Al-Zaytoonah University of Jordan ‫جـامعـة الـزيتـونــــة األردنيــة‬

Faculty of Nursing ‫كلية التمريض‬

QF03/0606-3.0 E Nursing Case Study Form/ Adult Nursing- Practice Course / Faculty of Nursing

Nursing Case Study Form

Student's Name Title of the Course Adult Nursing 2- practice

Student's ID. Number Year and Semester 2023-2024/1st semester
Area of Training Date of Submission
Teacher's Name M. Bayan AL-Washsh
Total score according to scoring system (10/10)

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 Al-Zaytoonah University of Jordan ‫جـامعـة الـزيتـونــــة األردنيــة‬
Faculty of Nursing ‫كلية التمريض‬

QF03/0606-3.0 E Nursing Case Study Form/ Adult Nursing- Practice Course / Faculty of Nursing

Nursing History (Total score: /10)

(score: /1)

Client's profile
S M W D
Client's name: age: gender: occupation marital status

Level of education: address: religion Medical Diagnosis

Communication Problems_____________________ Physical limitations __________________ Diet___________________

Allergy __________________ Date of Surgery __________________

(score: /1)

Admission data: date: , transferred from , client's condition.

Accompanied by client is ambulating or on, wheelchair, stretcher

(score: /2)

Chief complaints ( reason for seeking medical advice):

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 Al-Zaytoonah University of Jordan ‫جـامعـة الـزيتـونــــة األردنيــة‬
Faculty of Nursing ‫كلية التمريض‬

QF03/0606-3.0 E Nursing Case Study Form/ Adult Nursing- Practice Course / Faculty of Nursing

(score: /2)

History of the present illness: signs and symptoms during student's assessment:

Location onset duration intensity on pain scale

frequency description precipitating factors

Relieving factors associated symptoms .

(score: /1)

Other Present illness:

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 Al-Zaytoonah University of Jordan ‫جـامعـة الـزيتـونــــة األردنيــة‬
Faculty of Nursing ‫كلية التمريض‬

QF03/0606-3.0 E Nursing Case Study Form/ Adult Nursing- Practice Course / Faculty of Nursing

(score: /1)

Past history:

Prenatal and Birth History:

Problems in Growth and Development:

Common Childhood illnesses:

Immunizations:

Screening Tests:

Hospitalizations:

Serious Accidents, Injuries, Illnesses, Treatments:

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 Al-Zaytoonah University of Jordan ‫جـامعـة الـزيتـونــــة األردنيــة‬
Faculty of Nursing ‫كلية التمريض‬

QF03/0606-3.0 E Nursing Case Study Form/ Adult Nursing- Practice Course / Faculty of Nursing

(score: /1)

Family History:

Draw a Family Tree: Grandparents, parents, siblings, mate, children, grandchildren, indicate health status of each as age and (alive or dead), cause of
death and significant illnesses or problems such as cardiac ,hypertension, cancer, Epilepsy , Diabetes Mellitus and cause of death )added space / note

(score: /1)

Life style: smoking …cigarette| day alcohol consumption (glass\day) drugs diet preference
Sleep pattern: night sleep hours nap difficulties .

Social history: family relationship income\month support system .

Psychological data: recent major stressor coping mechanism .

QF03/0606 - Page 5 / 22
 Al-Zaytoonah University of Jordan ‫جـامعـة الـزيتـونــــة األردنيــة‬
Faculty of Nursing ‫كلية التمريض‬

QF03/0606-3.0 E Nursing Case Study Form/ Adult Nursing- Practice Course / Faculty of Nursing

Review of Body Systems (Total score: /11)

System Subjective Main Abnormal Findings Objective Main Abnormal Findings Score
1. Mental status (score: /1)

2. Skin (score: /1)

3. Head (score: /1)

4. Eye (score: /1)

5. Ears (score: /1)

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 Al-Zaytoonah University of Jordan ‫جـامعـة الـزيتـونــــة األردنيــة‬
Faculty of Nursing ‫كلية التمريض‬

QF03/0606-3.0 E Nursing Case Study Form/ Adult Nursing- Practice Course / Faculty of Nursing

6. Respiratory (score: /1)

7. Cardiovascular (score: /1)

8. Abdomen (score: /1)

9. Musculoskeletal (score: /1)

10. Neurological (score: /1)

11. Breast (for (score: /1)

Female)

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 Al-Zaytoonah University of Jordan ‫جـامعـة الـزيتـونــــة األردنيــة‬
Faculty of Nursing ‫كلية التمريض‬

QF03/0606-3.0 E Nursing Case Study Form/ Adult Nursing- Practice Course / Faculty of Nursing

Diagnostic Procedures (Total score: /4)

Procedure Pre/Post Nursing care

1. Pre: (score: /1)

Post:

2. Pre: (score: /1)

Post:

3. Pre: (score: /1)

Post:

4. Pre: (score: /1)

Post:

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 Al-Zaytoonah University of Jordan ‫جـامعـة الـزيتـونــــة األردنيــة‬
Faculty of Nursing ‫كلية التمريض‬

QF03/0606-3.0 E Nursing Case Study Form/ Adult Nursing- Practice Course / Faculty of Nursing

Laboratory Test Results (Total score: /5)

Date of test Test Result Normal Value Interpretation Nursing Implication

Hematology (score: /2)

Chemistry (score: /2)

Urine Analysis (score: /1)

QF03/0606 - Page 9 / 22
 Al-Zaytoonah University of Jordan ‫جـامعـة الـزيتـونــــة األردنيــة‬
Faculty of Nursing ‫كلية التمريض‬

QF03/0606-3.0 E Nursing Case Study Form/ Adult Nursing- Practice Course / Faculty of Nursing

Medications Taken in the Hospital (Total score: /5)

Name of the medication Action and Dose, route and Possible Nursing
(Trade and generic) classification frequency side effects interventions

QF03/0606 - Page 10 / 22
 Al-Zaytoonah University of Jordan ‫جـامعـة الـزيتـونــــة األردنيــة‬
Faculty of Nursing ‫كلية التمريض‬

QF03/0606-3.0 E Nursing Case Study Form/ Adult Nursing- Practice Course / Faculty of Nursing

Medications, cont.

Name of the medication Action and Dose, rout and Possible Nursing
(Trade and generic) classification frequency Side Effects Interventions

QF03/0606 - Page 11 / 22
 Al-Zaytoonah University of Jordan ‫جـامعـة الـزيتـونــــة األردنيــة‬
Faculty of Nursing ‫كلية التمريض‬

QF03/0606-3.0 E Nursing Case Study Form/ Adult Nursing- Practice Course / Faculty of Nursing

Intravenous fluids (Total score: /2)

IV fluid Total Amount Frequency Drop\m Added Medications (score: /1)

Equation: (write down how you calculate the amount of fluid) (score: /1)

_________________________________________________________

QF03/0606 - Page 12 / 22
 Al-Zaytoonah University of Jordan ‫جـامعـة الـزيتـونــــة األردنيــة‬
Faculty of Nursing ‫كلية التمريض‬

QF03/0606-3.0 E Nursing Case Study Form/ Adult Nursing- Practice Course / Faculty of Nursing

Discharge Plan and Teaching (Total score: /6)

1. Will the patient require assistance in any of the following after discharge? (score: /1)
Food preparation ___________________________________________________________________________________
Shopping __________________________________________________________________________________________
Transportation _____________________________________________________________________________________
Ambulation ________________________________________________________________________________________
Treatment / Dressing ________________________________________________________________________________
Medical Equipment / Supplies ________________________________________________________________________
2. Describe safety needs of patient after discharge. (score: /1)
Risk for imbalanced body temperature ___________________________________________________________________
Impaired home maintenance ___________________________________________________________________________
Risk for injury ______________________________________________________________________________________
Deficient knowledge _________________________________________________________________________________
Risk for poisoning __________________________________________________________________________________
Disturbed sensory/perception __________________________________________________________________________
Risk for suffocation _________________________________________________________________________________
Disturbed thought processes ___________________________________________________________________________
Risk for trauma _____________________________________________________________________________________
 Others (Specify) ____________________________________________________________________________________
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 Al-Zaytoonah University of Jordan ‫جـامعـة الـزيتـونــــة األردنيــة‬
Faculty of Nursing ‫كلية التمريض‬

QF03/0606-3.0 E Nursing Case Study Form/ Adult Nursing- Practice Course / Faculty of Nursing

3. What significant other, (if needed) is available to help at home? (score: /1)

4. Doctor follows up appointment given to the patient? (score: /0.5)

_______________________________________________________________________________________________________
5. Prescriptions for at home care are given to the patient? (score: /1)
_______________________________________________________________________________________________________
6. Instructions is given to the patient regarding: (score: /1)
- Effect of medications: ________
- Specific instructions: ________
- Medication side effects: ________
- Others (specify): ________________________________________________
7. What referral would the patient need before discharge? (score: /0.5)
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________

QF03/0606 - Page 14 / 22
 Al-Zaytoonah University of Jordan ‫جـامعـة الـزيتـونــــة األردنيــة‬
Faculty of Nursing ‫كلية التمريض‬

QF03/0606-3.0 E Nursing Case Study Form/ Adult Nursing- Practice Course / Faculty of Nursing

Disease Process (Total score: /8)

Definition of the Disease: (score: /2)

_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
____________________

Aetiology of the Disease: (score: /2)

According to Textbook In Your Patient

QF03/0606 - Page 15 / 22
 Al-Zaytoonah University of Jordan ‫جـامعـة الـزيتـونــــة األردنيــة‬
Faculty of Nursing ‫كلية التمريض‬

QF03/0606-3.0 E Nursing Case Study Form/ Adult Nursing- Practice Course / Faculty of Nursing

Pathophysiology: (score: /2)

___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
_______________________________________________________

Clinical Manifestations: (score: /2)

According to Textbook In Your Patient

QF03/0606 - Page 16 / 22
 Al-Zaytoonah University of Jordan ‫جـامعـة الـزيتـونــــة األردنيــة‬
Faculty of Nursing ‫كلية التمريض‬

QF03/0606-3.0 E Nursing Case Study Form/ Adult Nursing- Practice Course / Faculty of Nursing

Treatment Plan (as It Is Written in Patient 's File): (Total score: /2)

Medications

Diet

Special Orders

QF03/0606 - Page 17 / 22
 Al-Zaytoonah University of Jordan ‫جـامعـة الـزيتـونــــة األردنيــة‬
Faculty of Nursing ‫كلية التمريض‬

QF03/0606-3.0 E Nursing Case Study Form/ Adult Nursing- Practice Course / Faculty of Nursing

Nursing Care Plan

Use approved NANDA list as reference to write nursing diagnosis

Nursing Diagnosis No. 1: (score: /3)

Subjective & Objective Goal(score: /1) Implementation(score: /3) Rational(score: /1) Evaluation(score: /1)
S:

O:

Nursing Diagnosis No. 2: (score: /3)

Subjective & Objective Goal(score: /1) Implementation(score: /3) Rational(score: /1) Evaluation(score: /1)
S:

O:

QF03/0606 - Page 18 / 22
 Al-Zaytoonah University of Jordan ‫جـامعـة الـزيتـونــــة األردنيــة‬
Faculty of Nursing ‫كلية التمريض‬

QF03/0606-3.0 E Nursing Case Study Form/ Adult Nursing- Practice Course / Faculty of Nursing

Nursing Diagnosis No. 3: (score: /3)

Subjective & Objective Goal(score: /1) Implementation(score: /3) Rational(score: /1) Evaluation(score: /1)
S:

O:

Nursing Diagnosis No. 4: (score: /3)

Subjective & Objective Goal(score: /1) Implementation(score: /3) Rational(score: /1) Evaluation(score: /1)
S:

O:

QF03/0606 - Page 19 / 22
 Al-Zaytoonah University of Jordan ‫جـامعـة الـزيتـونــــة األردنيــة‬
Faculty of Nursing ‫كلية التمريض‬

QF03/0606-3.0 E Nursing Case Study Form/ Adult Nursing- Practice Course / Faculty of Nursing

Nursing Diagnosis No. 5: (score: /3)

Subjective & Objective Goal(score: /1) Implementation(score: /3) Rational(score: /1) Evaluation(score: /1)
S:

O:

References in APA
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________

QF03/0606 - Page 20 / 22
 Al-Zaytoonah University of Jordan ‫جـامعـة الـزيتـونــــة األردنيــة‬
Faculty of Nursing ‫كلية التمريض‬

QF03/0606-3.0 E Nursing Case Study Form/ Adult Nursing- Practice Course / Faculty of Nursing

Nursing Case Study Scoring Sheet

Items Ideal Points Student’s Points

Nursing Assessment:
 Nursing history 10 points
 Review of Body Systems 11 points
 Diagnostic procedures 4 points
 Laboratory Test Results 5 points
 Medications Taken in the Hospital 5 points
 Intravenous Fluids 2 points
 Discharge plan and Teaching 6 points
 Disease process 8 points
 Treatment Plan 2 points
Nursing Care Plan:
 Nursing diagnosis according to NANDA in priority 15 points
 Patient's Goal 5 points
 Nursing Interventions 15 points
 Rationales (for each intervention step) 5 points
 Evaluation Criteria / Expected Outcomes 5 points
 Clear writing style with no grammatical or spelling errors 2 points
Total 100/10=10 marks

QF03/0606 - Page 21 / 22
 Al-Zaytoonah University of Jordan ‫جـامعـة الـزيتـونــــة األردنيــة‬
Faculty of Nursing ‫كلية التمريض‬

QF03/0606-3.0 E Nursing Case Study Form/ Adult Nursing- Practice Course / Faculty of Nursing

Teacher's Signature _________________________________________ Student's Signature_________________________________

Date______________________________________________________ Date ____________________________________________

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