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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