MANILA TYTANA COLLEGES

Manila Doctors College of Nursing

Case Study Template
I. Case Abstract
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II. Nursing Health History
a. Biographic Data
Patients Initial:

Gender

Age

Educational Attainment

Occupation

Date of Admission:

No. of days in hospital

Date of Birth
Place of Birth

Order of Admission

Source of Information

b. Chief Complaint(s)
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c. History of Present Illness
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d. History of Past Illnesses*
Childhood illness(es)
Childhood/adult immunization(s)
Accidents and Injuries
Previous hospitalization/surgery
Medication prior to confinement
* Can add narrative statements under the table if deemed necessary.

e. Family History
General Family Information:
Name

Relation

Age

Gender

Educational
Attainment

Occupation

Diseases/Disorder

* Can add narrative statements under the table if deemed necessary.

Heredo-familial illnesses (use genogram and then explain the graph - one to two paragraphs): Please see attached for
legend
f. Developmental History
Theory
Age
Psychosexual
Psychosocial

Developmental Task

Client Description

Interpretation

Cognitive
Moral
Spiritual
g. Environmental History
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h. OB/Gyne History (If applicable)
Menarche Age:

Amount

Duration

Associated Symptom

Obstetric History
Complications:

Characteristic

Type of Delivery:

Exposure to Teratogenic Agents:

III. Gordons Typology of 11 Functional Health Pattern

a. Health Perception/Health Management Pattern
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Analysis:
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Interpretation:
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b. Nutritional/Metabolic Pattern
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Analysis:
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Interpretation:
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c. Elimination Pattern

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Analysis:
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Interpretation:
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d. Activity-Exercise Pattern
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Analysis:
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Interpretation:
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e. Sleep-Rest Pattern
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Analysis:
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Interpretation:
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f. Cognitive-Perceptual Pattern
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Analysis:
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Interpretation:
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g. Self-perception/Self-concept Pattern
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Analysis:
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Interpretation:
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h. Role-relationship Pattern
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Analysis:
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Interpretation:
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i. Sexuality-reproductive Pattern
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Analysis:
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Interpretation:
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j. Coping-stress Tolerance Pattern
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Analysis:
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Interpretation:
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k. Value-belief Pattern
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Analysis:
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Interpretation:
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IV. Physical Assessment

a. General Survey:
Body Built

Grooming/Hygiene

Signs of Distress:
Orientation:
Time____ Person_____
Quantity & Quality of Speech

Posture & Gait

Body Odor and Breath Odor

Obvious Signs of Illness(es)

Level of Consciousness:

Affect:

Place_____
Organization of thoughts

b. Anthropometric Measurement*
Height

Weight

IBW/BMI

* You may provide additional measurements (i.e. tricep skin fold, abdominal girth, etc.)

Mood:

For neonates:
Head Circumference

Chest Circumference

Abdominal Circumference

c. Vital Signs
Temperature

Pulse Rate

Respiratory Rate

Blood Pressure

d. Physical Examination
Body Part

Normal Findings

Actual Findings

Analysis & Interpretation

Skin
Hair
Nails
Head & Face
Eyes
Ears
Nose
Mouth & Pharynx
Neck
Spine
Thorax/Lungs
Cardiovascular/Heart
Breast & Axilla
(Optional)
Abdomen
Musculoskeletal
Genitals
(Optional)
Rectum and Anus
(Optional)

e. Neurologic Status
I
II

Cranial Nerves
IX
X

III,IV,VI

Reflexes*
Biceps Reflex

Touch

Sensory Function

Triceps Reflex

Pain

Brachioradialis Reflex

Temperature

XI

Patellar Reflex

Position

VII

XII

Achilles Reflex

Tactile Discrimination

VIII

Plantar/Babinski Reflex

* Scoring (+1, +2)

V. Anatomy and Physiology

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VI. Pathophysiology/Psychopathology (for NCM, RLE 105)

VII. Laboratory Results
Laboratory and Date

Normal Values

Result

Analysis & Interpretation

VIII. Drug Study

Drugs

Indication

Action

Brand Name:
Generic Name:
Classification:
Dose:
Route:
Preparation
Frequency:
Date Ordered:

(General)

(Client-based)

Side Effect(s) &

Adverse Effect(s)

Nursing Considerations/
Health Teachings
Based from the side
effect(s), adverse
effect(s) and clients
condition

IX. List of Prioritized problems (for NCM/RLE 101)

Cues

Nursing Diagnosis

Rank

Justification

X. Nursing Care Plan/Care Map/Peg

For NCM/RLE 101 only
Cues

Nursing Diagnosis

Rationale

For NCM & RLE 102, 103, 104, 105

Care Map*

* Connect one data from one another using line using standard color pens.

For NCM & RLE 106, 107,

Goals &
Objectives

Interventions

Rationale

Evaluation

Peg Nursing Care Plan

* Connect one data from one another using line using standard color pens

XI. Evidence-based Nursing (for NCM & RLE 103 & onwards)
Present Practice

Evidence-based Nursing

Recommendations to Present Practice

Reference:

XII. Ongoing Appraisal

Date

Progress Notes

Diagnostic Procedures

Medications

XIII. Health Teaching Plan

Topic:
Goal:
Time Allotment:
Learning Objectives

XIV. Discharge Plan

Medication

Exercise

Treatment

Health Education

Learning Content

Methodology

Resources

Method of Evaluation

OPD Follow-up

Diet

Spiritual