how to make a case study
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HOW TO MAKE A
CASE STUDY
ALMERIA, Krishna Rae Z., BERNARDO, Ryan Angelo, DE LOS SANTOS, Janet Alexis A.,
MENESES, Raza Crecia L., PEREZ, Ana Aumpta P., RUSSELL, Glynda
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A case presentation should only include
information that pertains to the case andrefrain from providing confusing and
superfluous data.
Daily patient progress including normal VS,
routine laboratory results, typical
consultations with other disciplines, step-
down transfer to wards, and other
irrelevant patient information MUST BE
AVOIDED.
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OUTLINEI. ABSTRACT
II. INTRODUCTION
III. COMPREHENSIVE NURSING HEALTH HISTORY
IV. PHYSICAL EXAMINATION
V. LABORATORIES & DIAGNOSTIC PROCEDURES
VI. ANATOMY & PHYSIOLOGY
VII. PATHOPHYSIOLOGY
VIII. SUMMARY OF CLINICAL FINDINGS
IX. PHARMACOLIGICAL SHEET
X. NURSING CARE PLANXI. DISCHARGE PLANNING
XII. PROGNOSIS
XIII. BIBLIOGRAPHY
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ABSTRACT
Composed of 100-250 words
Should include 4 sections as the main
text in a succinct form: Introduction and
objective, Case Presentation, discussion
and conclusion.
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INTRODUCTION
Written concise and salient and not more than 3
paragraphs and need not be labeled with a
heading. Should provide the background information that
present clarity to the subject of discussion.
The introduction should provide the subject,purpose and merit of the case report.
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Statistical records : LOCAL, NATIONAL,
INTERNATIONAL
Focused comprehensive literature review
Citations should be chronological 1-2 sentences description of the patients
case as a segway to the CASE
PRESENTATION.
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COMPREHENSIVE NURSING
HEALTH HISTORYA. Biographic Data
B. Chief Complaint
C. History of Present Illness
D. Past Medical History
E. Family History
F. Functional Health Patterns
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FUNCTIONAL HEALTH PATTERN
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1z
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PHYSICAL EXAMINATION
Cephalocaudal
Narrative
Should be written by following the
format:
IPePaA
IAPePa
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LABORATORIES and DIAGNOSTIC
EXAMS All laboratories (current and relevant)
should be presented in a tabular form.
Diagnostics:
Impression and Results
NAME OF PROCEDURE
Parameters Normal Value Patients value Interpretatio
n
Significance
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ANATOMY AND PHYSIOLOGY
Content should be concise and straight
to the point and should only focus on the
area or organ involved
An illustration or a picture should be
presented
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PATHOPHYSIOLOGYA. SCHEMA
B. NARRATIVE (explanation of the flow chart)
Definition: Gives rise to symptoms that are reported by
patients/signs that are observed by patients or
nurses or other health care providers OBSERVATION + PHYSIOLOGY +
PATHOPHYSIOLOGY
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Be able to explain processes in their own words
and translate these processes into technicalvocabulary
Explain by drawing processes, perhaps by flow
charts or map format. Label key steps and usecolors to emphasize main points
Ask yourself why? and whats the
consequence?
Relate what youre learning to what you
ALREADY know about physiology
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SUMMARY OF CLINICAL FINDINGS
AND MANIFESTATIONS A table of summary of clinical findings and
manifestations should be written after thenarrative pathophysiology.
Both POSSIBLE and ACTUAL MANIFESTATIONS
are recorded provided that the former isemphasized/highlighted or otherwise
written in two columns
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PHARMACOLOGICAL SHEET
Should be patient focused.
All medications of the patient should be
written in a pharmacological sheet HEADERs should be written on each page of
the pharmacological sheet:
a. Name of Patient c. Attending Physicianb. Age and Sex d. Chief complaint
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NURSING CARE PLAN
Is best thought of as a written reflection
of the nursing process. (Gulanick/Myers)
Is a written or computerized guide that
organizes information about the clients
care. (Kozier)
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DISCHARGE PLANNING
A. For patients with non complicated disease andno surgeries in the ward and private areas:
M
edications
E xcercise
T reatment and Visits
H ealth teachings /Hygeine O bservable signs and symptoms
D iet
S piritual / Support System
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B. For patients who are post operative:
H ealth teachings
A anticipatory Guidance
S piritual Care M edications
I ncision or wound care
N utrition E nvironment
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C. For patients with post delivery and post CS
B reast
U terus
B ladder
B owel
L ochia
E pisiotomy
S upport system / Spiritual
H omans sign
E motional
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PROGNOSIS
May be written according to the students
interpretation of the patients case
If there are prognosis written by the
health team, it is encouraged to include
it as an input.
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BIBLIOGRAPHY
Family name, name of author, TITLE OF
REFERENCE. Publisher. Year published.
Alphabetically arranged and categorized
according to:
a. Booksb. Journal
c. Websites
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