MINI CASE STUDY
I. HEALTH HISTORY
A. DEMOGRAPHIC (BIOGRAPHICAL) DATA
1. Client’s Name or Initial (Optional) :
2. Gender (Sex) :
3. Age :
4. Race / Nationality:
5. Religion:
B. REASON(S) FOR SEEKING CARE or CHIEF COMPLAINTS
(Problem with duration and accompanying s/s one or more symptoms or concerning using the patient to seek
care or may quote the patient's own words.)
Example:
“Noticed swelling in hands, feet, and face” 2 days ago
“Frontal Headache” won’t be relieve with a pain reliever
“Feeling irritable”
“Doesn’t want overhead lights on”
C. OB GYNE HISTORY (if applicable)
OB-Gyne History
Menarche (age): When:
Amount ad characteristics
Duration
Associated Symptoms
D. PEDIATRIC HISTORY (if applicable)
Maternal and Birth history
Birthdate : Hospital:
Birth Weight:
Type of Delivery:
Condition After Birth:
Mother:
Complications of Delivery:
Anesthesia during labor:
Exposure to Teratogenic agents during pregnancy:
II. DIAGNOSIS-BASED PATHOPHYSIOLOGY (Narrative Format)
- Include only the system involved in the diagnosis
III. Procedure (USN, Gavage, CTT, Surgery, etc.)
Nursing Responsibilities /
Procedure Indication / Analysis
Implications
IV. NURSING CARE PLAN
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective Short Term: Independent:
data:
Objective data: Long Term: Dependent:
Collaborative:
V. DRUG STUDY
Mechanism of Side effects & Nursing
Drug Name Indication Contraindication
Action Adverse Effects Responsibilities
Generic Name: Side Effects:
Classification:
Dosage: Adverse
Effects:
Frequency:
