HINT and TIPS:

1.       Once the topic is known, look for case reports following the guidelines.
2.       References should be based on credible sources. It should be scientifically presented.
3.       Refrain from using websites that are intended for “common tao”.
4.       DISCUSSION part in your case report is helpful.  You can utilize it for etiology, symptomatology,
pathophysiology, labs, management, etc.
5.       Follow the schedule of submission of parts.
6.       Utilize the library resources and some E-books at the students’ lounge.

GUIDELINES
FOR THE CASE ANALYSIS:

The following are the minimum requirements for

filling out or answering the Case Analysis forms in the Clinical Area Manual.

1. Cover page: write the name of the clinical

instructor and the inclusive dates of your exposure.

2. Table of Contents: do not forget to fill out

the page numbers

3. Introduction: Limit to three (3)

paragraphs only

    1st paragraph – includes the description

and or definition of the case; incidence and statistics worldwide and
nationally (Philippines); sources can be WHO or CDC and should be properly cited
or acknowledged (for example: According to WHO (2022),  (WHO, 2022) as end note)

    2nd paragraph – includes the

summary of the case scenario; focus on relevant data/profile of the patient;
signs/symptoms that will confirm the case; lab results that strongly confirm the case (if available); drug
of choice; diagnosis; medical, surgical, and nursing (if available) management.

   3rd paragraph - includes the

overall purpose of conducting the case analysis, for yourself, classmates and the subject.

4. Phenomenon: series of relevant events that lead to the diagnosis and even to
the discharge and follow-ups; present only the abnormal
results; it is just telling a story in chronological order with proper headings
5. Concept Map: a diagrammatic presentation of the phenomenon; presentation is
divided into 2 sides; all past histories (diagnoses,
hospitalization, medications/treatments and others) are written on the left side; while all recent events
(diagnosis, signs/symptoms, abnormal lab results only, medications, relevant management, etc)

6.Learning Objectives: a template is available; corresponding parts of the case

analysis must have a learning objective.

7.RLE Worksheet: The concept must be identified and properly filled in; fill in
the data whatever is available in the scenario;

8.Developmental data: comprises 2 paragraphs; 1st – normal psychosocial development (According

to Eric Erickson) according to the stage where your client belongs; 2nd
– the possible outcome of psychosocial development with the disease she is
suffering at present; full bibliography/reference must be written

9.Chief complaints: must be clearly identified and stated

10.  Health History: identify and clearly present; present illness must be in sentence form

11.  Definition: define the diagnosis in the scenario, not the topic assigne ; include the
complete reference/bibliography; 2 definitions must come from the library
sources or one (1) from library and one (1) from credible online site.

12.  Etiology: include cause/s and risk factors; present the present cause and risk factors
first then those which are basic but not present in your case scenario;
rationale should include the reason and not a DESCRIPTION; include endnote
(source of rationale)

13.  Symptomatology: include signs and symptoms; present the present s/s first then those which are
basic but not present in your case scenario; rationale should include the reason
and not a DESCRIPTION; include endnote (source of rationale)

14.  Anatomy & Physiology: present only the system affected in the case scenario;
include salient points of the involved system and in bullet presentation; A
picture or drawing can best describe the part of the system or the whole system
and may be presented side by side; structure and functions will be presented

15.  Mechanism/Process
of the system: the affected mechanism or process must be presented in a textual
and or diagrammatic form; reference must be credible preferably from Human
Anatomy and Physiology textbooks
16.   Pathophysiology: the abnormal changes in body functions that are the causes, consequences, or
concomitants of the disease process; physical and functional changes that occur are included; a
schematic diagram of the series of pathological events is presented; IDEAL pathophysiology will be
presented (not CASE-BASED); the data (predisposing & precipitating factors, signs and symptoms, labs,
management) present in the case scenario MUST be COLOR CODED; should start with
predisposing and precipitating factors and end with prognosis

17.   Laboratory and Diagnostic Tests: present first those with abnormal results and confirmatory tests;
then those with normal results; and last with those labs which are basic but not done to the patient. 
Clinical significance is not filled in for labs that are basic but not done; Nursing responsibilities should
include responsibilities during the conduct of the test, specifically BEFORE,
DURING, and AFTER the test;

18.   Drug Study: include all drugs presently administered to the patient; at least 5, especially include all
drugs of choice; mechanism of action MUST describe how a drug or other substance produces an effect
in the body, NOT a mere DESCRIPTION; Indication includes the specific reason why the medicine is
prescribed; Nursing responsibilities shall take into considerations the adverse and side effects of the drug

19.   Nursing Diagnosis: Prioritize; maybe stated in “related to” or “Problem-Etiology-Signs and Symptoms
(PES)” Approach; PES is more preferred; REMEMBER: signs and symptoms must describe the nursing
problem not the etiology (in PES)

20.   Nursing Care Plan:  The cues must be in CLUSTER, organized to form a problem, and may include the
s/s and lab results; Need is based on Maslow’s Hierarchy; Nursing Diagnosis must be rationalized based
on the pathophysiology of the case, not a description; Objective of Care must be SMART and should
include the following components – Patient behavior, criteria of performance, condition (if needed) and
time frame, refrain from using NORMAL, should relate with the nursing diagnosis; Nursing Interventions
shall include ALL appropriate nursing intervention, classified into INDEPENDENT, DEPENDENT,
INTERDEPENDENT/COLLABORATIVE and HEALTH TEACHINGS, all interventions shall GEAR
toward the achievement of the Objective of Care; Evaluation is based on the the objective of care, not a
mere COPYPASTE of the objective of care;

21.Evaluation and Implication of the case: Nursing Practice answers What might the case mean for other
nurses such as staff nurses caring the same case, future nurses; Nursing Education answers What might
the case contribute to education, should this topic be given emphasis in the nursing education and why?;
Nursing Theory applicable nursing theory in the care of the case.

22.   Recommendations/Referrals/Follow–ups: write at least 5 recommendations in each category

23.   Journal Reading Related to the Case (EBP Readings); follow instruction

24.   REFERENCES: Follow APA format