areas (depends on the diagnosis)

Normal Findings Actual Findings Interpretation and Analysis

VI. LABORATORY -DIAGNOSTIC RESULT

Laboratory procedure Interpretation and analysis

Date Component Normal Finding Actual Results
CBC RBC
HCT
WBC
HGB
LMP
Urine Exam Color
Transparency
Specific Gravity
Sugar
 Reaction (pH)
Sterility
Radiology Chest x-ray

VII. NURSING Care Plan-Based on priority

Cues Nursing Scientific Objectives Nursing Rationale Evaluation

Diagnosis Explanation Intervention

 5 or more nursing diagnosis

VIII. Drug Study

Name of Date Route/Dosage Action Indication Adverse Nursing

Drug Ordered and Reaction Consideration
Frequency

IX. MEDICAL/Surgical management

Management Rationale

IX.DISCHARGE PLAN

M-Medication to take

E.-Exercise

T-Treatments
H-Health Teachings

O-Out patient follow-up

D-Diet

X. CONCLUSION

XI. Acknowledgement

XII. BIBLIOGRAPY

A. Books

B. Online Resources

Case Study Components:

 Font Size: 12

 Font Style: ARIAL

 Margin: 1 inch in all sides except the left which is 1.5

 Spacing : 1.5

I. Title page;

 Reflects the school and department/program, the title of the case, the faculty, the
subject course, the teacher, the student , the date (month and year only)