Narrative Format Case Study


Can anyone tell me where I may find a good example of a nursing narrative case study. We where given a patient one day in clinicals and now we need to write a formal case study not a clinical prep. Thanks:typing

Daytonite, BSN, RN

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Specializes in med/surg, telemetry, IV therapy, mgmt. Has 40 years experience.

the ones that were post on the internet by one college were removed this past year. it is unlikely that you will find a good example although short ones do exist:

what you need to do is organize the paper by following the 5 steps of the nursing process. the entire thing is then presented, of course, in an essay format. these are the five steps of the nursing process used for care planning. your biggest part of this paper will be the assessment and i have laid out exactly what you need to include in the assessment.

  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)
    • 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.

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

[*]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

[*]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/condition that they have

[*]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.

[*]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

    [*]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)

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