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Nursing Case Study

Nursing Case Study

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Published by jaиïne guerrero

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Published by: jaиïne guerrero on Nov 10, 2011
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02/02/2013

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NURSING CASE STUDY:1. Cover page2. Table of Contents3. Rationale>must be 1 1/2 page>should give an overview of the rotation, case, patient>statistics of the case should be provided (international, national, local)>implications to Nursing Research, Practice & Education4. Goal & Objectives>SMART>KSA>BLOOMS TAXONOMY5. Data Base
A. BIOGRAPHICAL DATA
--Follow History form
B. CLINICAL DATA
i. chief complaintii. date of admissioniii. admitting dxiv. wardv. attending physicianvi. date of dischargevii. final dx
C. FAMILY HEALTH HISTORY 
i. Genogram
 
ii. NarrativeD. PAST HEALTH HISTORY--Follow history formE. HISTORY OF PRESENT ILLNESS>should start from the 1
st
onset of manifestation>follow history form>narrative presentationF. DEVELOPMENTAL TASKSa. Psychosocial theory (Erikson)-brief discussion of the theory-tabular presentation of the tasksStage Central taskActualJustification (Met orunmet)b. developmental tasks theory (Havighurst)-brief discussion of the theory-tabular pres. of the tasksDevelopmental TasksActualJustification (Met orUnmet)6. PHYSICAL ASSESSMENT/NEURO ASSESSMENT7. DEFINITION OF DIAGNOSIS-must have minimum of 3 definitions from diff. book sources or electronic sources-complete statement of reference must be stated every after each definition8. ANATOMY AND PHYSIOLOGY9. PATHOHYSIOLOGYA. Etiology
 
i. Predisposing factorsPresent/AbsentMechanism/Rationaleii. Precipitating FactorsPresent/AbsentMechanism/RationaleB. symptomatologySigns & SymptomsManifestationsMechanism/RationaleC. Schematic TracingD. Narrative pres.10. MEDICAL MANAGEMENTA. Diagnostic Exams (actual & possible)-tabular pres. Of all dx exams done-arrange accordingly-separate per type of procedure-if test is done >1, results should be tabulated as one-landscape formata. Actual1. Laboratory testsDateComponentDefinition& NormalRangeRationaleResultInterpretation &SignificanceNursingresponsibilities2. Diagnostic examsDateTestRationaleResult Interpretation &SignificanceNsg resp.

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