clinical case study

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CLINICAL CASE STUDY ASSIGNMENT

(Complete one per shift)

Introduction – explain who the patient is: age range, gender, etc. Explain what the problem is: what is the patient diagnosed with, or what happened/what brought them here. Introduce the main idea: what should you as a nurse focus on?

Pathophysiology – explain the disease, symptoms, and causes/etiology (cite sources)

History – explain what health problems the patient has (other diagnoses). Discuss other pertinent treatments, surgeries, etc.

Physical Assessment – include vital signs, assessment findings, labs, diagnostics, etc.

Treatments – what treatment is the patient receiving due to condition, and what is the rationale (medications, dressing changes, PT/OT, etc.)

Nursing Care Plan – two priority nursing diagnoses with appropriate SMART goal(s), interventions, and evaluations.

Recommendations – what should the nurse and patient focus on to promote recovery/improvement?

References/APA format – Prepare your assignment as an APA formatted paper, including a reference page as well as in-text citations. Please use textbooks or reliable sources from the internet that are geared toward heath care professionals.

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