Guidelines for Designing a Case Study

This document presents the guidelines to be used as basis for the format and content in
designing a case study. This format can be used across adult male and female medical and surgical
cases.

Part I. Technicalities
1. Font style: Times New Roman
2. Font size: 12 (This can be reduced to 11 or 10 when presenting tables, graphs, and/or schema.)
3. Paper Size: A4
4. Margin: 1” in all sides
5. Spacing: 1.5
6. Chapter headings are written in highlighted letters using upper- and lower-case letters. An
illustration is shown below.
Chapter 1
Introduction

Chapter 2
Patient’s Profile

Part II. Chapter Content

1. Objectives of the present case study:
General
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Specific
*must reflect the three domains: cognitive, affective, and psychomotor
Cognitive
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 Affective
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Psychomotor
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2. Introduction
*This chapter discusses the disease or disorder in general not specific to the patient yet.
*The narrative shall include prevalence rate, other epidemiologic findings, and
recent breakthroughs about its management.
*Maximum of two pages only
3. Patient’s Profile
*This section includes the following information: patient’s initials, age, biologic sex,
date of birth, place of birth, birth order, civil status, address, religion, educational
attainment, occupation, food, drug, & cosmetic allergies, and working or final
diagnosis
*This section is written in narrative or textual format. Outline or bullets are not allowed.
4. Patient’s History
This section is composed of four components, namely:
4.1 Hx of present illness (data prior to admission to include chief complaints,
meds/herbs taken prior to admission)
4.2 Past health hx (medical, surgical, dental, ob/gyne, maintenance meds taken)
4.3 Family health hx (to include genogram starting from the immediate
grandparents)
4.4 Environmental hx (place of residence from childhood until present)

5. Developmental task
*The student is required to use, apply, and discuss the Psychosocial Development
Theory of Erik Erikson based on the patient’s age category.
*The student is expected to make an expository discussion if the developmental task
was resolved (achieved) or not.
6. Health assessment
*The data in this chapter is extracted using Marjorie Gordon’s Functional Health Patterns
*A nursing diagnosis is required for each health pattern.
7. Physical examination

*The Review of Systems is done using IPPA from head to foot.

*The student is advised to use the school format.
*Deviations from the normal findings are written or typed in red.
8. Laboratory and dx studies
*The results are displayed using the template table below and in the next page. Both the
patient’s results and reference values are written so that the student can discuss the
clinical significance of the variations.
*The reference values written in the case study should be the one used by the hospital
laboratory or diagnostic center. The column for interpretation and significance has to be
filled by the student.
*This section is presented in table format as shown in the sample below.
Table 1. Complete Blood Count
Component Patient’s Results Reference Values Interpretation Significance
RBCs 5.5 million/mm3 4.5-5.5 million/mm3 normal This is a normal or
expected finding in
adult males. A typical
adult human has
approximately 4.3-5.9
million/mm3 accdg to
some authors.

Reference:
Dean L. (2005). Blood
Groups and Red Cell
Antigens [Internet].
Bethesda (MD): National
Center for Biotechnology
Information (US);. Table
1, Complete blood count.
Accessed from:
[Link]

WBCs 12,000/mm3 4,000-11,000/mm3 high This indicates a bacterial

infection or
inflammation.

Reference:
Mank V, Brown K.
(2022). Leukocytosis.
In: StatPearls [Internet].
Treasure Island (FL):
StatPearls Publishing;
2022 Jan-. Accessed
from:
[Link]

Table 2. Ultrasound, MRI, CT Scan, Doppler, ECG tracing, EEG tracing, etc
Conclusion:

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Significance:
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(Note: In this part of the case study, the student is expected to discuss how the findings affect or alter the
normal physiology of the human body.)
9. Summary of significant findings
*This section summarizes the findings observed during Health Assessment and
Physical Assessment which are found in Chapters 6 and 7.
*The nursing problems presented in this section must already be prioritized by the
student because this is the basis in formulating the nursing care plans found in
Chapter 11.
*The prioritization must be based on airway, breathing, circulation, disability, and
exposure (ABCDE). In other words, the arrangement is from the most life-
threatening or limb-threatening to the least life-threatening or limb-threatening
nursing problems.
*Nursing diagnosis is based on internationally accepted standards (e.g. North American
Nursing Diagnosis Association or NANDA) with the related factor and/or secondary factors.
*A secondary factor is not always necessary.
*A sample table is shown in the next page.
Table 3. Summary of Significant Findings
Objective or Subjective Actual Risk or Potential Nsg Wellness Nsg
Findings Nsg Diagnosis Diagnosis Diagnosis
Subjective: Hyperthermia related to
“Init kaayo akong lawas systemic release of
Mam/Sir.” pyrogens secondary to
inflammatory disease
process

Objective:
 temp. 38.50C
 skin warm to the
touch
 dry parched lips
 shivering

Subjective: Acute pain related to

“Nag sakit akong tiyan.” distension of intestinal
tissues by inflammation
Reports a pain scale of 9/10 secondary to obstructed
vermiform appendix
Objective:
facial grimace noted
muscle guarding in the
abdomen
restless
moaning and crying
irritable
sweating profusely

10. Anatomy & Physiology of the organ or system involved.

*The student is expected to have mastered the structure (anatomy) and function
(physiology) of the affected organ or system.

11. Pathophysiology of present illness

*This section is presented using the schematic diagram as shown in the next page.
*The schema should start with the:
Etiologic Factors (Host, Environment, Agent),
Risk Factors (Modifiable or Non-modifiable)
Precipitating Factors (a specific event or factor that triggers the onset of the
current illness, disease, accident, or behavioral response e.g. life
events, temperament, genetics, conflicts in relationships or identity)
 *The succeeding entries in the schema should show the abnormal or adaptive changes
which reflect the body’s response to the disease process
*The last part of the schema must illustrate the clinical manifestations (S/Sx) and
highlight the ones which are manifested by the patient.
*A sample is shown below.

Template for presenting the pathophysiology:

Risk Factors Etiologic Factors Precipitating Factors

initial or early changes inside the body

further changes inside the body

signs and symptoms

fever body malaise nausea vomiting

seizures dry skin headache loss of appetite

complications

12. Nursing Care Plans

*A little introduction should include the nursing theory applicable to the patient’s condition.
*The nursing diagnoses are lifted from Chapter 8 which shows the summary of
findings.
*The column for the scientific basis must have at least one reference.
*The column for the nursing interventions must have at least two references.
*Must classify interventions as to:
12.1 Independent
12.2 Dependent
12.3 Collaborative
*A sample is shown in the next page.
 Chapter 12
Nursing Care Plan
Nursing theorist: Dorothea E. Orem
Theory: Self-Care Deficit Theory
Patient-Care Classification:  Wholly Compensatory
 Partially Compensatory
 Supportive-Educative

Data Nursing Scientific Basis Objective/s of Intervention Rationale Evaluation

Diagnosis Care
Subjective: Knowledge Definition of nursing Use the SMART Independent: Actual:
“Init kaayo deficit diagnosis approach.
akong lawas Hyperthermia is an
Mam/Sir.” Hyperthermi abnormally high body The “time”
a related to temperature due to element depends The objective of
systemic failed on the acuity or care was:
Objective: release of thermoregulation. severity of the  resolved
 temp. pyrogens Hyperthermia occurs patient’s Dependent:  partially-
38.50C secondary to when your body condition. resolved
 skin warm inflammatory absorbs or generates  not resolved
to the disease more heat than it can Health teachings
touch process release. will require at
 dry parched least 45 minutes
lips Pathophysiologic and maximum of
 shivering basis 60 minutes. Collaborative:
Appendicitis, which is (Interdependent)
Labs: an inflammation of the
WBC count of appendix, usually
12 causes fever between
million/mm3 99°F (37.2°C) and References:
100.5°F (38°C). You (may have at least
may also have the two references
chills. If the appendix using the APA 7th
burstsm , the resulting Edition)
infection could cause
fever to rise. A fever
greater than 101°F
(38.3°C) and
tachycardia may mean
that the appendix has
ruptured.

Rationale
Fever occurs when the
body produces and/or
absorbs more heat than
it can dissipate.

References:
(may have 1 or more
references using the
APA 7th Edition)
13. Drug Study
*This section shall include all current medications prescribed (in case where the patient
has less than 3 medications, the CI must decide which drugs to include to meet desired
learning outcomes). This means that only medications encountered during the first
exposure to the area until the end of the exposure will be included in the study. Drugs which
were previously discontinued before the tour of duty are excluded.
*Attach the medication ticket for this drug (back and front). Only the patient’s initial
shall be written on the ticket without the hospital number. The student shall affix
his/her name an signature at the back of the ticket.
*The entries inside the ticket must reflect the format and style of CCMC.
*Use the template shown below for all students regardless of area of assignment or
year level.

Template for the drug study

Drug, Classification Mechanism Specific Effects Contraindications Nursing
Dosage, of Action Indication and Drug-to- Responsibilities
Frequency, Drug Interactions
and Route
Date Pharmacological: Side Effects: Before:
ordered: Antibacterial (at least 5)

Generic:
ciprofloxacin During:
Adverse (at least 5)
Trade name: Functional: Effects:
Ciprobay Flouroquinolone

Dosage: After:
(at least 5)

Frequency:

Route:

References: References: References: References:

(must have (must have at (must have at least (must have at least
at least one least one one reference) two references)
reference) reference)
14. Discharge Plan
*The student is expected to use the METHODS approach
Medications
Environment, Exercise and Activity
Treatment
Health Teachings
Observable S/Sx or Out Patient Visit
Diet
Spiritual Care
*A sample of a basic discharge plan is given below.

Introduction
A case of XYZ, 28 years old, male, single, Filipino, Roman Catholic was admitted on
January 28, 2023 for complaints of fever, rashes, and photophobia with the final diagnoses of
Systemic Lupus Erythematosus and hypokalemia. He decided to go home against medical advice as
of January 31, 2023.
Data
Subjective data: “Mo uli nalang mi kay dili nami ka-afford sa gasto sa ospital.”, as
verbalized.
Objective data: seen packing things
signed HAMA form
received directions from physician
Nursing Diagnosis
Noncompliance related to inability to pay cost of hospital stay
Planning
After 30-45 minutes of health teaching, the patient will be able to enumerate activities that
will enhance his independence in the performance of his ADL’s with safety and infection
precautions.
Interventions
M 1. Emphasized to patient the importance of adhering to the prescribed therapeutic regimen.
 2. Enumerated accepted herbal medicine that could possibly serve as alternatives to prescribed
drugs
E 1. Advised patient to gradually resume to usual activities as tolerated.
2. Advised to schedule periods of uninterrupted rest especially at bedtime.
T 1. Taught methods to alleviate pain such as warm compresses and topical liniments.
H 1. Instructed patient to minimize contact with individuals with respiratory tract infections and
other communicable diseases.
2. Encouraged patient and SO to always maintain a clean and safe environment.
O 1. Informed the patient to seek help from physician if symptoms exacerbate.
2. Referred patient to social services and support groups that could assist them financially and
psychologically.
D 1. Encouraged a high protein diet.
2. Advised patient not to skip meals.
3. Help him identify food rich in potassium, vitamins, and minerals.
S 1. Motivated the patient to remain hopeful amidst his trials.
2. Encouraged the patient to remain steadfast in his faith.

Evaluation
Goal was met. “Muadto lang unya mi sa social worker, basig makatabang pa nanamo.”, as
verbalized.