case study advice

a case study is pretty much constructed in an essay form. it is merely a discussion of the patient and their nursing problems--it's an expanded care plan. follow the steps of the nursing process to organize the paper. steps #1 and #2 will be the largest part of the paper. step #3 will be the goal and nursing interventions. assessment will be big because it involves how you will be coming to the decision of what the patient's nursing problems are (what the abnormal data is) as well as a little discussion of their medical condition. this website, although for doctors, can help you organize your initial assessment and lab data:

http://depts.washington.edu/medclerk/student/presentation.html - format for writing the case study (docs have to present written case studies during their internship and residency all the time). you can use this as a kind of guide to organize as well:

1. assessment (collect data from medical record, do a physical assessment of the patient, assess adl's, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
   
   • a physical assessment of the patient
     
   • assessment of the patient's ability and any assistance they need to accomplish their adls (activities of daily living) with the disease
     
   • data collected from the medical record (information in the doctor's history and physical, information in the doctor's progress notes, test result information, notes by ancillary healthcare providers such as physical therapists and dietitians (https://allnurses.com/nursing-student-assistance/help-preparing-clinical-227507.html)
     
   • knowing the pathophysiology, signs/symptoms, usual tests ordered, and medical treatment for the medical disease or condition that the patient has. this includes knowing about any medical procedures that have been performed on the patient, their expected consequences during the healing phase, and potential complications. if this information is not known, then you need to research and find it.
     
     • use: https://allnurses.com/forums/f205/medical-disease-information-treatment-procedures-test-reference-websites-258109.html - medical disease information/treatment/procedures/test reference websites
       

[*]reviewing the signs, symptoms and side effects of the medications/treatments that have been ordered and that the patient is taking

[*]determination of the patient's problem(s)/nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use). it helps to have a book with nursing diagnosis reference information in it. there are a number of ways to acquire this information.

• your instructors might have given it to you.
  
• you can purchase it directly from nanda. nanda international nursing diagnoses: definitions and classifications 2009-2011. cost is $34.99. http://www.nanda.org/marketplace/nandaipublications.aspx
  
• many authors of care plan and nursing diagnosis books include the nanda nursing diagnosis information. this information will usually be found immediately below the title of a nursing diagnosis.
  
• the nanda taxonomy and a medical disease cross reference is in the appendix of both taber's cyclopedic medical dictionary and mosby's medical, nursing, & allied health dictionary
  
• there are also two websites that have information for about 75 of the most commonly used nursing diagnoses that you can access for free:
  
  • http://www1.us.elsevierhealth.com/evolve/ackley/ndh7e/constructor/
    
  • http://www1.us.elsevierhealth.com/merlin/gulanick/constructor/index.cfm
    

  [*]always sequence actual nursing problems before potential (risk for) or anticipated problems

  • use maslow's hierarchy of needs to sequence the diagnoses in order of priority of importance
    
  • http://en.wikipedia.org/wiki/maslow's_hierarchy_of_needs - maslow's hierarchy of needs
    

[*]planning (write measurable goals/outcomes and nursing interventions)

• goals/outcomes are the predicted results of the nursing interventions you will be ordering and performing. they have the following overall effect on the problem:
  
  • improve the problem or remedy/cure it
    
  • stabilize it
    
  • support its deterioration
    

  [*]how to write goal statements: see post #157 on thread https://allnurses.com/general-nursing-student/careplans-help-please-121128.html

  [*]interventions are of four types

  • assess/monitor/evaluate/observe (to evaluate the patient's condition)
    
    • note: be clear that this is assessment as an intervention and not assessment done as part of the initial data collection during step 1.
      

    [*]care/perform/provide/assist (performing actual patient care)

    [*]teach/educate/instruct/supervise (educating patient or caregiver)

    [*]manage/refer/contact/notify (managing the care on behalf of the patient or caregiver)

[*]implementation (initiate the care plan)

[*]evaluation (determine if goals/outcomes have been met) - this is an assessment. you will specifically look for the defining characteristics that supported your nursing diagnoses to see if, or how, they have changed (improved, stabilized or gotten worse) as well as for the evidence of any new nursing problems.

while you will focus a bit on the medical condition in the assessment portion of the paper, be very sure you hit the nursing problems. in the assessment part of the outline above i list out what we nurses assess. it is a bit different than the testing that docs do although you should mention how the docs diagnose whatever medical condition your patient in the paper will have. we, as nurses, primarily focus on how the patient responds to their medical condition and what we do for it. that should be a very major part of the remainder of your paper.