Case study assignment

i provided a list of current online care plans in the other thread for you. a case study is merely a care plan that follows the steps of the nursing process and is written in an essay form. because the nursing process is a problem solving process and you use it to organize your case study, your paper will be very rational in its presentation. all the commercial care plan book authors follow the nursing process when formulating care plans for their books. it is important that you begin by presenting the patient's medical problem, the pathophysiology, and how you assess for it. assessment is the first step of the nursing process. assessment consists of:

• reviewing the pathophysiology, signs and symptoms and complications of their medical condition
  
  
• a health history (review of systems)
  
• performing a physical exam
  
• assessing their adls (at minimum: bathing, dressing, mobility, eating, toileting, and grooming)
  
• reviewing the signs, symptoms and side effects of the medications/treatments that have been ordered for them
  

abnormal data from the assessment is what goes into the care plan and development of your nursing diagnoses (step #2 of the nursing process). the remainder of the steps are:

• step #3 - 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)
      

  [*]step #4 - implementation (initiate the care plan)

  [*]step #5 - evaluation (determine if goals/outcomes have been met)