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                                 PLT COLLEGE, INC.
                                    Bayombong, Nueva Vizcaya
                            School of Health Sciences-College of Nursing


                                            CASE STUDY
                                              (Format)


I.        PATIENTS PROFILE

          Name: (initial only)
          Address:
          Birthday:
          Age:
          Occupation:
          Marital Status:
          Religion:
          Educational Attainment:
          Ward:
          Room:
          Chief Complaint:
          Admitting Diagnosis:
          Principal Diagnosis:
          Date/Time of Admission:
          Date/Time of Discharge:

II.       NURSING HISTORY

          A.   History of Past Illness
          B.   History of Present Illness
          C.   Socioeconomic History
          D.   Environmental History
          E.   Occupational History
          F.   Family History
          G.   Lifestyle
          H.   Recreational Activities

III.      PATTERNS OF FUNCTIONING

                                      Before              During
            Patterns               Hospitalization     Hospitalization Interpretation/Analysis
      1. Health Perception
         and Health
         Management
      2. Nutrition and
         Metabolism
      3. Elimination
      4. Activity and Exercise
      5. Cognition and
         Perception
      6. Sleep and Rest
2


      7. Self-perception Self-
          concept
      8. Role and
          Relationships
      9. Sexuality and
          Reproduction
      10. Coping and Stress
          Tolerance
      11. Values and Beliefs

 IV.       PHYSICAL ASSESSMENT

          A. General Survey

          B. Vital Signs
       Vital Signs          Normal Range         Findings        Interpretation/Analy
                                                                          sis
Pulse Rate
Respiration
Temperature
Blood Pressure
         C. Height and Weight (Compute for Body Mass Index)

          D. Cephalocaudal Assessment
         Part         Normal Findings            Findings        Interpretation/Analysis



 V.       DIAGNOSTIC EXAMINATION(S)

Diagnostic Exam            Normal Range          Findings        Interpretation/Analysis



 VI.      ANATOMY AND PHYSIOLOGY

 VII.     PATHOPHYSIOLOGY


 VIII. DRUG STUDY

Classification:
Brand Name:
Generic Name:
  Mode of           Indication     Contraindication    Side Effect       Nursing
   Action                                                               Implication



 IX.      COURSE IN THE WARD

 X.       LIST OF IDENTIFIED PROBLEMS (According to priority)
3


                                NURSING CARE PLAN
Assessment    Nursing     Analysis Goal    Nursing      Rationale     Evaluation
                Dx                       Intervention
Subjective:                                                         Efficiency:
                                                                    Yes___No___
Objective:                                                          Why_______

                                                                    Effectiveness:
                                                                    Yes___No___

                                                                    Adequacy:
                                                                    Yes___No___

                                                                    Appropriateness:
                                                                    Yes___No___


 XI.     DISCHARGE PLANNING

         Medication
         Exercise/Environment
         Treatment
         Health Teaching
         OPD Appointment
         Diet
         Spirituality/Sexuality

 XII.    ETHICO-LEGAL ISSUE(S)

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  • 1. 1 PLT COLLEGE, INC. Bayombong, Nueva Vizcaya School of Health Sciences-College of Nursing CASE STUDY (Format) I. PATIENTS PROFILE Name: (initial only) Address: Birthday: Age: Occupation: Marital Status: Religion: Educational Attainment: Ward: Room: Chief Complaint: Admitting Diagnosis: Principal Diagnosis: Date/Time of Admission: Date/Time of Discharge: II. NURSING HISTORY A. History of Past Illness B. History of Present Illness C. Socioeconomic History D. Environmental History E. Occupational History F. Family History G. Lifestyle H. Recreational Activities III. PATTERNS OF FUNCTIONING Before During Patterns Hospitalization Hospitalization Interpretation/Analysis 1. Health Perception and Health Management 2. Nutrition and Metabolism 3. Elimination 4. Activity and Exercise 5. Cognition and Perception 6. Sleep and Rest
  • 2. 2 7. Self-perception Self- concept 8. Role and Relationships 9. Sexuality and Reproduction 10. Coping and Stress Tolerance 11. Values and Beliefs IV. PHYSICAL ASSESSMENT A. General Survey B. Vital Signs Vital Signs Normal Range Findings Interpretation/Analy sis Pulse Rate Respiration Temperature Blood Pressure C. Height and Weight (Compute for Body Mass Index) D. Cephalocaudal Assessment Part Normal Findings Findings Interpretation/Analysis V. DIAGNOSTIC EXAMINATION(S) Diagnostic Exam Normal Range Findings Interpretation/Analysis VI. ANATOMY AND PHYSIOLOGY VII. PATHOPHYSIOLOGY VIII. DRUG STUDY Classification: Brand Name: Generic Name: Mode of Indication Contraindication Side Effect Nursing Action Implication IX. COURSE IN THE WARD X. LIST OF IDENTIFIED PROBLEMS (According to priority)
  • 3. 3 NURSING CARE PLAN Assessment Nursing Analysis Goal Nursing Rationale Evaluation Dx Intervention Subjective: Efficiency: Yes___No___ Objective: Why_______ Effectiveness: Yes___No___ Adequacy: Yes___No___ Appropriateness: Yes___No___ XI. DISCHARGE PLANNING Medication Exercise/Environment Treatment Health Teaching OPD Appointment Diet Spirituality/Sexuality XII. ETHICO-LEGAL ISSUE(S)