CENTRAL LUZON DOCTORS’ HOSPITAL

EDUCATIONAL INSTITUTION
San Pablo, Tarlac City

CASE STUDY FORMAT

I. Introduction
II. Objectives
Nurse centered
III. Nursing Process
A. Data Base
a. Nursing health history A
1. Demographic data
2. Chief complaint
3. History of present illness
4. Past medical history
5. Family history
6. Social and personal history
7. Review of system
b. Nursing health history B
1. General Description Of Client
2. Health Perception-Health Management Pattern
3. Nutritional-Metabolic Pattern
4. Elimination Pattern
5. Activity-Exercise Pattern
6. Sleep-Rest Pattern
7. Cognitive-Perceptual Pattern
8. Self-Perception – Self-Concept Pattern
9. Role-Relationship Pattern
10. Sexuality-Reproductive Pattern
11. Coping-Stress Tolerance Pattern
12. Value-Belief Pattern
c. Physical examination
d. Laboratory Findings
e. Review of anatomy and physiology
f. Pathophysiology (highlight patient manifestation)

B. NCP
C. Drug Study
D. Medical and Nursing Management
E. METHOD
IV. Evaluation
a. Narrative evaluation of the objectives
b. Patient condition upon discharge
V. Recommendation
VI. References/Bibliography
 CENTRAL LUZON DOCTORS’ HOSPITAL
EDUCATIONAL INSTITUTION
San Pablo, tarlac city

CASE STUDY FORMAT

I. Introduction

a. Introduction about patient/background

• Age

• Gender

• Address

b. Significance/relevance to the concept

c. Background knowledge

• Definition

• Causative agent

• Clinical manifestation

• Mode of transmission

d. Current/target population

e. Risk factors/contributing factors

f. Prognosis and complications

II. Nurse centered

a. Objectives
 NURSING HEALTH HISTORY A

Demographic data

Patient:
Date: Ward: Bed:
Age: Sex: C/S: Religion
:
Examiner:
Informant:

I. Chief complaint

II. History of present illness

III. Past medical history (include dates and complications, if any)

A. Pediatric and Adult Illness

Mumps Pertussis HPN

Measles Rheumatic Heart Disease
Chicken Pox Pneumonia Hepatitis
Rubella Tuberculosis Others

B. Immunizations/Tests

BCG HEP B For Pneumonia

DPT Measles Others
OPV For Flu

C. Hospitalizations

D. Injuries

E. Transfusions

F. Obstetrics/gynecologic History

G. Medications
 H. Allergies

IV. Family history

AGE List: Health Status Diseases Present in the

Parents, Spouse, Children or Cause of Family
L D Death

L = Living TB = Tuberculosis HPN = Hypertension OB = Obesity

D = Deceased DM = Diabetes Mellitus CA = Cancer J = Jaundice
HD = Heart Disease MI = Mental Illness KD = Kidney Disease O = Others

V. Social And Personal History

Birthplace: Birthday:
Education: Ethnic Background:
Age and Sexes of Children (if any):
Client’s position in the family:
Residence
Home Environment:

Occupation
Nature of present occupation: (stresses, hazards, etc.)

Financial Support System:

Habits (tobacco/alcohol use, others):

Diet (meal distribution, others)

Physical Activity/Exercise, if any:

 Brief Description of Average Day:

VI. Review of system

General Description:
Weight Loss: __________ Fatigue: ____________ Anorexia: ____________

Night Sweats: ____________ Weakness: __________

Skin:
Itch: _________________________ Bruising: ________________________
Rash: ________________________ Bleeding: ________________________
Lesions: ______________________ Color Change: ____________________
Eyes:
Pain Itch Vision Loss
Diplopia Blurring Excessive Tearing
Glasses/Contact Lenses
Ears:
Earaches Discharge Tinnitus Hearing Loss
Nose:
Obstruction Epistaxis Discharges
Throat and Mouth:
Sore Throats Bleeding Gums Tooth Aches Decay
Neck:
Swelling Dysphagia Hoarseness
Chest:
Cough Sputum: (Amount & Character) Hemoptysis
Wheeze Pain on Respiration Dyspnea: Rest/Exertion
Breast: Lumps Pain Bleeding Discharge
CVS:
Chest pain Palpitation Dyspnea on exertion Edema
PND Orthopnea Others: _________________________
GIT:
Food tolerance Heartburn Nausea Jaundice
Vomiting Pain Bloating Excessive Gas
Constipation Change in BM Melena
GU:
Dysuria Nocturia Retention Polyuria Dribbling
Hematuria Flank pain
Male: Penile Discharge Lesion Testicular pains others:
Female: Menarche: (age) LMP: (date) Cycle: _____ others:
Extremities:
Joint pains varicose veins Claudication
Edema Stiffness Deformities
Neuro:
Headaches Dizziness Memory Loss Fainting
 Numbness Tingling Paralysis: ____________ Paresis: _________
Seizures Others: ______________________________
Mental Health Status:
Anxiety Depression Insomnia
Sexual Problems Fears

NURSING HEALTH HISTORY B

General Description Of Client

•

Health Perception-Health Management Pattern

•

Nutritional-Metabolic Pattern
•

Elimination Pattern
•

Activity-Exercise Pattern
•

Sleep-Rest Pattern
•

Cognitive-Perceptual Pattern
•

Self-Perception – Self-Concept Pattern

•

Role-Relationship Pattern
•

Sexuality-Reproductive Pattern
•

Coping-Stress Tolerance Pattern

•
 Value-Belief Pattern
•

PHYSICAL EXAMINATION

GENERAL SURVEY:
Height: ______ Weight: ______ Body Makeup: ______ Communication Pattern: ______
Skin: Color: __________ Turgor: ___________ Bruises: __________
State of Hydration: _____________
Eyes: Sclera: _____________________ Pupils: ______________________
Respiratory: Easy Breathing in Distress No Distress
VITAL SIGNS:
HR ___________ / min Temperature: ____________
BP Supine R/L arm ___________ mmHg Capillary Refill: ____________
Sitting R/L arm ___________ mmHg RR: _____________________
Standing R/L arm ___________ mmHg
Others: ______________________________
BODY POSITION/ALIGNMENT:
Supine: _______ Fowlers: ________Semi-Fowlers: _______ others: _________________
Alignment: Appropriate Inappropriate
MENTAL ACUITY:
Oriented coherent appropriately responsive others: ___________
Disoriented incoherent inappropriately responsive
SENSORY/MOTOR RESTRICTIONS:
Amputation deformity paresis paralysis fracture
Gait hearing disorder speech others: ______________________
EMOTIONAL STATUS:
Euphoric Depressed Apprehensive
Angry/Hostile Others: ___________________________
MEDICALLY IMPOSED RESTRICTIONS:
CBR w/out BRP_____ BR w/ BRP_____ OOB – Chair_____ Restricted Ambulation _____
OTHER HEALTH RELATED PATTERNS:
Fatigue Restlessness Weakness Insomnia Coughing
Dyspnea Dizziness Pain Others: ______________________
ENVIRONMENT:
Room Temperature: Adequate Inadequate
 Lighting: Adequate Inadequate
SAFETY:
Violations of medical asepsis: ________________________________________________
Violations of safety measures: ________________________________________________

ACTIVITIES OF DAILY LIVING:

Can/Cannot perform
Feeding Brushing teeth Bathing Transferring
Dressing Combing Others: __________________________________

PHYSICAL EXAMINATION FINDINGS

HEAD/SKULL:

EYES/VISION:

EARS/HEARING:

NOSE, MOUTH AND THROAT:

NECK AND LYMPH NODES:

THORAX (CHEST AND LUNGS):

Anterior:

Posterior:

HEART AND CARDIOVASCULAR SYSTEM:

ABDOMEN:

NEUROLOGICAL:

MUSCULOSKELETAL:

GENITALIA:
EXTREMETIES:

(Follow IPPA format when documenting Physical Examination findings)

LIST OF IDENTIFIED NURSING PROBLEMS

PRIORITIZATION OF NURSING PROBLEM

1. Oxygenation
2. Nutrition
3. Elimination
4. Activity and Exercise
5. Comfort and Safety
6. Sexual- Reproductive
7. Psychological
8. Psychosocial

LABORATORY FINDINGS
Review of anatomy and physiology
Pathophysiology (highlight patient manifestation)
NCP

ASSESSMENT INTERVENTION
EVALUATION
CUES PROBLEM
NURSING SCIENTIFIC STATEMENT NURSING
DIAGNOSIS EXPLANATION (GOAL) INTERVENTION RATIONALE
 Drug Study

DRUG DOSAGE/
NAME/ CLASSI- STOCK ACTION INDICATION CONTRA SIDE ARVERSE NURSING
GENERIC FICATION DOSE INDICATION EFFECTS REACTION RESPONSIBILITIES
Medical Management (
Nursing Management
Discharge Planning

METHOD (Example)

M (Medications):
Lasix (Furosemide). Decreases swelling and blood pressure by increasing the amount
of urine. Expect increased frequency and volume of urine. Report irregular heartbeat,
changes in muscle strength, tremor, and muscle cramps, change in mental status,
fullness, ringing/roaring in ears. Eat foods high in potassium such as whole grains
(cereals), legumes, meat, bananas, apricots, orange juice, potatoes, and raisins. Avoid
sun/sunlamps. Take with breakfast to avoid GI upset.
Digoxin (Lanoxin). Used to treat CHF. Taking too much can result in GI disturbances,
changes in mental status and vision. Report the following signs/ symptoms to your
doctor: Nausea, vomiting, lack of appetite, fatigue, headache, depression, weakness,
drowsiness, confusion, nightmares, facial pain, personality changes, sensitivity to light,
light flashes, halos around bright objects, yellow or green color perception. Take pulse
rate for one minute before dose and call doctor if pulse is below 60 before taking
medication. Don’t increase or skip doses. Don’t take over the counter medications
without talking to MD. Report for follow-up visits with your doctor to monitor lab values.
E (Exercise/Environment):
Your eldest daughter will provide help with activities of daily living in the home. She will
transport you to followup appointments. It is important to take steps to prevent falls: use
of a 3-point cane for stability with ambulation; removing objects like throw rugs, cords
that may cause fall; pausing before standing and again before walking to prevent drop
in blood pressure. The “life line” allow you to access 911 for emergency help. You may
resume activities as tolerated and you have a follow-up appointment with the doctor in 1
week.
T (Treatments):
Apply A & D ointment to reddened coccyx and heels three times a day. Keep pressure
off of these areas by keeping off of back and elevating heels off of bed. Keep skin clean
and dry. Report any changes in skin condition to doctor. (i.e. open areas, drainage,
elevated temp.)
H (Health knowledge of disease):
Lasix can cause a loss of potassium. It is important to eat foods high in potassium and
to have regular blood levels drawn to make sure potassium level stays normal.
Monitoring the pulse rate before taking digoxin is important because this medicine can
cause the pulse to drop. Call the doctor if pulse rate is below 60 beats per minute. New
signs and symptoms should be reported to the physician, because they may indicate
electrolyte imbalance &/or digoxin toxicity. Sodium causes water retention so it is
important to limit sodium intake by eating a no added salt diet. Be careful to check
labels for hidden salt content.
O (Outpatient/inpatient referrals): (include resources such as websites and
organizations): American Heart Association www.americanheart.org Visiting Nurses’
Association for F/U skin assessment. Referral made to outpatient dietician for diet
planning. Meals on Wheels.
D: (Diet):
Do not add salt to your diet. Eat foods high in potassium such as bananas. We will
arrange for you to meet with the dietician.
Evaluation
a. Narrative evaluation of the objectives
b. Patient status after discharge

Recommendation

References/Bibliography