CARE STUDY FORMAT AND RUBRIC

I. Introduction
a. Description of the Condition
b. Current trends
c. Nursing objectives
II. Nursing Assessment
a. Personal Data
i. Demographic data
ii. Socio-economic and cultural factors
iii. Environmental factors
iv. Lifestyle
b. Maternal history (if applicable)
i. Maternal Obstetric Record
ii. Antepartal / Prenatal Preparation(s)
iii. Significant Trimester Changes
c. Family Health-Illness History
d. History of Past Illnesses
i. Past health history related to the present condition
ii. History of vaccination(s)
e. History of Present Illness
f. Physical Assessment
i. General Survey
ii. Cephalocaudal Assessment, or
iii. IPPA Assessment (as necessary)
g. Diagnostic and Laboratory Procedures
Diagnostic / Date Indication Results Normal Analysis and Nursing
Laboratory Ordered / Purpose Values Interpretation Responsibilities
Procedure and
Released
III. Anatomy and Physiology
IV. Pathophysiology (Book-based)
a. Schematic Diagram
b. Synthesis of the Condition
i. Definition of the Disease
ii. Predisposing and Precipitating Factors
iii. Pathologic Changes
iv. Signs and symptoms with rationale
V. Pathophysiology (Client-Centered)
a. Schematic Diagram
b. Synthesis of the Condition
c. Predisposing Factors
d. Pathologic Changes
e. Signs and Symptoms with rationale
VI. Patient and His Care
a. Medical Management
i. IVT, BT, NGT, TPN, Oxygen Therapy, etc.
Date ordered
Medical Indication(s) Client’s
Date General
Management/ Or response to the
performed Description
treatment Purposes treatment
Date changed
**Include Nursing Responsibilities for each medical management
ii. Pharmacotherapy
Date Ordered Client’s
Route of
Generic Name Date Given Mechanism Response to
Administration / Indication/s
Brand Name Date Changed of Action the
Frequency
Medication
**Include Nursing Responsibilities for each medical management
 iii. Diet
Date Ordered, Client
General Indication &
Type of Diet Date Performed, Response to
Description Purpose
Date Changed Treatment
**Include Nursing Responsibilities for each medical management
iv. Exercise
Date Ordered, Client
General Indication &
Type of Exercise Date Performed, Response to
Description Purpose
Date Changed Treatment
**Include Nursing Responsibilities for each medical management
VII. Nursing Care Plan

Nursing Scientific Nursing

Assessment Objectives Rationale Evaluation
Diagnosis Explanation Interventions
**Should be properly prioritized
VIII. Conclusion(s)
IX. Recommendation(s)
X. References

NOTE: DO NOT FORGET TO INCLUDE A COVER PAGE AND A TABLE OF

CONTENTS
 GUIDELINES IN GRADING CASE STUDY
CONTENT SCORE

I. Introduction 5 POINTS
a. Description of the Condition
b. Current trends
c. Nursing objectives
II. Nursing Assessment
a. Personal Data 10 POINTS
i. Demographic data
ii. Socio-economic and cultural factors
iii. Environmental factors
iv. Lifestyle
a. Maternal history (if applicable)
i. Maternal Obstetric Record
ii. Antepartal / Prenatal Preparation(s)
iii. Significant Trimester Changes
b. Family Health-Illness History 5 POINTS
c. History of Past Illnesses 5 POINTS
i. Past health history related to the present condition
ii. History of vaccination(s)
d. History of Present Illness
e. Physical Assessment 5 POINTS
i. General Survey
ii. Cephalocaudal Assessment, or
iii. IPPA Assessment (as necessary)
f. Diagnostic and Laboratory Procedures 10 POINTS
III. Anatomy and Physiology 5 POINTS
IV. Pathophysiology (Book-based) 10 POINTS
a. Schematic Diagram
b. Synthesis of the Condition
i. Definition of the Disease
ii. Predisposing and Precipitating Factors
iii. Pathologic Changes
iv. Signs and symptoms with rationale
V. Pathophysiology (Client-Centered)
a. Schematic Diagram
b. Synthesis of the Condition
c. Predisposing Factors
d. Pathologic Changes
e. Signs and Symptoms with rationale
VI. Patient and His Care
a. Medical Management 5 POINTS
i. IVT, BT, NGT, TPN, Oxygen Therapy, etc.
ii. Pharmacotherapy 5 POINTS
iii. Diet 3 POINTS
iv. Exercise 2 POINTS
VII. Nursing Care Plan 15 POINTS
VIII. Conclusion(s) 5 POINTS
IX. Recommendation(s) 5 POINTS
X. References 5 POINTS
TOTAL 100 POINTS
Grading WRITTEN OUTPUT:
First written output 50%
Final written output (with revisions) 50%
TOTAL 100%
**transmutes as 30% of the FINAL CASE STUDY GRADE

Grading FINAL CASE STUDY:

Written output 70%
Oral presentation 30%
TOTAL 100%