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Case Study Format

This document outlines the format for a case study involving a community nursing case. It includes sections for an introduction, assessment data on the family's structure and health status, identification of health conditions and nursing problems, a family nursing care plan, and a teaching plan. The introduction would briefly describe the case and identify the patient, condition, and significance for nursing. The assessment data involves collecting information on the family's characteristics, home, and each member's health. The nursing care plan includes setting objectives and interventions to address the identified health conditions and nursing problems.

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ALIZA BAKIL
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© © All Rights Reserved
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Download as DOCX, PDF, TXT or read online on Scribd
376 views

Case Study Format

This document outlines the format for a case study involving a community nursing case. It includes sections for an introduction, assessment data on the family's structure and health status, identification of health conditions and nursing problems, a family nursing care plan, and a teaching plan. The introduction would briefly describe the case and identify the patient, condition, and significance for nursing. The assessment data involves collecting information on the family's characteristics, home, and each member's health. The nursing care plan includes setting objectives and interventions to address the identified health conditions and nursing problems.

Uploaded by

ALIZA BAKIL
Copyright
© © All Rights Reserved
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Ateneo de Zamboanga University

College of Nursing
Format for Case Study (HOSPITAL)
I. INTRODUCTION:
1. Brief introduction of the case
2. Patient and the problem-Explain the case/condition (client-centered).Reason of
choosing this case.
3. 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?
a. Significance of the study:
i. Nursing Education
ii. Nursing Practice
iii. Nursing Research
b. Objectives
4. Anatomy and Physiology- (Discuss the related system with regards to the case/condition)
Explain the condition (What are the symptoms? What causes it?)

II. NURSING PROCESS:


A. Assessment
a. Biographic data
i. Name/Alias
ii. Address
iii. Age
iv. Birth Date
v. Sex
vi. Race
vii. Marital Status
viii. Occupation
ix. Religious Orientation
x. Health Care Financing and usual source of medical care
b. Comprehensive Nursing History
 Explain what health problems the patient has (Has she/he been diagnosed
with other diseases?)
 Detail any and all previous treatments (Has she/he had any prior surgeries
or is he/she on medication?)
i. History of Present Illness
A. Ask what was the chronological sequence of events in reference to the
client’s chief complaints:
1. When was the start of the symptoms?
2. How often?
3. Type of activity when before problem occurred?
4. Was help/consultation sought?
5.Medication used?
B. Asks how the problem interfered with activities of daily living
ii. Past History
A. Childhood diseases
B. Immunizations
C. Allergies
D. Accidents and injuries
E. Hospitalization (when and why?)
F. Medication
iii. Family History of Illness
A. Health and ages of patient’s sibling, children, or ages at death and
causes
B. Illnesses in the family similar to the patient
C. Familial incidence of rheumatic fever, hypertension, tuberculosis,
diabetes, mental illness, other especially as suggested by the present
illness
c. Marjorie Gordon’s 11 Functional Health Problem (Pre-confinement and during
confinement, should be written in narrative form)

d. 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
a. (Explain the aim of the procedure and discuss the significance of the results, give
interpretations)
D. Drug study (Follow the format provided)
E. Nursing Care Plan
a. Explain what your nursing diagnosis is (What is the main problem for this
patient? What need to be addressed?)
b. Explain what your goal is for helping the patient recover (What do you want to
change for the patient?)
c. Explain how you will accomplish your nursing goals, and support this with
citations (Reference the literature)
d. For Medical-Management (Refer to any latest MS book)

F. 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)
III. EVALUATION
1. Explain how effective the nursing intervention was (What happened after your
nursing intervention? Did the patient get better?)

IV. RECOMMENDATIONS

1. 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

Drug study format

Drug Mechanism of Indication/Contraindication Nursing responsibilities


action

Brand name:

Generic name:

Classification:

Route:

Dosage:

Frequency:

NCP Format

CUES NURSING GOALS AND NURSING IMPLEMENTATION EVALUATION


DIAGNOSIS DESIRED OUTCOME INTERVENTION
w/ Rationale
Laboratory format

TEST RESULTS NORMAL RANGE CLINICAL SIGNIFICANCE

ORDER OF YOUR CASE STUDY BOOK

Seal and the title Page


Acceptance sheet
Acknowledgement
Table of contents
List of figures

Chapter/s Page

I. INTRODUCTION

II. NURSING PROCESS

III. EVALUATION

IV. RECOMMENDATION

V. BIBLIOGRAPHY

Cover page (Hardbound – color: Navy blue)


Size: long bond paper
Ateneo de Zamboanga University
College of Nursing

Case Title

Name of Students

S.Y. 2020-2021
1st semester
Ateneo de Zamboanga University
College of Nursing
Format for Case Study (COMMUNITY)
I. INTRODUCTION:
1. Brief introduction of the case
2. Patient and the problem-Explain the case/condition (client-centered).Reason of
choosing this case.
3. 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?
a. Significance of the study:
i. Nursing Education
ii. Nursing Practice
iii. Nursing Research
b. Objectives
4. Anatomy and Physiology- (Discuss the related system with regards to the case/condition)
Explain the condition (What are the symptoms? What causes it?)

II. ASSESSMENT DATA BASE IN FAMILY NURSING PRACTICE:


A. FAMILY STRUCTURE, CHARACTERISTICS, & DYNAMICS/RELATIONAL PATTERN
B. SOCIO ECONOMIC & CULTURAL CHARACTERISTICS
C. HOME AND ENVIRONMENT
D. HEALTH STATUS OF EACH FAMIY MEMBER
E. VALUES, HABITS, PRACTICES ON HEALTH PROMOTION, MAINTENANCE AND DISEASE
PREVENTION

Health Condition & Problem Sheet Format


Supporting Health Nursing Problems Date
data/Cues Conditions & Identified Resolved
Problems

Scale Ranking Health conditions and Problems Format sometimes

Criteria Computation Actual Justification


Score
1. Nature of the condition
of Problem presented
2. Modifiability of the
condition or problem

3. Preventive potential

4. Salience

Family Nursing Care Plan

Health Objectives of Plan of Evaluation Plan


condition/s Nursing are Interventions Outcome criteria/ Methods/
Problems & Indicators, tools
Family Nursing standards
Problems

Service and Progress Notes

Date Health Nursing Observations, Printed Name &


Condition/Nursing Actions taken, Responses & Signature
Problems Evaluation of
Progress/Outcomes
Column for nurses notes
Write briefly & concisely & in
telegraphic form
Specify outcomes of each
nurse-family contact (eg.
reactions or responses to
interventions, changes in
decision or health status &
problem identified)

G. TEACHING PLAN
1. Medication - (What are the important thing to keep in mind in taking medication)
2. Economy/Exercise - (What are the alternative/cheaper ways on how to manage the
disease)
3. Treatment/Therapy - (What are recommendations of the doctor in treating the disease)
4. Health Teachings/Hygiene (What health practices should be emphasized to prevent
progression of the disease).
5. Out-patient consultation-(Instructing the client to visit the doctor if symptoms
persist)
6. Diet-(Discuss what are the foods to be taken and avoid)
7. Sex - (Suggestions in keeping the client potent)

IV. RECOMMENDATIONS

1. 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)

III. BIBLIOGRAPHY

Drug study format

Drug Mechanism of action/Side Indication/ Nursing responsibilities


effects
Contraindication

Brand name:

Generic name:

Classification:

Route:

Dosage:

Frequency:

Laboratory format

TEST RESULTS NORMAL RANGE CLINICAL SIGNIFICANCE

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