Help With Case Study for Psychosocial Class

[designer-mommy, BSN, RN]

Hello everyone! Happy Easter to you all :redpinkhe

I have been reviewing a lot of the threads here that relate to case studies, but I am still a little confused. I am currently trying to do my first case study since starting nursing school. Yikes! Anyway, it's on a patient that I interviewed in a psych hospital, and I have a ton of information from her chart regarding her diagnosis, meds, etc. I found an awesome thread here https://allnurses.com/nursing-student-assistance/narrative-format-case-382267.html by Daytonite that basically gives the template for a case study, but I am stuck on the last 2 parts: Implementation and Evaluation. This may be a very stupid question, but how am I going to implement and evaluate when I will never see this patient again? We go back on Tuesday, and I'm sure she will be gone since I interviewed her like 2 weeks ago. They say that they don't stay there too long in that particular hospital. It's more of a rehab, personal/emotional crisis type place, as opposed to a state mental hospital. So, what do I do for those last two parts? Also, how many pages is a typical case study? Thanks in advance!

[ParkerBC,MSN,RN, PhD, RN]

Here is an example of a Care Study I recently completed. I hope it helps.

1. Decreased Cardiac Output r/t altered contractility AEB patient’s BNP at 4600 with baseline of 3300 (Ackley & Ladwig, 2008).

2. Goals

a. The client will demonstrate adequate cardiac output as evidenced by blood pressure and pulse rate and rhythm within normal parameters for client; strong peripheral pulses; and an ability to tolerate activity without symptoms of dyspnea, syncope, or chest pain within two days(Ackley & Ladwig, 2008).

b. The client will remain free of side effects from the medications used to achieve adequate cardiac output within four days(Ackley & Ladwig, 2008).

c. The client will explain actions and precautions to take for primary or secondary prevention of cardiac disease within seven days (Ackley & Ladwig, 2008).

3. Interventions

a. The nurse will monitor for symptoms of heart failure and decreased cardiac output; listen to heart sounds and lung sounds (Ackley & Ladwig, 2008).

b. The nurse will monitor laboratory work such as complete blood count (CBC), sodium level, and serum creatinine (Ackley & Ladwig, 2008).

c. The nurse will watch laboratory data closely, especially arterial blood gases, electrolytes including potassium, and B-type natriuretic peptide (BNP essay) (Ackley & Ladwig, 2008).

4. Evaluation

a. Client has met this goal. The client’s BP with back within normal range for the client. The client’s BMP is also decreasing. The last lab value indicated the client’s BMP is 3900.

b. The client has also met this goal. The client is not experiencing any side effects of his medication regimen.

c. The client met this goal. The client understands the importance of his medication regimen. He understands that if he continues being noncompliant, he will soon end up back in the hospital.

The intervention section is what the nurse will do to get the client to meet his/her goals. This information is found in a Nursing Diagnosis Book (hence the references). Our professor asked us to look at the client on the day of admission and compare to the day of clinical. What evidence is the client showing that he/she is meeting the goals. However, I have also had professors who said write, “unable to determine if goal was met because I did not have the client again.”

So, the evaluation part I would encourage you to ask your professor.

I hope this helps. Good luck!