Republic of the Philippines

ISABELA STATE UNIVERSITY

Echague, Isabela
COLLEGE OF NURSING

BSN 3-2/ Group 3

CASE STUDY GUIDE

WHAT IS A CASE STUDY IN NURSING?

 gives a comprehensive look at an individual patient

 case studies focus on specific patients and provide information
 test the knowledge of nursing student, that she/he has acquired in the classroom in a more
realistic way

Tips on completing a successful Case Study

 Pay attention to and obtain important and relevant information.
- ask the right questions
- pay attention to vitals
- consider the symptoms
 Republic of the Philippines
ISABELA STATE UNIVERSITY
Echague, Isabela
COLLEGE OF NURSING

BSN 3-2/ Group 3

PARTS OF CASE STUDY:

1. Overview of the Disease
- brief and concise
2. Demographic Data

Name:
Age:
Gender:
Civil Status:
Birth date:
Nationality:
Religion:
Address:
Educational Background:
Occupation:

3. Nursing History
History of Present Health
Past Medical History
Family Health History

4. Gordon’s Physical Assessment (Marjorie Gordon's 11 Functional Health Patterns)

Health perception and health management
Nutrition and metabolism
Elimination
Activity and exercise
Cognition and Perception
Sleep and rest
Self-perception and self-concept
Roles and relationships
Sexuality and reproduction
Coping and stress tolerance
Values and belief
 Republic of the Philippines
ISABELA STATE UNIVERSITY
Echague, Isabela
COLLEGE OF NURSING

BSN 3-2/ Group 3

Physical Assessment: (Overt Cues Relevant to the Case)

Vital Signs: (Include Vital Signs)

AREA METHOD NORMAL ACTUAL ANALYSIS

ASSESSED USED FINDINGS FINDINGS
SKIN
 Color Inspection Fair complexion Pale d/t decreased tissue
perfusion and
peripheral
vasoconstriction

5. Anatomy and Physiology

6. Pathophysiology

7. Laboratory and Diagnostic Result with Interpretation

E.g. CBC Date Tested:

Parameters Result Normal Range Analysis
WBC 12.4x103 /mm3 3.5-10 d/t increase pyrogens
RBC 3.83x106 /mm3 3.8-5.8 Normal
Hgb 11.4 g/dl 11.0-16.5 Normal
Hct 37.0% 35-50 Normal
PLT 188x103/mm3 150-390 Normal
 Republic of the Philippines
ISABELA STATE UNIVERSITY
Echague, Isabela
COLLEGE OF NURSING

BSN 3-2/ Group 3

8. Course in the Ward

E.g.
Day 1

A (age) old (gender) was admitted at exactly (time) last

(date), accompanied
was admitted
(Diet), temperature,
(laboratory and
physician ordered (Fluid e.g.,
(medication).
by her son, with a chief complaint of (signs and symptoms). She
under the service of (Doctor) and following orders were given.
pulse rate and respiratory rate must be recorded every shift, for
diagnostic tests). It was done at the same day. The
D5LR.). The physician also ordered

9. Nursing Care Plan

- Should be S-M-A-R-T
S - Specific
M - Measurable
A - Attainable
R - Realistic
T - Time-bound

- Nursing Diagnosis – refer to NANDA

10. Drug Study

Drug Mechanism of Indication Contraindicatio Adverse Nursing
Action n Effects Considerations
and Side
Effects
Generic Name
Brand Name
Classification
Dosage
Route
Frequency
Form
 Republic of the Philippines
ISABELA STATE UNIVERSITY
Echague, Isabela
COLLEGE OF NURSING

BSN 3-2/ Group 3

11. Discharge Plan

- Should include
 Medication
 Exercise
 Treatment
 Hygiene
 Outpatient Orders
 Diet
E.g.
Content Strategy
 Follow up checkup The patient will be having One-on-one discussion
a follow up checkup regarding the patients
regarding… scheduled follow up check
up..