NURSING CASE STUDY FORMAT

     

ACKNOWLEDGEMENT

Myself _________ student of ___________ in __________ College of Nursing. During my ____________ clinical experience, I came to know about many new things and procedure. During this period, in the ________ward, I make a case study on a patient __________, who is suffering from ________. I am very thankful of my teachers and the ward sisters who help me for the completion of my case study.

INTRODUCTION

Myself _______ student of ________ in _______ College of Nursing. During my ________ Clinical Experience, I got a chance to give care to the patient _________ in ________. Through this case study, I explained about the definition, etiology, clinical manifestations, investigations, medical and nursing management of the disease condition.

                                                  

Patient’s profile

1.      Identification Data:

Client name:

Age/sex:

Father/spouse name:

Hospital registration number:

Ward:

Bed No.:

Address:

Education:

Occupation:

Marital status:

Religion:

Date of admission:

Date of discharge:

Diagnosis:

Surgery (if any):

Date of Surgery:

Doctor In-charge:  

2.      History of Illness:

• Chief complaints: for e.g. complaints of dyspnoea, low blood pressure and cold and clammy skin.
• Present medical history: for e.g.  complaints of backache, low blood pressure, fever, etc.
• Present surgical history: any history of surgical procedure.
• Past medical history: history of any hypertension, Diabetes mellitus, asthma, COPD or other disease.                                                          
• Past surgical history: history of any surgery in the past.

Family History:

S. No.	Name of family members	Age/sex	Occupation	Relation to family member	Health status	Education

Family Tree:

Personal History:      

·         Dietary habits: vegetarian/ non vegetarian.

·         Addiction: history of smoking, drug addiction, alcohol consumption, etc.

·         Socio-economic status:

Lab investigations:

Name of test	Normal value	Patient value	Remarks

Vital Signs:

S. No.	Vital signs	Normal value	Patient’s value	Remarks

Medications: trade name, pharmacological name, action, route, dose. frequency.

Physical Examination

General Appearance:

·         Body build:

·         Height:

·         Weight:

·         Vital signs: Temperature:

                    Pulse:

                    Respiration:

                    B.P:

·         Colour of skin:

Head:

·         Shape and size of skull:

·         Scalp:

·         Face:

Eyes:

·         Vision:

·         Eye brow and eyelid:

·         Eye ball:

·         Conjunctiva:

·         Sclera:

·         Cornea and iris:

·         Pupil:

·         Lens:

Ear:

·         External ear:

·         Tympanic membrane:

·         Hearing problem:

Nose:

·         External nares:

·         Nostrils:

Mouth and pharynx:

·         Mouth:

·         Teeth:

·         Tongue:

·         Throat and pharynx:

Neck:

·         Thyroid gland:

·         Lymph node:

·         Range of motion:

Chest:

·         Breath sounds:

·         Lungs:

·         Heart:

Abdomen:

·         Inspection:

·         Auscultation:

·         Palpation:

·         Percussion:

Extremities:

·         Upper:

·         Lower:

Back: assess redness, bed sores, etc.

Genital and rectum:

Systematic examination:

·         Central nervous system:

·         Sensory system:

·         Respiratory system:

·         Cardiovascular system:

·         Gastro intestinal system:

·         Musculoskeletal system:

·         Genitourinary system:

·         Integumentary system:

ANATOMY AND PHYSIOLOGY: (for e.g. heart)

DISEASE CONDITION: (for e.g.- Aortic stenosis)

Definition:

Etiology:

Pathophysiology:

Clinical Manifestations:

Book Picture	Patient Picture
For e.g. Dizziness, fainting	Present

Diagnostic Tests:

Book Picture	Patient Picture
For e.g. CBC	Done

Management:

Medical Management:

Book Picture	Patient Picture
For e.g. Antibiotics	Given i.e. vancomycin

Surgical Management:

Book Picture	Patient Picture
For e.g. Valve replacement	Not done

Complications:

Nursing Process:

Day 1

S. No.	Needs	Problems

Nursing diagnosis:      

Nursing care plan:

Assessment	Nursing diagnosis	Goals	Interventions	Implementations	Rationale	Evaluation

                                                          Nursing Process:

                                                                   Day 2

S. No.	Needs	Problems

Nursing diagnosis:

Nursing care plan:

Assessment	Nursing diagnosis	Goals	Interventions	Implementations	Rationale	Evaluation

                                                          Nursing Process:

                                                                  Day 3       

S. No.	Needs	Problems

Nursing diagnosis:

Nursing care plan:

Assessment	Nursing diagnosis	Goals	Interventions	Implementations	Rationale	Evaluation

Theory application:      

Roy’s Adaptation-

In this model the person is viewed as an adaptive system; nursing intervention is needed when there is a deficit between the adaptation level and environment demands. The major concepts are-

·         Regulator

·         Cognator

·         Adaptive

Adaptation is the process of coping with external and internal stimuli. It is determined by the effects of three classes of stimuli- focal, contextual and residual.

Health education:

Discharge plan:   

 

Summary:

Bibliography: