Ateneo de Zamboanga University

College of Nursing
Format for Case Study (Hospital)
I. INTRODUCTION:
 Brief introduction of the case
 Patient and the problem-Explain the disease condition (client-centered). Reason of
choosing this case.
 The information includes the following:
- Explain who the patient including the age, gender and etc.
- Explain what the case/problem is all about, what happen, what was he
or she diagnosed (Client-centered)
- Introduce your main argument. What should you as a nurse focus on or
do?

Significance of the study:

o Nursing Education
o Nursing Practice
o Nursing Research
Objectives
 General objectives
 Specific objectives

Anatomy and Physiology-(Discuss the related system with regards to the condition case/disease)
Pathophysiology (in paradigm form with explanation)
- Explain the disease (What are the symptoms? What causes it?)

II. NURSING PROCESS:

A. Assessment
o Biographic data
o Comprehensive Nursing Health History (see guide interview sheet)
 History of Present Illness - Explain what health problems the patient has (Has
she/he been diagnosed with other diseases?)
 Past Illness - Detail any and all previous treatments (Has she/he had any prior
surgeries or is he/she on medication?)
 Family History – history of genetic and hereditary diseases.
o Marjorie Gordon’s 11 Functional Health Problem (Pre-confinement and
during confinement, functional pattern should be written in narrative form)
o Physical Assessment – Cephalocaudal (Head to Toe) and written in narrative
form (Follow the Bates Assessment tool)

B. Diagnostic Tests ((Explain the aim of the procedure and discuss the significance of
the results, give interpretations)
 C. Laboratory results (follow format)
 (Explain the aim of the procedure and discuss the significance of the
results, give interpretations)
TEST RESULTS NORMAL RANGE CLINICAL
SIGNIFICANCE

D. Drug study (Follow the format provided)

Drug Mechanism of Indication/ Nursing responsibilities
action/Side effects Contraindication
Brand name:
Generic name:
Classification:
Route:
Dosage:
Frequency:

E. Nursing Care Plan (follow format)

o Explain what your nursing diagnosis is (What is the main problem for this
patient? What need to be addressed?)
o Explain what your goal is for helping the patient recover (What do you want
to change for the patient?)
o Explain how you will accomplish your nursing goals, and support this with
citations (Reference the literature)
o For Medical-Management (Refer to any latest MS book)
o NCP Format
CUES NURSING GOALS AND NURSING IMPLEMENTATION EVALUATION
DIAGNOSIS DESIRED OUTCOME INTERVENTION

F. Health Teachings /Discharge Instructions / Teaching Plan

 Medication – (What are the important thing to keep in mind in taking medication)
 Economy/Exercise – (What are the alternative/cheaper ways on how to manage the
disease)
 Treatment/Therapy – (What are recommendations of the doctor in treating the disease)
 Health Teachings/Hygiene (What health practices should be emphasized to
prevent progression of the disease).
 Out-patient consultation-(Instructing the client to visit the doctor if symptoms
persist)
 Diet-(Discuss what are the foods to be taken and avoid)
 Sex - (Suggestions in keeping the client potent)
Teaching Plan format:
Topic/s:
Venue:
General Objectives:
Learning Content Time Allotment Strategies/Methodology References Evaluation
Objectives

III. EVALUATION

 Explain how effective the nursing intervention was (What happened after your nursing
intervention? Did the patient get better?)

IV. RECOMMENDATIONS

 Explain what the patient or nurse should do in the future to continue

recovery/improvement. Your paper will be graded on how well you complete each of
the above sections.  You will also be graded on your use of APA style (see the APA
section of this website)

IV. REFERENCES/BIBLIOGRAPHY