CASE STUDY FORMAT - KSU
CASE STUDY FORMAT INTRODUCTIONPatient unit Patient Profile Patient’s name ( Initial only)AgeGenderEducational attainmentChief complaintAdmitting DiagnosisDate of AdmissionHow many day from admissionBrief Statement of your client’s caseRationale for choosing the case ASSESSMENT ( Narrative)General Survey History of Present Illness ( reason for admission)Client’s personal and Family History Past Health History ( Diet, Lifestyle, Psychosocial, Immunizations, Previous Illness, Allergy, Nutritional Assessment )Physical Assessment ( Head to Toe, per system)*Body PartNormal FindingsPatient FindingsSignificanceSkin Head, Eyes , Ears , NoseRespiratoryCardiovascularGastrointestinalUrinaryMusculo skeletal Nervous System Anatomy And Physiology of the Affected Organ or SystemPathophysiology / Etiology of the Disease (Narrative as well as Diagram)Laboratory/ Diagnostic Tests*Laboratory Tests/ Diagnostic TestsNormal RangePatient Findings/ ResultSignificance IMPLEMENTATIONComprehensive Nursing Process *Nursing Diagnosis Goal/ PlanningInterventionRationaleExpected Outcome/ Evaluation Discussion of Treatment Modalities (Cite Medical or Surgical Interventions done) * ProcedureCite Patient Based IndicationPatient PreparationFrequency / Schedule Of TreatmentNursing responsibilityEvaluationExample:Tracheostomy CareSuctioningOxygenationWound DressingIV TherapySpecify Other procedure MV/CVC/CVP /urine catheter /NGT …… etcDrug Study / Pharmacology *DrugClassification, Mechanism of ActionIndication,ContraindicationSide EffectNursing ResponsibilityName of Drug , Dosage, Frequency, Route of AdministrationDISCHARGE PLANDiscuss according to the following aspects:MedicationsExerciseTreatmentHygieneOccupationDietSpiritual, Social Aspect* Please Follow Table Format ................
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