St.

John Colleges
Chipeco Ave., Calamba City

Case Study Format

I. Biographic Data
Name:
Address:
Age: Gender: Religious Affiliation:
Marital Status: Occupation:
Room and Bed #:
Chief Complaint:
Provisional Diagnosis:
Attending Physician:

II. Nursing History

A. Past Health History
1. Childhood Illness
2. Immunizations
3. Allergies
4. Accidents
5. Hospitalizations
6. Medications used or currently taken
7. Foreign travel (when, length of stay)
B. History of Present Illness
C. Family History
D. Obstetric History (for OB cases only)
E. Development History (for pediatrics cases only)

III. Patterns of Functioning

A. Psychological Health
1. Coping Patterns
2. Interaction Patterns
3. Cognitive Patterns
4. Self-Concept
5. Emotional Patterns
6. Sexuality
7. Family Coping Patterns
Interpretation:
Analysis:

B. Socio-Cultural Patterns
1. Cultural Patterns
2. Significant Relationships
3. Recreation Patterns
4. Environment
5. Economic
Interpretation:
Analysis:

C. Spiritual Patterns
1. Religious Beliefs and Practices
2. Values and Valuing
2
 Interpretation:
Analysis:

IV. Activities of Daily Living

ADL Before During Interpretation and

Hospitalization Hospitalization Analysis
1. Nutrition
2. Elimination
3. Exercise
4. Hygiene
5. Substance Use
6. Sleep and Rest
7. Sexual Activity

V. Physical Assessment

Norms Actual Findings Interpretation and

Analysis
General Appearance
1. Posture/Gait
2. Skin Color
3. Personal Hygiene/
Grooming
4. Nutritional Status
5. Age Appropriateness
6. Verbal Behavior
7. Non-Verbal Behavior
Measurements
1. Temperature
2. Pulse Rate
3. Respiratory Rate
4. Blood Pressure
5. Weight
6. Height

Body Part Norms Actual Findings Interpretation and

(Technique Used) Analysis

VI. Laboratory and Diagnostic Examinations Results

Date Procedure Norms Result Interpretation and Analysis

VII. Medications, IV Infusions, Blood Transfusions, Treatments Given

Generic/ Dosage/ Classification Indication Contraindication Side Nsg

Trade Name Frequency Effects Responsibilities

Treatment/ Infusion Classification Indication Contraindication Nsg Responsibilities

2
VIII. Anatomy and Physiology
IX. Pathophysiology
X. Ecologic Model
A. Hypothesis
B. Predisposing Factors
1. Host 2. Agent 3. Environment
a. Age a. Mechanical a. Physical
b. Sex b. Physical b. Biologic
c. Race c. Chemical c. Socio-economic
d. Nationality
e. Behavior
f. Customs
g. Heredity
C. Ecologic Model
1. Lever
2. Wheel
3. Web
4. Triangle
D. Analysis (with reference)
E. Conclusions and Recommendations

XI. Prioritized List of Nursing Problems

Date Nursing Problems Cues Justification

Identified

XII. Nursing Care Plan

Nursing Analysis Goal/ Nursing Rationale Evaluation

Problem Objectives Interventions
Cues
NANDA Scientific Effectiveness
Implication SMART Supplemental (With Efficiency
Subj. Immediate Reference) Adequacy
Cause: Developmental Appropriateness
Intermediate Acceptability
Cause:
Obj. Root Cause: Facilitative

Discharge Plan
(to be submitted by students whose patients are for discharge)

M - Medications to take at home

E - Exercise

T - Treatments

H - Health Teachings

O - Out patient follow up

D - Diet

S - Sexual Activity (optional)

2
 Case Study Output Format

I. Introduction
II. Objectives
III. Biographic Data
IV. Nursing History
V. Patterns of Functioning
VI. Activities of Daily Living
VII. Physical Assessment
VIII. Laboratory and Diagnostic Examinations Results
IX. Medications, IV Infusions, Blood Transfusions, Treatments Given
X. Anatomy and Physiology
XI. Pathophysiology
XII. Ecologic Model
XIII. Prioritized List of Nursing Problems
XIV. Nursing Care Plan
XV. Conclusion/Recommendation