Nursing Case Study

NURS 2290 Case Study

Student: _______________________________________ Date care was provided:__________________

Directions: Complete this case study on your assigned client. You will submit your preclinical preparation form with this case study. This form is due one week after you have cared for the client. Use APA citation every time you look up information from a resource. Include a reference list.

1. Pathophysiology of primary health concern. 3 pts

What is the reason for the client hospitalization? ______________________

Describe the disease process in your own words.

What is the recommended treatment for this condition? (include citation where you got this information).

2. Complications. 3 pts

Identify any complications that your client developed during this hospitalization?

What potential complications is this patient at risk for?

What interventions will help prevent complications?

3. Safety. 3 pts

What threatens this patient’s safety at this time? What can you do to protect him/her? Is client aware of safety concerns?

4. Priorities/Care Plan

Your priorities may have changed after you cared for your client (or it may be the same as you identified prior to patient care). Identify two priority physical problems and one psychosocial priority.

8 pts

Defend why you selected this as top priority.

#1 Nursing Priority Physical Problem you identified during your clinical day:
Data that supports this as your priority:
		Defend why you selected this as top priority.
Expected Patient Outcome (written as a smart goal):
Priority Nursing Interventions Rationale (include citation) (Include at least 5 1. 1. 2. 2. 3. 3. 4. 4. 5. 5.
Evaluation of Expected Patient Outcome:
Has the overall status of the patient improved, declined, or remain unchanged? What changes would you make to your plan of care to assist the patient in meeting the expected patient outcome?
#2 Nursing Priority Physical Problem you identified during your clinical day: 8 pts
	Data that supports this as your priority:
	Expected Patient Outcome (written as a smart goal):
	Priority Nursing Interventions Rationale (include citation) (Include at least 5) 1. 1. 2. 2. 3. 3. 4. 4. 5 5.
	Evaluation of Expected Patient Outcome:
	Has the overall status of the patient improved, declined, or remain unchanged? What changes would you make to your plan of care to assist the patient in meeting the expected patient outcome?

Data that supports this as your priority:

Defend why you selected this as top priority.

Expected Patient Outcome (written as a smart goal):

Priority Nursing Interventions Rationale (include citation)
(Include at least 5)
1. 1.
2. 2.
3. 3.
4. 4.
5 5.

Evaluation of Expected Patient Outcome:

Has the overall status of the patient improved, declined, or remain unchanged? What changes would you make to your plan of care to assist the patient in meeting the expected patient outcome?

#1 Nursing Priority Psychosocial Problem you identified during your clinical day: 8 pts

5. Patient Education: 3 pts

What did you teach your client during your clinical shift?

What methods did you use to teach the information?

Identify factors that could/did affect your client’s ability to learn.

How did you evaluate if the client understood what you taught?

Identify other topics that would have been appropriate to teach this client?

6. Health Promotion: 3 pts

What does the client do to stay healthy?

What goals does the client have to improve their health?

What suggestions could you give the patient to promote health?

7. Growth and Development: 3 pts

Identify the developmental stage of your client according to Erikson. ________________

How does the developmental stage of your client impact the care that you provide?

8. Cultural Issues/Social Roles 3 pts

Identify the various groups that this client is a member of. How will this hospitalization effect the client in fulfilling his/her social role? Are there any cultural norms that the nurse should be aware of to provide holistic care?

9. Ethics/Legal 3 pts

Identify potential or real ethical issues that could or did occur?

10. Discharge Plan: 3 pts

Discuss discharge plans and needed referrals.

11. Journal Article: 3 pts

Find a journal article that applies to the care of this client. Article must be an evidenced based article from a medical/nursing journal, written by a healthcare provider, and is less than five years old. You must either attach the article or provide a working link to the article.

How could you use the information in this article to validate the care that was provided or make suggestions to improve care?

12. Self-Reflection: 4 pts

What did you learn today that you can apply to future patients you care for?

What did you do well today?

What could you have done better?

What is your plan to make any weaknesses a future strength?

13. APA 2 pts

Citations were completed appropriately. Reference list correctly done.

PatientInformation I collected on clinical day

Please use below information to assist with assignment.

Client is an 87 yrs old male

Diagnosis: Pulmonary Thromboembolism

Last Wt: 84.7 kg (186 lbs 11.7 oz)

Code Status: NCB (No code blue)

Vitals: T-96.3, P-86, R-18, BP-108/55, and 02 sats 92 % on room air.

Medications Presently taking

1. Amoxicillin-pot Clavulanate 875 mg BID orally

2. Carbamazepine (Tegretol x R) 200 mg TID orally

3. Enoxaparin (Levenox) 1 mg/kg subcutaneous Q12H

4. Furosemide (Lasix) 10 mg/ml 60 mg IV BID

5. Lisinopril (Zestril, Prinivil) 2.5 mg daily orally

6. Potassium Chloride (klor-con) 20 mEq BID orally with meals

7. Gabapentin 100-200 mg BID orally. 100 mg (1 cap) at 11 am and 200 mg (2 caps) at 5 pm.

8. Quetiapine (Seroquel) tab 25 mg orally at night.

9. Spironolactone (Aldactone) 12.5mg daily by mouth

10. Tamsulosin (Flomax) 24 hours capsule 0.4 mg daily by mouth

On admission x-ray did confirm substantial pleural effusion on the left side. This may be contributing to his symptoms of shortness of breath, fatigue and low blood pressure. There were also presence of pulmonary emboli and possible pneumonia, he was admitted for further management of these issues.

Patient is generally oriented to person and place though not time. He has periods of confusion and difficulty with memory.

Plan: patient will be discharge to skilled nursing facility once medically stable but OT and PT continue to see him 1-2 times a day during his remaining inpatient stay.

OT- continue to see patient 1-2 times a day to assist with selfcare management training.

PT- see patient 1-2 times per day working on increasing his exercise tolerance and independent with transfers while maintaining oxygen saturation greater than 90.