Seeking suggestions information to include in case study!

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We are happy to help with homework but we ask that you show us what you have first. Case studies do include a TON of information. To be better able to help you, what semester are you in right now?

The basics......for ALL case studies.....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. The biggest part of this paper will be the assessment. This is a collaboration with a dear member Daytonite (RIP)

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.
     
     • use: medical disease information/treatment/procedures/test reference websites I prefer medscape as on of my go to favorites....Medscape: Medscape Access it requires registration but it is FREE!!!!!!
       

[*]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.

• Your instructors might have given it to you. NANDA nursing diagnoses 2012-2014
  
• you can purchase it directly from Nanda.NANDA nursing diagnosis home page
  
• Many authors of care plan and nursing diagnosis books include the NANDA nursing diagnosis information. I use Ackley: Nursing Diagnosis Handbook, 9th Edition and Gulanick: Nursing Care Plans, 7th Edition
  
• 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
  
• 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: from a dear contributor Daytonite........see post #157(https://allnurses.com/general-nursing-student/careplans-help-please-121128-page16.html) on thread https://allnurses.com/general-nursing...se-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)

Case studies can be quite long...you're welcome!