Tarlac State University

College of Science
Department of Nursing

CLINICAL CASE STUDY FORMAT

GENERAL WARD/ ICCU

I. INTRODUCTION
a. Brief description of the disease condition.
b. Current trends and Statistics about the disease condition.
c. Reasons for choosing the case for presentation
d. Objectives (General and specific)

II. NURSING PROCESS

A. ASSESSMENT

1. Personal Data
a. Demographic data (name, age, sex, civil status, occupation, role/position
in the family, address, date and place of birth, nationality, chief complaint,
admitting diagnosis)
b. Environmental Status
c. Lifestyle( habits, recreation, hobbies)

2. Family history of health and illness

a. To consider up to 3rd degree of consanguinity
b. Present schematic diagram (reference: ESTES) and if possible include
dates/ age
c. To ascertain risk factors for a disease, the ages of siblings, parents, and
grandparents and their current state of health, or if they are deceased, the
cause of death (must be obtained)

3. History of past illness

a. Consider diseases relevant to client’s present condition
b. Childhood illnesses
c. Childhood immunization
d. Allergies: to drugs, animals, food, insects, or other environmental agents.
Type of allergies that has occurred
e. Accidents and injuries (how, when, where it happened. Treatment
received and complications (if any)
f. Hospitalization (reason for hospitalization, dates, surgeries (if any),
course of recovery, and complications.
g. Medications (all currently used prescription and OTC meds.)

4. History of present illness

a. When the symptoms started
b. Whether the onset of symptoms was sudden or gradual
c. How often the problem occurs
d. Activity the client is involved with when the problem occurred
e. Symptoms associated with the chief complaint
f. Factors that aggravate or alleviate the problem

5. Physical Assessment (IPPA)

a. Use 13 Areas of Assessment for patients 6 yrs old and above
 Note: standard/ analysis/ interpretation for any abnormal findings.

b. Use CEPHALOCAUDAL APPROACH for patients 5 yrs old and below.

Cephalo-Caudal (PE)

Date performed Area / Region Findings Normal Interpretation/analysis

Findings

6. Laboratory and diagnostic procedures

Nursing
Diagnostic/ Date Indication/ Result Analysis and responsibilities
laboratory ordered/ Purposes interpretation of prior to, during,
procedure date done/ results (related to and after the
the disease) procedure

7. Anatomy and Physiology (of the affected or involved organ ONLY)

8. PATHOPHYSIOLOGY
 Book based- focus on the main diagnosis
 Client based- reflect only manifestations and data present in the
patient

B. PLANNING
NURSING CARE PLAN
THREE-FIVE PRIORITY NURSING DIAGNOSES
*USE ADPIE FORMAT-NCP
DATE

ASSESSMENT NURSING PLANNING IMPLEMENTATION RATIONALE EXPECTED

DIAGNOSIS OUTCOME

C. IMPLEMENTATION

1. DRUGS

Name of Date Route of General Client’s nursing

drugs administered administration, action Indication/ response responsibilities
(generic dosage and Mechanism Purpose to med. prior to,
and brand frequency of of action With actual during, and
name) administration side after
effects(if administration
any)

2. MEDICAL MANAGEMENT
 IVFs, BT, nebulization, oxygen therapy, etc.

Medical Date performed/ General Indication/ Client’s reaction

management/ changed/ description purpose to treatment
treatment discontinued

3. SURGICAL MANAGEMENT

Name of Date Brief Indication/ Client’s Nursing

procedure performed description purposes response to responsibilities, prior
operation to, during, and actual
surgical procedure
(actual)

4. DIET

TYPE OF DIET Date Indication/s Nursing Responsibility

5. ACTIVITY/ EXERCISE

TYPE OF GENERAL INDICATION/ CLIENT’S RESPONSE

EXERCISE DESCRIPTION PURPOSE

6. NURSING MANAGEMENT ( AT LEAST 3 DAYS)

For Your Charting Utilized SOAPIE or FDAR.

Note: Surgery ward- includes pre op and post op care.

D. EVALUATION

-Discharge planning
a. General condition upon discharge
b. METHOD approach (medication, exercise, treatment, health
teachings, OPD follow- up, diet)

III. CONCLUSION
IV. RECOMMENDATION
V. REVIEW OF RELATED LITERATURE/ STUDIES
VI. BIBLIOGRAPHY