LA CONSOLACION UNIVERSITY PHILIPPINES

Malolos, Bulacan
COLLEGE OF ALLIED MEDICAL PROFESSIONS
BACHELOR OF SCIENCE IN NURSING
A.Y 2022-2023

A Clinical Case Study Submitted in Partial Fulfillment of the Requirements in

NCM122/ Intensive Nursing Practicum - Care of Any Group of Clients in the Hospital and Community

A Clinical Case Study of a Patient with [Insert Medical Diagnosis]

Submitted by:
[Insert Name – 4 columns, 3 rows]
BSN Year Level – Group #

Submitted to:
[Insert Name of Panelists – 3 columns]
Level IV Clinical Instructors

[Insert Name] Dr. Joseph Erol T. Cuevas, RN, MAN

Case Study Adviser Dean, College of Allied Medical Professions
 TABLE OF CONTENTS
I. Introduction —--------------------------------------------------------------------------------------------------------------------------------------------------------------- ----
Case Objectives —--------------------------------------------------------------------------------------------------------------------------------------------------- ----
II. Nursing Health History —-------------------------------------------------------------------------------------------------------------------------------------------------- ----
Demographic Data —------------------------------------------------------------------------------------------------------------------------------------------------ ----
Chief Complaint —-------------------------------------------------------------------------------------------------------------------------------------------------- ----
History of Present Illnesses —------------------------------------------------------------------------------------------------------------------------------------- ----
History of Past Illnesses —----------------------------------------------------------------------------------------------------------------------------------------- ----
OB History ( For OB Patient Only) ------------------------------------------------------------------------------------------------------------------------------- ----
Occupational History (For Adult Patient Only) ----------------------------------------------------------------------------------------------------------------- ----
Heredo-familial Diseases—---------------------------------------------------------------------------------------------------------------------------------------- ----
III. Gordon’s Functional Health Pattern —-------------------------------------------------------------------------------------------------------------------------------- ----
Health Perception and Health Management Pattern —--------------------------------------------------------------------------------------------------------- ----
Nutritional and Metabolic Pattern —------------------------------------------------------------------------------------------------------------------------------ ----
Elimination Pattern —----------------------------------------------------------------------------------------------------------------------------------------------- ----
Activity-Exercise Pattern —---------------------------------------------------------------------------------------------------------------------------------------- ----
Sleep-Rest Pattern —------------------------------------------------------------------------------------------------------------------------------------------------ ----
Cognitive-Perceptual Pattern —----------------------------------------------------------------------------------------------------------------------------------- ----
Self-Perception and Self-Concept Pattern —-------------------------------------------------------------------------------------------------------------------- ----

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 Role-Relationship Pattern —--------------------------------------------------------------------------------------------------------------------------------------- ----
Sexuality-Reproductive Pattern —--------------------------------------------------------------------------------------------------------------------------------- ----
Coping-Stress Pattern —-------------------------------------------------------------------------------------------------------------------------------------------- ----
Value-Belief Pattern —---------------------------------------------------------------------------------------------------------------------------------------------- ----
IV. Nursing Theory —----------------------------------------------------------------------------------------------------------------------------------------------------------- ----
V. Pathophysiology —---------------------------------------------------------------------------------------------------------------------------------------------------------- ----
VI. Physical Assessment —----------------------------------------------------------------------------------------------------------------------------------------------------- ----
VII. Diagnostic Procedures —--------------------------------------------------------------------------------------------------------------------------------------------------- ----
VIII. Medical Surgical Management —---------------------------------------------------------------------------------------------------------------------------------------- ----
Supportive/Palliative Management -------------------------------------------------------------------------------------------------------------------------------- ----
Surgical Management -------------------------------------------------------------------------------------------------------------------------------- ----
Drug Study —-------------------------------------------------------------------------------------------------------------------------------------------------------- ----
Diet —--------------------------------------------------------------------------------------------------------------------------------------------------------------- ----
IX. Nursing Management —------------------------------------------------------------------------------------------------------------------------------------------------- ----
Nursing Problem Prioritization —------------------------------------------------------------------------------------------------------------------------------- ----
Nursing Care Plan —---------------------------------------------------------------------------------------------------------------------------------------------- ----
X. Discharge Planning —---------------------------------------------------------------------------------------------------------------------------------------------------- ----
XI. Conclusion —--------------------------------------------------------------------------------------------------------------------------------------------------------------- ----
XII. Bibliography —------------------------------------------------------------------------------------------------------------------------------------------------------------ ----

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XIII. Appendices —-------------------------------------------------------------------------------------------------------------------------------------------------------------- ----
Appendix A: Documentation of the Clinical Case Study ----------------------------------------------------------------------------------------------------- ----
Appendix B: Consent Form to Gather Data for Clinical Case Study --------------------------------------------------------------------------------------- ----

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I. Introduction

The case should begin with a brief passage presenting the patient by his or her initials, age, medical diagnosis, and other related information,
whenever applicable. It then shall document a general description of the medical condition or disease that continues and summarizes other
information, such as manifestations, diagnostics, and managements, to provide readers or listeners with a wider understanding and knowledge about
the selected disorder for case presentation. The body of the introduction discusses the following information:
1. Clinical manifestations

2. Diagnostic procedures

3. Medical management (it may include any surgical, pharmacological, nursing approaches that applies to the study)

4. Evaluation and Prognosis

Lastly, it is also vital that presenters include the disease epidemiology which denotes local and foreign statistics of disease occurrence within
the last 5 years.

Case Objectives

1. General Objective
2. Client and Student-Specific Objectives (Knowledge-Skills-Attitude Format)

The client and student-specific objectives must have minimum of 3 objectives per domain of knowledge, skills and attitude following
nursing principle of S-M-A-R-T.

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II. Nursing Health History

A. Demographic Profile

Name: (Initials only)

Address:

Age:

Birthdate:

Birthplace:

Gender:

Religion:

Race/Ethnic Origin:

Occupation:

Educational Attainment:

Marital Status:

Number of Children:

Chief Complaints:

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 Date of Admission:

Room & Bed Number:

Admitting Diagnosis:

Final Diagnosis:

Medical Insurance: (if any)

B. Chief Complaint or Reason for Clinic Visit

To present a more direct and clearer picture of the patient’s condition, it is recommended that actual verbalization of the patient is documented in

subjective data format (e.g. “Hirap akong huminga dahil sa matinding sipon at ubo,” as verbalized by the client).

C. History of Present Illnesses

1. Ask for the chronological sequence of events in reference to the client’s chief complaint is: C.O.L.D.S.P.A

2. Was help or any medical consultations sought?

3. What home remedies or medications were taken to relieve these symptoms?

4. How the health problem and its symptoms have interfered with daily life?

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D. History of Past Illnesses

1. Childhood diseases

2. Immunizations

3. Allergies

4. Accident and Injuries

5. Hospitalizations (This must include all previous hospitalizations and any surgical procedures encountered)

6. Medications (This should state medications the patient have been prescribed oftentimes and/or any OTC drugs commonly taken for illnesses)

E. OB History (For OB Patient Only)

F. Occupational History (For Adult Patient Only)

Inclusive Dates/Years Occupation

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G. Heredo-familial Illnesses

1. Familial incidence of diseases: Diabetes Mellitus, Hypertension with underlying disorder, Cancer, Mental Illnesses, Rheumatic Fever, Etc.

2. Health conditions and ages of parents, siblings and/or children at death and its causes

3. Genogram of the patient. A 3rd level generation is the least/minimum requirement for presentation. See a sample below.

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Page 10 of 32
 III. Gordon’s Functional Health Pattern

This segment requires presenters to arrange information using a table that shows a narrative comparison of assessment prior and during hospitalization.

Below are sample table and interview questions for Functional Health Pattern contents.

Functional Health Before Hospitalization During Hospitalization Interpretation and Analysis

Pattern (with reference)
Health Perception and
Health Management
Pattern
Nutritional and Metabolic 72 hr diet Recall 72 hr diet Recall
Day 1 Day 2 Day 3 Day 1 Day 2 Day 3
Breakfa
Breakfast st
Lunch Lunch
Dinner
Dinner

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Elimination Pattern Output Amount Frequen Characte Output Amount Frequen Characte
cy ristic cy ristic
Urine Urine
Stool Stool
Others Others
Activity-Exercise Pattern
Gordon’s Functional Level Classification: Gordon’s Functional Level Classification:
Level 0 - Full Self-Care or Completely Level 0 - Full Self-Care or Completely
Independent Independent
Level I – Requires use of equipment or device Level I – Requires use of equipment or device
Level II – Requires help from another person for Level II – Requires help from another person for
assistance, supervision, or teaching assistance, supervision, or teaching
Level III – Requires help from another person and Level III – Requires help from another person and
equipment device equipment device
Level IV – Dependent, does not participate Level IV – Dependent, does not participate

ADL Score ADL Score

ADL Score ADL Score
Feeding 0 Toileting 0
Feeding 0 Toileting 0
Dressing 0 Bed 0
mobility Dressing 0 Bed 0

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 Bathing 0 General 0 mobility
mobility
Bathing 0 General 0
mobility
Groomin 0 Exercise 0
g
Groomin 0 Exercise 0
g

Sleep-Rest Pattern Time of Sleep at Night Time of Sleep at Night

Time of Wake Up Time of Wake Up

Total Hours of Sleep at Total Hours of Sleep at Night

Night
Time of Sleep in the
Time of Sleep in the Afternoon
Afternoon
Time of Wake Up
Time of Wake Up
Total Hours of Sleep in the
Total Hours of Sleep in the Afternoon
Afternoon
Total Hours of Sleep
Total Hours of Sleep
Cognitive Perceptual
Pattern
Self-Perception and Self-
Concept Pattern

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 Role-Relationship Pattern
Sexuality-reproductive
Pattern
Coping-Stress Pattern
Value-Belief Pattern

Guide Questions for Gordon’s Functional Health Pattern:

F.1 Health Perception and Health Management Pattern

1. How has the general health been for the patient?

2. Are there important health practices he/she always abides to stay healthy? (This depicts any folk/traditional/home remedies for illnesses; e.g. cold
remedy)

3. Does the patient smoke or drink alcoholic beverages? If yes, quantify.

4. In the past, has it been easy to comply with doctors’ prescription and nurses’ advices? If any difficulties experienced, specify and explain.

5. If patient had hospitalizations or clinic visits in the past, are there important issues, suggestions, and reminders the patient would like to
raise to improve healthcare delivery? How can nurses be more helpful to patients?

F.2 Nutritional and Metabolic Pattern

1. 3-Day Diet Recall:

a. Typical daily food intake. (This should include vitamins and supplements, if there is any)

b. Typical daily fluid intake. (For accurate result, this should be measured in mL)
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 2. Ask how the patient describes his/her appetite.

3. Ask if patient experiences eating discomfort or is currently on specific diet restrictions. (E.g. dental problems, low fat diet)

4. Interview for weight gain or weight loss.

5. Know if patient has wound healing issues.

F.3 Elimination Pattern

1. Urinary/Bowel Elimination Pattern. It discusses frequency, amount, color, discomfort and other characteristics on urination and defecation.

2. Analysis and Interpretation for the table presented.

3. Also, it may discuss other elimination-related concerns if necessary. (E.g. hyperhidrosis or excessive perspiration)
F.4 Activity – Exercise Pattern

1. Discuss and describe the Patient’s Activities of Daily Living (ADL)

2. Is energy sufficient to sustain daily activities?

3. Leisure activities and child-play activities, if appropriate.

4. Perceived Ability to Perform ADL (Graded by Level):

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 Feeding Bathing Toileting Bed Mobility

Dressing Grooming Cooking Home Maintenance

Outdoor Activities (E.g. Shopping) General Mobility

Suggested Functional Level Classification:

Level 0 – Full Self Care or

Completely Independent Level I –
Requires use of equipment or
device
Level II – Requires help from another person for assistance, supervision,
or teaching Level III – Requires help from another person and equipment
device
Level IV – Dependent, does not participate in activity

F.5 Sleep – Rest Pattern This portion discusses:

1. Approximate hours of sleep at night

2. Sleep characteristics (if continuous or not; if with sleeping difficulty)

3. Is there a need for sleep-inducing medications?

4. Does the patient feel rested after waking?

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 5. Is the patient taking naps in the afternoon? If yes, how long?

6. Relaxation habits (watch movie, reading books, dancing, shopping, etc.)

F.6 Cognitive – Perceptual Pattern
It presents:

1. Sensostatus (visual, auditory, olfactory, gustatory issues; balance and muscle coordination)

2. Use of eyeglasses, hearing aids and previous checkups

3. Memory status (memory losses, if one has)

4. Learning Strategies (if the patient understands things better by reading, listening, or in other ways of learning)

5. Perception of pain (case-to-case basis, pain tolerance and threshold may need to be discussed)
F.7 Self- Perception and Self-Concept Pattern

1. A nurse may ask: “How do you describe yourself? Do you feel good about yourself?”

2. How the patient see the physical changes in his/her body and changes on activities he/she usually does. (This may apply on cases that
dramatically affect one’s body image. E.g. Amputation of limb)
3. What are the things or situations that easily make the patient angry, annoyed, fearful, anxious or depressed? What helps him/her to cope with
these?

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F.8 Role – Relationship Pattern

1. Is the patient living alone? If living with his/her family, describe their family structure and availability of support system.

2. Common family problems and how these were handle?

3. Issues with dependent member in the family and how these get managed, if applicable.

4. If appropriate, how do significant others feel about the illness and/or hospitalization?

5. Problems encountered within social groups, close friends, workplace.

F.9 Sexuality – Reproductive Pattern

1. If appropriate, discuss any changes or problems in sexual relations

2. If appropriate, inquire about use of contraceptives and family planning.

3. If appropriate, include menarche, LMP, menstrual problems, and pregnancy-related concerns.

F.10 Coping – Stress Tolerance Pattern A nurse may ask:
1. Tense a lot of time? What helps? Use of any medicine, drugs or alcohol?

2. Who’s most helpful in overcoming life stresses? Are they available at all times?

3. Any big changes which put an impact to your life in the last year or two?

4. How do you handle life stressors? Is your coping mechanism found to be effective?

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 F.11 Value – Belief Pattern

1. It discusses things or relations patient value the most.

2. Religion and religious practices.

3. It discusses how the patient sees his/her spiritual being and how one’s belief help or interfere in any health-related matters.

IV. Nursing Theory Application

Discussion of nursing theory should only mention topics, theories or models that will apply to the patient’s condition (at least 3)

Theory Theorist Description Application of Theory to the Patient

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V. Pathophysiology

A. Anatomy and Physiology

Shall focus on the affected anatomical features and functions only.

Illustrations will be substantive as well so long it focuses on the affected body areas only.

B. Overview of Disease
C. Contextual Mapping / Schematic Diagram

This segment of the study briefly defines the disease process the client has encountered. Following a sentence or passage of description, it will
discuss the entire mechanism of the disorder using a schematic diagram that begins with risk factors contributing to the occurrence of a disease –
modifiable and non-modifiable causative factors. Sometimes the identification or justification of one or two risk factors as either modifiable or non-

modifiable may vary from one patient to another (e.g. stress of different types). The diagram continues to narrow down following arrowed lines that
navigate to explain the whole disease process until each branch ends up with the patient’s clinical manifestations.

VI. Physical Assessment

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Height: (in ft / in)

Weight: (in kg)

BMI:

BMI Interpretation:

BODY PART ASSESSMENT NORMAL FINDINGS ACTUAL FINDINGS ANALYSIS AND

(CEPHALOCAUDAL) METHOD USED INTERPRETATION
(NORMAL OR
DEVIATION FROM (WITH REFERENCE)
NORMAL)

If not assessed, indicate: No opportunity to assess due to *specify reason (Example: COVID Safety Protocol, Patient Refusal, etc.)

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 Summary of Significant Findings:

VII. Diagnostic (Laboratory and/or Radiologic) Procedures

PROCEDURE DATE ACTUAL NORMAL ANALYSIS AND NURSING

PERFORMED VALUES/ VALUES INTERPRETATI RESPONSIBILITIES
RESULTS ON
(WITH
REFEENCE)
1. Hematology (sample only) Prior: (at least 3 each)
During:
After:
2. Chest X-ray (sample only) Prior:
During:
After:

The contents of the tables above for presentation must deliver data that directly relates to the patient only. Likewise, each procedure done must be
arranged chronologically according to the date it was ordered.

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VIII. Medical-Surgical Management

A. Supportive and/or Palliative Management

MEDICAL PROCEDURES DATE ORDERED/ GENERAL INDICATION/ CLIENT’S NURSING

TAKEN/ CHANGED/ DESCRIPTION PURPOSE RESPONSE RESPONSIBILITIES
DISCONTINUED (CLASSIFICATION/
ACTIONS)
1. IVFs (sample only) Prior:
During:
After:
2. Oxygen Therapy Prior:
(sample only) During:
After:

The contents of the table above for presentation must deliver data that directly relates to the patient only. Likewise, each procedure or
management done must be arranged chronologically according to the date it was ordered.

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 B. Surgical Management (if any)
SURGICAL PROCEDURES DATE PERFORMED GENERAL CLIENT’S NURSING
DESCRIPTION RESPONSE RESPONSIBILITIES
AND PURPOSE
1. Appendectomy (sample only) Prior:
During:
After:

C. Drug Study

DATE CLIENT’S NURSING

ORDERED/ ROUTE OF RESPONSE RESPONSIBILITIE
MECHANIS (THERAPEUTI
MEDICATIO GIVEN OR ADMINISTRATIO INDICATIO CONTRAINDICATIO S
TAKEN/ M OF C EFFECT,
N N/ DOSAGE/ N N (PRIOR, DURING,
DISCONTINUE FREQUENCY ACTION SIDE EFFECT,
AFTER – AT LEAST 3
ADVERSE
D EACH)
EFFECT)
Generic: Date Ordered: Route: Therapeutic Prior:
Effect:

Brand: Date Given: Dosage: Side Effect: During:

Adverse After:
Classification: Date Frequency: Effect:
Discontinued:

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The contents of the table above for presentation must deliver data that directly applies or relates to the patient only. Likewise, each medication must be
arranged according to the date it was ordered, i.e. in chronological order.

If the medication was not given during your shift, write in the Client’s Response Column: No opportunity to observe. However, here are the possible
therapeutic, side, and adverse effects ….

D. Diet
TYPE OF DIET GENERAL INDICATION/ SPECIFIC CLIENT’S NURSING
DESCRIPTION PURPOSE FOODS TAKEN RESPONSE RESPONSIBILITIES

Prior:

During:

After:

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IX. Nursing Management
A. Nursing Problem Prioritization

LEVEL OF DATE IDENTIFIED CUES NURSING DIAGNOSIS JUSTIFICATION / BASES IN

PRIORITY PRIORITIZING THE
PROBLEM
I Subjective:

Objective:
II Subjective:

Objective:
III Subjective:

Objective:

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 B. Nursing Care Plan

EVALUATION
INTERVENTION
PLANNING (Short-Term and Long-
(at least 3 Independent,
ASSESSMENT NURSING DIAGNOSIS (Short-Term and Long- RATIONALE Term)
3 Dependent, 3
Term) Met, Partially Met,
Collaborative)
Unmet
Subjective: Short-Term Goal: Short-Term Evaluation:

______ Met
______ Partially Met
______ Unmet

as evidenced by:
Objective: Long-Term Goal:

Long-Term Evaluation:

______ Met
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 ______ Partially Met
______ Unmet

as evidenced by:

Develop NCP for the Top 3 Prioritized Problems.

X. Discharge Planning

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 M Medicines (Take Home Meds)

E Exercise

T Treatment

H Health Teaching (and/or

Hygiene)
O Outpatient Care

D Diet

S Spiritual (or Sexual Concerns)

XI. Conclusion

This portion shall comply and be congruent to the enumerated general and specific objectives of the study.

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XII. Bibliography

List each source/reference following the APA format. Samples of documenting book and online resources are shown below respectively.

XIII. Appendices
Appendix A: Documentation of the Clinical Case Study

Provide for Client Privacy

Appendix B: Consent Form to Gather Data for

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Clinical Study

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 Grammar/Margins/Fonts/Other Formatting Concerns

Since clinical case study serves as one of the prime examples of nursing researches, students must narrate their study using third person
point of view. (E.g. “Nursing students” or “researchers” as sentence subjects, instead of saying “I” or “We”)
For typing and printing concerns, please observe the following:

✔ Font Style: Times New Roman

✔ Font Size: 12

✔ Margins: 1 inch all borders

✔ Front Page: (See samples provided)

✔ Footer: Page numbers only.

E.g. Page 3 of 38

✔ Binding: Hard – Binding

✔ Hard – bind Color: Royal Blue

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