A clinical case study example for nursing shows how to apply the nursing process to one patient: assessment, diagnosis, planning, implementation and evaluation. Each section must build on the one before it.
This guide walks through the standard structure, a worked example for a patient with COPD, the steps to build your own and the mistakes that cost the most marks.
The Five Parts of a Nursing Case Study
Most nursing case studies follow ADPIE. You assess the patient, write prioritized NANDA-I diagnoses, plan SMART goals, describe cited interventions and evaluate whether the goals were met.
The marks go to the links between them. Each diagnosis must come from the assessment data, and each intervention must target the diagnosis's cause.
The Standard Structure of a Nursing Case Study
A typical paper opens with a short, de-identified patient introduction, then moves through the nursing process as formal sections. References come last and usually follow APA 7.
| Section | What it contains | What markers look for |
|---|---|---|
| Patient introduction | Age, reason for admission, relevant history | Only details that matter clinically |
| Assessment | Subjective and objective data, kept separate | Completeness and clear organization |
| Nursing diagnoses | Two or three prioritized NANDA-I statements | Correct format and links to the data |
| Planning | One or two SMART goals per diagnosis | Goals that can actually be measured |
| Implementation | Three to five interventions per diagnosis, with rationale | Evidence-based, cited rationale |
| Evaluation | Met, partially met or not met, with reasons | Honest judgment tied to the goals |
Many programs also expect you to bring in pathophysiology and pharmacology. A heart failure case, for example, should connect the drugs, the cardiac mechanism and the nursing care for this patient.
Worked Example: A Patient with COPD
The example below shows how each section links to the next. It uses a hypothetical patient, so there is no identifying information.
Patient introduction. Mr K, 68, is admitted with increasing breathlessness over three days. He has COPD and hypertension and is an ex-smoker of 40 pack-years.
Assessment. Subjective: he reports he "cannot catch his breath" walking to the bathroom and has a productive cough. Objective: respiratory rate 26, SpO2 89 percent on room air, coarse crackles at both bases, use of accessory muscles.
Priority diagnosis. Impaired gas exchange related to alveolar-capillary membrane changes as evidenced by SpO2 of 89 percent, dyspnoea on exertion and a respiratory rate of 26.
Goal. Mr K will maintain SpO2 between 88 and 92 percent, the target range his team has set, at rest within 24 hours.
Interventions. Give controlled oxygen as prescribed to the target range; sit him upright to aid lung expansion; monitor SpO2 and respiratory rate every hour; teach pursed-lip breathing. Each would be cited to a current guideline or peer-reviewed source.
Evaluation. Partially met. SpO2 reached 90 percent at rest by 24 hours but fell to 86 percent on exertion, so the plan continues with paced activity and a physiotherapy referral.
Notice the chain. The diagnosis uses the exact data from the assessment, the goal measures the same sign, and the evaluation reports against that goal.
Writing NANDA-I Nursing Diagnoses
A nursing diagnosis is not a medical diagnosis. "COPD" is the medical diagnosis; "impaired gas exchange" is the nursing response you can act on.
An actual (problem-focused) diagnosis has three parts. Risk diagnoses have only two, because the problem has not happened yet.
| Type | Format | Example |
|---|---|---|
| Problem-focused | Problem related to cause as evidenced by signs | Acute pain related to surgical incision as evidenced by pain score 7/10 and guarding |
| Risk | Risk for problem related to risk factors | Risk for infection related to surgical wound and diabetes |
| Health promotion | Readiness for enhanced behavior as evidenced by statement | Readiness for enhanced self-care as evidenced by a wish to learn inhaler technique |
Prioritize with a recognized framework such as airway, breathing and circulation, or Maslow's hierarchy. Two or three well-developed diagnoses score better than a long, shallow list.
Writing Interventions with Rationale
Each intervention needs three things: what the nurse does, why it works for this patient, and a source. The rationale is where you show clinical reasoning, so do not skip it.
| Intervention | Rationale |
|---|---|
| Sit the patient upright or in a tripod position | Lowers the diaphragm and improves lung expansion, reducing the work of breathing |
| Give controlled oxygen to the prescribed target range | Corrects hypoxaemia while avoiding the risks of excess oxygen in some COPD patients |
| Teach pursed-lip breathing | Slows the breathing rate and helps empty trapped air from the lungs |
| Space care activities with rest periods | Reduces oxygen demand and the breathlessness that follows exertion |
Group independent nursing actions, such as positioning and teaching, separately from collaborative ones, such as giving prescribed oxygen. Many rubrics ask you to show the difference.
Planning SMART Goals
Goals must be specific, measurable, achievable, realistic and time-bound. If a marker cannot check whether a goal was met, it will lose marks.
- Weak: "Patient will breathe better."
- Strong: "Patient will report dyspnoea at or below 3 on a 0 to 10 scale when walking to the bathroom within 48 hours."
- Weak: "Patient will understand his medicines."
- Strong: "Patient will demonstrate correct inhaler technique to the nurse before discharge."
How to Build a Case Study from a Scenario
- Read the whole scenario and note every clinically relevant detail, including medicines, allergies and social context.
- Sort the data into subjective and objective before you write the assessment.
- Choose two or three priority diagnoses using your taught framework.
- Write each in full NANDA-I format, using details from the scenario.
- Set one or two SMART goals for each diagnosis.
- Choose interventions that target the cause in each "related to" clause, and cite each one.
- Evaluate honestly, including partially met goals and next steps.
- Check that every section refers to this patient, not a generic one.
How the Scenario Shapes the Case Study
The clinical focus decides which diagnoses and interventions carry the most weight. Recognizing the pattern early helps you plan your time.
| Scenario | Common diagnoses | Key interventions |
|---|---|---|
| Respiratory (COPD, pneumonia) | Impaired gas exchange, ineffective airway clearance | Positioning, oxygen to target, airway clearance |
| Cardiac (heart failure) | Decreased cardiac output, excess fluid volume | Daily weights, fluid balance, medicine timing |
| Post-surgical | Acute pain, risk for infection | Pain assessment, wound care, early mobility |
| Mental health | Anxiety, ineffective coping, risk for self-harm | Therapeutic communication, safety planning |
| Diabetes | Risk for unstable blood glucose | Monitoring, education, foot care |
If the case study feeds into a later care plan or concept map, keep the patient's details identical across both. Markers notice inconsistencies.
Common Mistakes to Avoid
- Plain-language diagnoses: "has trouble breathing" needs the full NANDA-I format.
- Too many diagnoses: prioritization is part of the mark, so develop two or three in depth.
- Unmeasurable goals: "feel better" cannot be evaluated.
- Interventions that miss the cause: if pain limits lung expansion, treat the pain as well as the oxygen level.
- Mixed data: keep subjective and objective findings separate.
- Every goal "fully met": realistic evaluation shows better judgment.
- Uncited interventions: even standard care needs a current source.
- No psychosocial care: include education, family and emotional needs where relevant.
Using a Real Patient from Placement
Check your program's policy before using a real patient. Most require full de-identification under local privacy rules, such as HIPAA in the United States.
Remove names, dates, ward names and any rare detail that could identify someone. Some programs prefer composite or fully hypothetical patients for this reason.
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Frequently Asked Questions
Assessment, diagnosis, planning, implementation and evaluation, the five steps of the nursing process that most case studies follow.
Usually two or three prioritized diagnoses developed in depth. Check your rubric, as some tutors set an exact number.
For a problem-focused diagnosis: the problem, "related to" the cause, and "as evidenced by" the signs and symptoms from your assessment.
Yes. Citing a current guideline or peer-reviewed source shows evidence-based practice, which most rubrics reward even for routine care.
Say so and explain why, then give realistic next steps. Honest evaluation shows stronger clinical reasoning than a tidy ending.
Only if your program allows it, and only after full de-identification. Some programs require hypothetical patients instead.
Tables work well for assessment data and care plans, as long as your template allows them. Keep the rationale and evaluation in full sentences.
A case study applies the nursing process to one patient as a single assignment. A capstone is a larger project, often a quality improvement or evidence-based practice change.