BULACAN STATE UNIVERSITY

COLLEGE OF NURSING
FORMAT FOR CASE STUDY
I.

I.

II.
III.

Introduction
a. Current trends about the disease condition
b. Reason for choosing such case study
c. Objective
Nursing Assessment
a. Personal History
1. Demographic Data
(name, age, sex, civil status, position in the family, address,
date/place of birth, nationality, educational attainment, health care
financing/usual source of medical care, date of admission and
discharge, final diagnosis)
b. Reasons for visit/Chief Complain
c. History of past illness
d. History of present illness
e. Family Health illness history
f. Functional Health Patterns
1. Health Perception/Health Management Pattern
2. Nutritional Metabolic Pattern
3. Elimination Pattern
4. Activity/Exercise Pattern
5. Sleep Rest Pattern
6. Cognitive Perceptual Pattern
7. Self Perception/Self Concept Pattern
8. Role relationship Pattern
9. Sexuality Reproductive Pattern
10.Coping Stress Tolerance
11.Values Belief Pattern
g. Growth and Development(selected case)
Anatomy and Physiology(with visual aids)
The patient and his illness
a. Pathophysiology(Client illness)
1. Schematic diagram
2. Definition of the disease
3. Predisposing/Precipitating factors
4. Sign and symptoms with rationale
5. Review of system
Note: Specific dates for the occurance of each manifestation should
be included

Diagnostic
Laboratory
Procedure

Date
Ordered and
Date result
in

Indications
or Purpose

Result(1st,
2nd, 3rd)

Normal
Values(unit
used in the
hospital)

Analysis
and
interpretatio
n of the

results)
Note: Nursing Responsibilities prior to, during and after the procedure should be
included.
IV.

The patient and his care

A. Medical Management
a. IVF, BT, NEBULIZATION, NGT, TPN, OXYGENATION THERAPHY, ETC.

Medical
Management
Treatment

Date
General
Indications/Purp
Clients
Ordered/Date
Description
oses
response to
Performed/Dat
the treatment
e Change or
DC
Note: Nursing responsibilities prior to, during and after treatment should also be
included
b. Drugs

Generic
name/bran
d name

Date
ordered,
taken/give
n Date
changed/D/
C

Route of
administrati
on, dosage,
frequency

General
action,
classificatio
n,
Mechanism
of action

Indications/Purp
ose

Client
response
to thye
medication
, actual
side
effects
Note: Nursing responsibilities prior to, during and after administration should also
be included
c. Diet

Type of
Diet

Date
General
Indications/Purp
Specific
Client
started/Dat Description oses
foods
response
e
taken
to the diet
changed/D/
C
Note: Nursing responsibilities prior to, during and after administration should also
be included
d. Activity/Exercise

Type of
Exercise

Date Ordered,
Date started,
changed/D/C

General
Description

Clients
response to
the
activity/exercis
e
Note: Nursing responsibilities prior to, during and after exercise should also be
included
B. Surgical Management(selected case)
1. Brief Description

Indications/Purp
oses

2. Visuals if applicable
3. Patients response to operation
4. Nursing responsibilities prior to, during, and after the operation
Note: Include the date ordered, date performed, and the specific items
included in the doctors orders about the operation
C. Nursing Care Plan
Note: Prioritize the Problem.
D. Health Teaching
V.

Discharge Planning
a. General Condition of the client upon discharge
b. Method2

VI.

Conclusions

VII.

Bibliography

Functional classification of labor

Principal Clinical Features on the Functional Divisions of Labor

Characterist Preparatory
ic
Division

Dilatational
Division

Functions

Contractions
Cervix
coordinated,
actively
polarized,
dilated
oriented;
cervix
prepared

Interval

Latent
acceleration
phases

Measureme
nt

Elapsed duration

Diagnosable Prolonged
disorders
phase

and Phase
maximum
slope

Pelvic Division
Pelvis
negotiated;
mechanisms of labor;
fetal descent; delivery

of Deceleration
phase
and second stage

Linear rate of Linear rate of descent

dilatation

latent Protracted
dilatation;
protracted

Prolonged
deceleration;
secondary arrest

of

descent

dilatation; arrest
descent;
failure
descent

72 hours diet recall

August 7, 2009
Breakfast:

August 8, 2009
Breakfast:

August 9,2009
Breakfast:

4pieces of bread

2 cup of rice

2 cup of rice

480 ml of water

1 pc. Of scrambled

1 pc. Of fried egg

egg

5 slices of eggplant

720 ml of water

720ml of water
Lunch:

Lunch:

Lunch:

2 cup of rice

1 cup of adobong

2 cup of rice

1 cup of sinigang na

manok

1 cup of chopsuey

bangus

2 cup of rice

720 ml of water

720 ml of water

720 ml of water

1pc. Of banana
Dinner:

1pc. Of banana
Dinner:

Dinner:

1 cup of rice

1 cup of rice

1 cup of rice

1 cup of chopsuey

1 cup of adobong

1 cup of adobong

720 ml of water

manok

kangkong

720 ml of water

720 ml of water

of
of

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