Case Study Instructions, Guidelines & Format Note: this is not the overall format or guide for the

case study on all levels this is just what I want for my own student and this should be based on the nursing care audit guidelines. Output paper Typing and Printing Margin = 1 at the top and bottom, 1.5 on the left, and .5 on the right side. This is applicable for portrait only except tables for nursing care management or care plan. For tables, if landscape 1.5 at the top and .5 on the other 3 sides. Indention = Indent the first line of a paragraph (TAB) and justify the paragraph. Bring all subsequent lines to the right margin. Font and Font size = All text should be encoded using Century Gothic. Font size must be 11, even when bold. Highlight in bold every heading or title of the topic. Cover page = refer to page 4. After cover page= Provide introduction of the case. Definition and description even photographs and including current events. For patients profile: Name: Age: Sex: Status: Address: Name of Hospital: Date of Admission: Ward and Bed #: Case: Chief Complaints: Medical Diagnosis:

Gordons functional health pattern: Must be in a table format. During Hospitalization

Before hospitalization Physical assessment: Table format.

Gordons FHP

P.E. During admission Date: Laboratory and Diagnostic studies:

Organ/system

P.E. Start of care Date: IPPA IPPA

Table format depends on the number and types of laboratory examination done. This can be in portrait or landscape format.

Laboratory Examination

Normal Values

Date 1st

Date 2nd

Interpretatio n

Complete Blood Count WBC Hemoglobin 140-180g/L Hematocrit MCV MCH RBC Diagnostic procedure 1. Ultrasound 2. CT-Scan 3. Chest X-Ray Date

120

125

Interpretation/Conclusion

Note: make a different table for other types of laboratory examination and or diagnostic procedures done also Medical or Surgical management given.

Medical and Surgical Management Medical Procedure 1. Nasogastric tube insertion 2. Catheterization Surgical Procedure 1. Cystoscopy 2. Lithotripsy 3. Pyelolithotomy Summary of Significant findings: Note: Landscape format is more applicable to utilize the space/page properly. List all found significant on each appropriate table.
Gordons Functional Health Pattern Subjective Data Health Assessment or Physical Examination Objective Data Laboratory and Diagnostic Studies Laboratory Findings Therapeutic Management Medical and Surgical Management Nursing Care Management Nursing Diagnoses or Nursing Problems

Purpose/Rationale

Pre-op & post-op Diagnosis

Pathophysiology = Landscape or portrait can be utilized. Include or connect the sign and symptoms and include the medical surgical management. Utilized your significant finding to help you come up with a good chart. Follow

Host

Agent

Environment

Nursing Care Management = best presented in a table format. Please follow the margin for table format stated above. The best and right way to come up with a nursing problem is to use the summary significant findings.

UNIVERSITY OF SOUTHERN PHILIPPINES FOUNDATION Salinas Drive, Lahug, Cebu City COLLEGE OF NURSING

Care of a Client With Diagnosis

A Nursing Care Audit Presented to the Faculty of the College of Nursing

Aldave, Dave Axel Aldemita, Nikko James Caballero, Charles Ciano, Christian Paul Jalang, Leizel Labro, Alyssa Jem

Ranilo A. Sabellano R.N., M.A.N. Clinical Instructor March 2012