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									                     MISSOURI WESTERN STATE COLLEGE
                     DIVISION OF PROFESSIONAL STUDIES
                          DEPARTMENT OF NURSING
                                            NUR376

                              NURSING CASE STUDY FORMAT

Each student will be required to submit one nursing case study to fulfill requirements for the
clinical course. The student and instructor will jointly select the patient for the case study
assignment. The purpose of the case study assignment is to allow the student the opportunity to
do an in-depth study of a patient's health problems and management, in order to better relate
theory to clinical practice using the nursing process. Students will do a history and physical on
the patient while caring for the patient. These will be due the next week of class along with
nursing diagnoses and evaluation of developmental. The original textbook picture will be turned
in the week following care with the comparison done for actual patient. The remainder of the
case study will be due in two weeks.

The Nursing Case Study will consist of these components:

       A.      Introduction                                                10 pts

       B.      Diagnostic Procedures & Evaluation
               and Nursing Implications                                    15 pts

       C.      Teaching/Learning Needs                                     10 pts

       D.      Standards Analysis of Care                                  10 pts

       E.      Mechanics                                                    5 pts

                                             TOTAL                          50 points
NUR376 Case Study Format   2
NUR451 Case Study Format                                                                             3


A.     INTRODUCTION

       The introduction is a narrative account of the patient's current hospitalization. It should
       include:

              1.      Date of admission and discharge with medical diagnoses.
              2.      Chief concern (admitting signs and symptoms).
              3.      Events which precipitated or resulted in this admission.
              4.      Pertinent past history.
              5.      Pertinent biographical data (e.g. age, marital status, occupation).
              6.      A brief summary of progress during this hospitalization especially
                      significant events, such as surgical procedures performed, complications,
                      etc.
              7.      General statement about patient's present condition. (Relate initial
                      symptoms to present status and progress at last visit.)

       The purpose of this introduction is to help the student sort and organize data into a
       concise, complete clinical picture.

B.     DIAGNOSTIC PROCEDURES EVALUATION

       This section should address all abnormal laboratory tests ordered (including blood gases,
       x-ray and EKG) and special tests done during the hospitalization. A comparison should
       be made between normal values, the patient values, the reason for the variation from
       normal limits and implications for nursing care. If there are more than three values for
       one lab, use only the admission, mid-admission, and most recent values. Group all values
       for one lab together by lab test not by date.

       These will be recorded in ink on a provided form. References must be listed following
       data, and will be noted in APA format.

C.     TEACHING/LEARNING NEEDS

       The write-up should include teaching needs and instruction given during care and prior
       to discharge. Special home needs should be identified with follow-up action or referral to
       resources. The student should identify and make referrals as necessary for problems
       assessed. The patient's response verbally or behaviorally (skills) must be included.
       Relate each teaching intervention to physiological, psychological, and sociocultural
       dimensions. References must be listed and will be noted in APA format.

D.     STANDARD ANALYSIS OF CARE

       The student will develop an analysis of standard of care for one priority problem utilizing
       Nursing Department forms. References must be listed and will be noted in APA format.
       The following must be included: nursing diagnosis with the defining characteristics,
       outcomes, what should be done with rationale, actual actions, and evaluation of your
       actions. Attach a narrative describing application of the problem to primary, secondary,
       and tertiary prevention.
NUR376 Case Study Format                                                                         4


E.     FORMAT/MECHANICS

       The paper will be graded on the following areas: Neatness, correct spelling, grammar,
       medical terminology and interrelatedness of parts of the case study. All parts of the paper
       must be typed (double-spaced) or written legibly in ink on special forms. The report
       should be turned in with a cover or in a folder with the grading front sheet. References
       must be listed in APA format, e.g. from care plan, TBP, lab, teaching and utilized
       appropriately with content. A final list of references must be typed and included at the
       back of the paper. Within the paper, references listed in APA format must be cited with
       material used.

F.     The textbook picture (and comparison), physical assessment, history, nursing diagnosis
       and developmental evaluation from the clinical experience will be attached as an
       appendix.

G.     The Case Study is due two weeks from the last date of care. A penalty of two points per
       day will be deducted for a late paper. Papers are to be turned in on Tuesday.
                 MISSOURI WESTERN STATE COLLEGE
                   DIVISION OF PROFESSIONAL STUDIES
                        DEPARTMENT OF NURSING

                        NURSING CASE STUDY EVALUATION

 Name                                    Date


 Clinical Area                           Clinical Instructor




                     Section                    Total Possible   Total Received
 A. Introduction                                    10 pts

 B. Diagnostic Procedures & Evaluation              15 pts

 C. Teaching/Learning Needs                         10 pts

 D. Standard Analysis of Care                        10 pts

 E. Mechanics                                        5 pts

                     TOTAL                         50 points




Attach to Case Study.

								
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