Nursing Case Analysis Format

In a short white bond paper and submit in a slide folder (Blue or Green)
I. Assessment:
 Demographic profile
 History – Medical, past, present and Nursing History
 PCR format on assessment
 Significant Laboratory and Diagnostic Examinations with corresponding
Inferences and elaborate
 Nurses Notes ( Significant)
II. Anatomy and Physiology
 Include pictures and organs affected
III. PAthophysiology
 In a flow chart format
 Highlight signs and symptoms present in your Client
IV. Discussion of the OR Procedure
 Rationale for the surgery
 Include Pictures relevant to the surgery
 Significant Discussion of the Surgery Performed
 Positive and negative aspects related to the surgery
 Other related Surgery if Applicable ( Ex. Differentiate Open Chole from
Lap Chole)
 OR technique with significant discussion
V. Drug Analysis
 Include generic and specific brand name used
 Include Medications given pre, intra and post operatively
 Indicate the mechanism of action
 Reason or rationale for giving the medication specific to the condition of
the client
 Relevant and significant nursing care or measures
VI. Nursing Care Plans
 Prioritize your problem
 With actual cues and clues identified. ( NO assumptions)
 Make at least 2 pre op diagnosis, 3 intra op and 2 post op
 Objectives must be SMART ( Specific, Measurable, Attainable, Realistic
and Time bound)
 Prioritize interventions, Do not limit the number of Interventions but write
those applicable only in our setting
VII. References:
 Books
 Journals
 Internet web sites