COLLEGE OF HEALTH SCIENCES
Related Learning Experience
CASE ANALYSIS FORMAT
(Individual)
Group: Date:
Year Level:
Name of Healthcare Facility: Unit/Ward:
Course Code and Title: Score:
A. Introduction/Overview of the case: (3 points)
• How do you present the case scenario including patient’s profile
• Admitting diagnosis
Patient information: (Do not use any real names – Data Privacy Act)
Name: Age: Gender:
Room/Bed number: Attending Physician/Surgeon:
Chief complaints:
Diagnosis:
B. Client’s Health History (3 points)
• History of Past and present illness including management and medication
• Social History, Family History
Vital Signs:
Known Allergies:
C. Pathophysiology (may use concept mapping/diagram) (20 points)
➢ Provide a brief overview of the disease
• Risk factors
• Pathophysiology
• Causes
• Clinical manifestations
• Genetic predispositions
• Expected outcomes
• Nursing interventions
D. The Nursing Process (10 points)
I. Assessment (7 pts)
a. Physical Assessment (Head to Toe assessment performed by the nurse)
• Based on the scenario given, what should you assess physically?
b. Diagnostic Procedures/Laboratory Tests (3 pts)
Name of the Date Ordered Normal Values Results Interpretation
Procedure/Tests and Analysis
II. Planning and Implementation (30 points)
a. Nursing Care Plan (in order of priority) one only (20 pts)
Assessment/ Nursing Outcomes* Implementation Rationale Evaluation
Data Diagnosis
* Outcomes should include STG and LTG and should be SMART
b. Drug Study (5 pts)
Drug/ Dose, Route Mechanism Side Nursing Responsibilities
Classification and of action Effects
Frequency of
administration
c. Communication (ISBAR) – if you are going to refer your patient to a facility or to another unit or
health care professional, how do you communicate using ISBAR? (5 pts)
Identify
Situation
Background
Assessment
Recommendations
III. Evaluation (2 points)
a. Health Promotion/Discharge Plan
• Collaborative approach to follow-up care/home care to ensure continuity of care
• Includes referrals to local health units, involvement of physiotherapist, specialist nurses and
other members of the multi-disciplinary team
E. Reflective Journal (5 points)
• Provide a journal/study related to the situation
• Must be taken from authentic sources of not more than 5 years old
• Provide a reflection that includes your opinion on what the author is trying to say. Do not
repeat or copy/paste the statements from the articles. All reflections will be AI checked with
corresponding deductions for those who used AI (150-200 words only)
F. References (2 points)
• Not more than 5 years old
• Use APA 7 format
