Nursing case Study Format 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) o 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: http://allnurses.com/forums/f205/medical-disease-informationtreatment-procedures-test-reference-websites-258109.html - Medical Disease Information/Treatment/Procedures/Test Reference Websites o reviewing the signs, symptoms and side effects of the medications/treatments that were ordered or that the patient is taking o 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 o a physical assessment of the patient o 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 2. 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. o Your instructors might have given it to you. o You can purchase it directly from NANDA. NANDA-I Nursing Diagnoses: Definitions & Classification 2007-2008 published by NANDA International. Cost is $24.95 http://www.nanda.org/html/nursing_diagnosis.html o Many authors of care plan and nursing diagnosis books include the NANDA nursing diagnosis information. This information will usually be found immediately below the title of a nursing diagnosis. o 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 o There are also two websites that have information for about 80 of the most commonly used nursing diagnoses that you can access for free: http://www1.us.elsevierhealth.com/Evolve/Ackley/NDH7e/Constructor/

http://www1.us.elsevierhealth.com/MERLIN/Gulanick/Constructor/index. cfm o always sequence actual nursing problems before potential (Risk for) or anticipated problems o 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 3. Planning (write measurable goals/outcomes and nursing interventions) o 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 o how to write goal statements: See post #157 on thread http://allnurses.com/general-nursing-student/careplans-help-please-121128.html o 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) 4. Implementation (initiate the care plan) 5. Evaluation (determine if goals/outcomes have been met)

Section Introduction (patient and problem)

Information to Include Explain who the patient is (Age, gender, etc.) Explain what the problem is (What was he/she diagnosed with, or what happened?) Introduce your main argument (What should you as a nurse focus on or do?) Explain the disease (What are the symptoms? What causes it?) Explain what health problems the patient has (Has she/he been diagnosed with other diseases?) Detail any and all previous treatments (Has she/he had any prior surgeries or is he/she on medication?)

Pathophysiology History

Nursing Physical Assessment Related Treatments Nursing Care Plan Nursing Diagnosis & Patient Goal

List all the patients health stats in sentences with specific numbers/levels (Blood pressure, bowel sounds, ambulation, etc.) Explain what treatments the patient is receiving because of his/her disease Explain what your nursing diagnosis is (What is the main problem for this patient? What need to be addressed?) Explain what your goal is for helping the patient recover (What do you want to change for the patient?) Explain how you will accomplish your nursing goals, and support this with citations (Reference the literature) Explain how effective the nursing intervention was (What happened after your nursing intervention? Did the patient get better?) Explain what the patient or nurse should do in the future to continue recovery/improvement

Nursing Interventions Evaluation

Recommendations

Your paper will be graded on how well you complete each of the above sections. You will also be graded on your use of APA style (see the APA section of this website) and on your application of nursing journals into the treatments and interventions. For integrating nursing journals, remember the following:

Make sure to integrate citations into all of your paper Support all claims of what the disease is, why it occurs and how to treat it with references to the literature on this disease Always use citations for information that you learned from a book or article; if you do not cite it, you are telling your reader that YOU discovered that information (how to treat the disease, etc.)