WESLEYAN UNIVERSITY - PHILIPPINES

College of Nursing

INDIVIDUAL / GROUP CASE STUDY FORMAT

I. TITLE PAGE (1 whole page)

case

A Case of (Final Diagnosis)

Presented by: (Name of the Student/ Section/ Group)

Submitted to : Name of Faculty

Submitted on: Date Submitted

II. INTRODUCTION

a. Definition of case
b. Etiology
c. Incidence (International-WHO; Local-DOH)
d. General signs and symptoms
e. Theoretical Framework (theory applicable for the care of the patient)

III. OBJECTIVES OF THE CASE

a. General
b. Specific

IV. PATIENT’S PROFILE

a. Name
b. Address
c. Age
d. Gender
 e. Religion
f. Occupation
g. Marital Status
h. Number of Children (if applicable)
i. Chief complaint
j. Date of admission
k. Ethnicity
l. Educational Attainment
m. Admitting Diagnosis/ Final Diagnosis

V. NURSING HEALTH HISTORY

a. History of Present illness

1. Signs and Symptoms

2. Inclusive dates

3. Precipitating and alleviating factors

4. Effect on other body parts

5. Interventions/treatment done

6. Effects of treatment/ intervention done

b. History of Past illness

1. Heredo-Familial tendency (genogram with legend)

2. OB history (for female patients)

3. Immunization history (0-15 mos. only)

4. Travel history

5. Surgical Procedures done

6. Hospitalizations

7. Accident/ Injuries

8. Childhood illnesses

9. Socio-economic history

10. Allergies
 VI. PHYSICAL ASSESSMENT (CEPHALOCAUDAL)

a. General Survey

b. Measurement (Height, Weight, BMI, Vital sign)

Date Organ Method Normal Actual Interpretation

assessed findings findings
And analysis

(with
reference)

VII. ACTIVITIES OF DAILY LIVING (NARRATIVE FORMAT)

Functional Before Hospitalization During Analysis (with reference and

Pattern Hospitalization interpretation after each
pattern)

Subjective Cue Subjective cue

Objective Cue

a. Health Perception-Health Management Pattern

 Client’s perceived pattern of health and well–being and how health is being
managed.

b. Cognitive- Perceptual Pattern

 Sensory, perceptual, and cognitive patterns according to age level

c. Self –Perception- Self- Concept Pattern

 Self–concept and perception of self (body comfort, image, feeling state)

 d. Role-Relationship Pattern

 Pattern of role engagement and relationships according to ordinal position

and role in society

e. Sexuality-Reproductive Pattern

 Pattern of satisfaction and dissatisfaction with sexuality pattern, describes

reproductive pattern according to age level

g. Value- Belief Pattern

 Pattern of values and beliefs including spiritual and moral that guide choices
or decisions according to age level

h. Nutritional –Metabolic Pattern

 Pattern of food and fluid consumption relative to metabolic need

 3-day food recall

i. Elimination Pattern

 Pattern of excretory function (bowel, bladder, sweating/ vomiting)

j. Activity-Exercise Pattern

 Pattern of exercise, activity, leisure, and recreation ( 7 days)

k. Sleep-Rest Pattern

 Patterns of sleep, rest and relaxation (7 days)

VIII. DEVELOPMENTAL MILESTONE (NARRATIVE FORMAT)

Date of interview Before During Analysis

Hospitalization Hospitalization
(with reference)

a. Age of the patient Subjective Subjective

b. Theory used

Objective

c. Proponent
 IX. COURSE IN THE WARD (narrative format from admission to discharge that
includes date, treatment, diet, procedures given and doctor’s order)

X. ANATOMY AND PHYSIOLOGY (with picture and reference)

XI.PSYCHO-PATHOPHYSIOLOGY (Concept mapping/ Schematic Diagram with

reference)

XII. LABORATORY FINDINGS

Date Laboratory Normal Result Clinical Nursing

exam values Interpretation Responsibilities
with analysis

(with
reference)

XIII. DRUG STUDY (MEDICATIONS AND INTRAVENOUS FLUID GIVEN)

Date Name of the drug Mechanism Indication Contraindication Side Nursing

of action Effect Responsibility

a. Generic name Includes

classification

b. Brand Name

c.
Dose/dosage/route
 XIV. TREATMENT

(Treatment includes those prescribed by the physician i.e., regular monitoring of

blood sugar, nebulization, etc.)

Date Name of treatment Indication/ purpose Nursing

responsibilities

XV. PROBLEM IDENTIFICATION AND PRIORITIZATION

Nursing Diagnosis/ Cues Type and Rank Justification

Based on NANDA or Activities Actual According to ABC or Maslow’s

of daily living Hierarchy of needs or triage
Risk

Possible

Wellness

Syndrome
 XVI. NURSING CARE PLAN

Dat Assessment Diagnosis Analysis Planning Intervention Rationale Evaluation

e
(with
reference)

Subjective NANDA a. Brief SMART Identify Reference Parameters:

explanation what type at
the end of 1. Adequacy
in narrative each
Objective form a. Short
term management
(at least 3) goal then indicate 2. Effectiveness
a reference
b. Starts
Measurement from b. Long- 3.
diagnosis term Appropriateness
to the goal
etiology
4. Efficiency
to
symptoms

then 5. Acceptability
endpoint is
the
problem State the status
of the patient
after
administering the
management
XVII. DISCHARGE PLANNING (APPLICABLE ONLY IF THE PATIENT IS
DISCHARGE)

 M-Medication (only includes those that were prescribed by the physician and
were required to be taken at home)

Name of Dosage and Route Time Curative Side effects

drug frequency effects

 E-Environment/ Exercises (if the physician did not order any particular
exercise regimen for the patient, just include those activities that may be
essential to the patient’s faster recovery)

Type of Procedure/ Use of Restriction Rationale

activity/ steps equipment (if
allowed/ to be any)
continued at
home

T-Treatment (Treatment includes those prescribed by the physician i.e., regular

monitoring of blood sugar, nebulization, etc)

Name of treatment Indication/ purpose Nursing responsibilities

 H-Health teaching

 O-Out Patient ( Date of return/ Time/ Place: Room number and name of the
institution / Physician)

 D-Diet (It must be specific. Take mention examples for breakfast, lunch and
dinner including its servings and explain why these particular foods are
essential to the client’s condition. Also, provide list of foods contraindicated
 to the patient. Provide a 3-day food meal. Furthermore, show the diet
prescription computation before filling the diet plan).

Meal Serving Rationale

Breakfast

Snack (if applicable)

Lunch

Snack (if applicable)

Dinner

 S-Spiritual and Sexual (if applicable) - These may include spiritual

counseling, anger management, family therapy, and reconciliation of
conflicted relationships.

XVIII. IMPLICATIONS OF THE CASE TO THE FOLLOWING AREAS:

a. Nursing research

b. Nursing Education

c. Nursing practice (clinical)

XIX. HEALTH TEACHING PLAN (BASED ON THE DISCHARGE PLANNING)

Objectives Content Method of Time Resources Methods of

allocated evaluation
(with instruction
references)

a. Cognitive a. Demonstration

b. Affective b. Lecture

c. c. Laboratory
Psychomotor
 d. Deductive

e. Inductive

f. Project method

XX. BIBLIOGRAPHY (APA format)

Prepared by:

JUDILIZA GUINTO VELAYO, MHA, RN

RLE PROGRAM HEAD
Wesleyan University- Philippines

DR JOHDEL CABALUNA
Dean
Panpacific University Urdaneta Pangasinan