How to Write a Nursing Case Study (With Examples)

TL;DR: A nursing case study analyzes a patient scenario using clinical reasoning. Structure it with: patient intro, health history, assessment findings, NANDA diagnoses, care plan (with rationales), evaluation, and reflection. Use evidence-based practice, cite your sources, and show your clinical thinking — don't just list facts.

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What Is a Nursing Case Study?

A nursing case study is a detailed analysis of a patient's condition, care plan, and outcomes. It's designed to show that you can think critically about patient care — not just follow orders, but understand why you're doing what you're doing.

Unlike regular essays, nursing case studies combine clinical knowledge, evidence-based practice, and real-world application. They bridge the gap between textbook learning and actual patient care.

Whether you're working from a real clinical rotation patient or a textbook scenario, the structure and approach are the same. Let's break it down.

The Nursing Case Study Structure

Most nursing programs expect this format:

1. Patient Introduction
2. Health History
3. Assessment Data
4. Pathophysiology
5. NANDA Nursing Diagnoses
6. Nursing Care Plan
7. Interventions and Rationales
8. Evaluation
9. Reflection/Discussion
10. References

Your professor might combine or rearrange some sections, so always check your assignment rubric first.

Step 1: Patient Introduction

Start with a brief overview of your patient. Include:

• Age, sex, and relevant demographics
• Chief complaint (why they're seeking care)
• Admitting diagnosis
• Relevant social/cultural context

Important: If using a real patient, follow HIPAA guidelines. Use initials or pseudonyms, never full names. Remove identifying details.

Example: "Mrs. J.T. is a 68-year-old female admitted to the medical-surgical unit with a primary diagnosis of community-acquired pneumonia. She presented to the emergency department with a 3-day history of productive cough, fever (101.4°F), and shortness of breath. She has a past medical history significant for Type 2 diabetes mellitus, hypertension, and COPD."

Step 2: Health History

Provide a comprehensive picture:

Past Medical History:

• Chronic conditions
• Previous surgeries
• Previous hospitalizations
• Allergies (with reactions)

Medications:

• Current medications (name, dose, frequency, route)
• Note any recent changes

Family History:

• Relevant genetic/hereditary conditions

Social History:

• Living situation
• Smoking/alcohol/substance use
• Occupation
• Support system
• Relevant cultural or religious considerations

Review of Systems: Hit the major systems briefly — cardiovascular, respiratory, neurological, GI, musculoskeletal, etc. Focus on what's relevant to the chief complaint.

Step 3: Assessment Data

Present your assessment findings systematically. Most programs want a head-to-toe assessment organized by body system.

Vital Signs

• Temperature, pulse, respirations, blood pressure, SpO2, pain level

Physical Assessment by System

Neurological: Level of consciousness, orientation, pupil response, motor/sensory function

Cardiovascular: Heart sounds, rhythm, peripheral pulses, edema, capillary refill

Respiratory: Breath sounds, respiratory effort, cough, sputum, oxygen needs

GI: Bowel sounds, abdomen (soft/firm/distended), last BM, diet tolerance

GU: Urine output, color, continence

Integumentary: Skin color, turgor, integrity, wounds, IV sites

Musculoskeletal: Mobility, strength, range of motion, fall risk

Lab Values and Diagnostics

Include relevant results with normal ranges:

Lab Test	Patient Value	Normal Range	Significance
WBC	14.2 x 10³/μL	4.5-11.0	Elevated — indicates infection
BUN	28 mg/dL	7-20	Elevated — possible dehydration
Glucose	186 mg/dL	70-100	Elevated — consistent with DM

Also include imaging results (chest X-ray, CT scan, etc.) and their findings.

Step 4: Pathophysiology

Explain the disease process in your own words. Show you understand:

• What's happening in the body at a cellular/organ level
• How the disease progresses
• Why the patient has the specific symptoms they do
• How comorbidities complicate the picture

Example for pneumonia: "Community-acquired pneumonia occurs when pathogens (commonly Streptococcus pneumoniae) invade the lower respiratory tract, triggering an inflammatory response. The alveoli fill with fluid, exudate, and white blood cells, impairing gas exchange. This explains Mrs. J.T.'s decreased SpO2 (91% on room air), crackles on auscultation, and productive cough. Her COPD compounds the issue by further limiting airway clearance and gas exchange capacity. Her uncontrolled diabetes (A1C 8.2%) impairs immune function, increasing susceptibility to infection and potentially slowing recovery."

Notice how this isn't just a textbook definition — it connects the pathophysiology to this specific patient's presentation.

Step 5: NANDA Nursing Diagnoses

NANDA International provides standardized nursing diagnoses. They follow this format:

[Problem] related to [Etiology/Cause] as evidenced by [Signs/Symptoms]

Priority Diagnoses (List 3-5, in priority order)

#1: Impaired gas exchange related to alveolar-capillary membrane changes secondary to pneumonia as evidenced by SpO2 of 91%, crackles bilaterally, and dyspnea on exertion.

#2: Ineffective airway clearance related to excessive mucus production and COPD as evidenced by productive cough with yellow sputum, rhonchi on auscultation, and difficulty expectorating.

#3: Risk for unstable blood glucose level related to infection process and stress response as evidenced by current glucose of 186 mg/dL and A1C of 8.2%.

#4: Activity intolerance related to imbalance between oxygen supply and demand as evidenced by dyspnea and fatigue with ambulation, requiring rest after 50 feet.

Common Mistakes with NANDA Diagnoses

• Using medical diagnoses ("pneumonia") instead of nursing diagnoses ("impaired gas exchange")
• Missing the "related to" or "as evidenced by" components
• Not prioritizing (ABCs — Airway, Breathing, Circulation first)
• Using outdated NANDA terminology (check current edition)

Step 6: Nursing Care Plan

For each diagnosis, create a care plan with:

Diagnosis #1: Impaired Gas Exchange

Patient Goal: Patient will maintain SpO2 ≥ 95% on ≤ 2L nasal cannula within 48 hours.

Interventions:

1. Monitor SpO2 continuously; assess respiratory status every 2 hours
   • Rationale: Early detection of respiratory deterioration allows prompt intervention (Lewis et al., 2023)
2. Administer supplemental oxygen as ordered, titrating to maintain SpO2 ≥ 95%
   • Rationale: Supplemental oxygen corrects hypoxemia; however, caution in COPD patients — high-flow O2 may suppress respiratory drive (Ignatavicius et al., 2024)
3. Elevate head of bed to 30-45 degrees
   • Rationale: Semi-Fowler's position promotes lung expansion by reducing pressure of abdominal contents on the diaphragm
4. Encourage incentive spirometry every 1-2 hours while awake
   • Rationale: Deep breathing exercises promote alveolar expansion and prevent atelectasis
5. Administer prescribed antibiotics (azithromycin 500mg IV daily) on schedule
   • Rationale: Timely antibiotic administration targets the infectious process causing alveolar inflammation

Evaluation: After 48 hours, patient's SpO2 was 96% on 1L NC. Goal met/partially met/not met. (Document what actually happened.)

Step 7: Interventions and Rationales

For each intervention, you need a rationale — this is what separates nursing school writing from just following orders.

What Makes a Good Rationale?

Bad: "Because the doctor ordered it."

Good: "Semi-Fowler's positioning promotes optimal lung expansion by allowing gravity to pull the diaphragm downward, increasing tidal volume and improving ventilation-perfusion matching (Lewis et al., 2023, p. 487)."

Your rationale should:

• Explain the physiological reason the intervention works
• Include a citation from a nursing textbook or journal
• Connect to the patient's specific situation when possible

Evidence-Based Practice

Wherever possible, cite current evidence:

• Nursing textbooks (Lewis, Ignatavicius, Potter & Perry)
• Clinical practice guidelines (CDC, AHA, ADA)
• Peer-reviewed nursing journals
• Hospital policy and procedures

Step 8: Evaluation

For each goal, document:

• Was the goal met, partially met, or not met?
• What evidence supports your conclusion?
• If not met, what would you change?

Example: "Goal partially met. Patient's SpO2 improved to 94% on 2L NC by hour 48 (target was ≥95% on ≤2L). Crackles decreased but still present in bilateral lower lobes. Plan: Continue current interventions, add chest physiotherapy, and reassess in 24 hours. Consider pulmonology consult if no improvement."

Step 9: Reflection/Discussion

This section is your chance to demonstrate clinical reasoning and professional growth. Address:

1. What went well in the patient's care?
2. What would you do differently next time?
3. What did you learn from this case?
4. How does this case connect to course content or nursing theory?
5. Ethical or cultural considerations you encountered?

Be honest and thoughtful. Professors value self-awareness here.

Formatting and Writing Tips

Tone: Professional but clear. Avoid overly casual language, but don't make it so academic that it's unreadable.

Person: Most programs want third person ("The nurse administered...") not first person. Check your guidelines.

Abbreviations: Spell out on first use, then abbreviate. Use only standard medical abbreviations.

Citations: Usually APA format. Cite your textbooks, clinical guidelines, and journal articles. Check out our APA format guide if you need help.

Length: Varies widely — could be 5 pages or 20 pages depending on the assignment. Focus on quality over quantity.

Common Mistakes to Avoid

1. Writing a medical case study instead of a nursing case study. Focus on nursing assessments, diagnoses, and interventions — not medical treatment plans.

2. Listing data without analysis. Don't just dump vital signs and lab values. Explain what they mean for your patient.

3. Forgetting rationales. Every intervention needs a "why." That's the whole point.

4. Not prioritizing. Use ABCs (Airway, Breathing, Circulation) and Maslow's hierarchy to rank your diagnoses.

5. Using outdated NANDA terms. Make sure you're using the current NANDA-I edition.

6. Ignoring the patient as a person. Include psychosocial, cultural, and educational needs alongside physical care.

Getting Help With Your Nursing Case Study

Nursing case studies are some of the most complex assignments in college. If you're stuck on structuring your analysis, framing your NANDA diagnoses, or writing rationales, Gradily can help you work through the clinical reasoning process step by step.

You can also check out our guides on APA format, research paper writing, and how to proofread to polish your final draft.

Wrapping Up

A strong nursing case study shows that you can connect knowledge to practice. It's not about listing facts — it's about thinking like a nurse. Assess the patient, identify the problems, plan your interventions with rationale, and evaluate the outcomes.

Start with good data collection, use NANDA-approved terminology, back everything with evidence, and always ask yourself "why?" for every intervention you propose.

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Need help with other types of academic writing? Check out our guides on discussion posts, research papers, and persuasive essays.