In order to write a paper on a case study, you must carefully address a number of sections in an exact order with specific information contained in each.
The guideline below outlines each of those sections.
Section Information to Include
Patient Information & Chief Complaint
Explain who the patient is. (age, gender, etc.)
Explain the problem. (What were they diagnosed with, or what led up to their medical issues?)
Introduce your main argument. (What should you as a nurse focus on or do?)
Explain the disease. (What are the symptoms? What causes it?)
Medical, Surgical, & Social History
Explain what health problems the patient has. (Have they been diagnosed with other diseases?)
Describe any surgeries the patient has had. Why were they performed?
Socioeconomic/Cultural/Spiritual Orientation & Psychosocial Considerations/Concerns (can include education, economic stability (ie. Do they have medical insurance? Are they on a fixed income?), support systems, environment/neighborhood, occupation, ethnicity, religion, etc.
Nursing Physical Assessment
List all the patient’s health stats in sentences with specific numbers/levels (blood pressure, temperature, heart rate, respirations, oxygen saturation, pain level, height, weight, BMI, etc.)
Discuss any abnormalities in the physical assessment. It’s easiest if you break the assessment into a Review of Systems (neurological, cardiovascular, respiratory, gastrointestinal, genitourinary, integumentary, endocrine, psychosocial, etc.)
Include diagnostic tests completed. (X-Rays, CT scan, MRI etc.)
Include laboratory results with normal levels listed with the abnormal findings. Explain the cause of any abnormal results.
Explain what treatments the patient is receiving because of their disease.
List all medications that the patient is taking. Include over-the-counter medications and supplements. Be sure to state important nursing considerations for each one (Does it need to be given with food? On an empty stomach? Does it have to be given by a particular route? Are there adverse reactions, interactions, or contraindications to be aware of?)
Nursing Diagnosis & Patient Goals
Explain what your nursing diagnosis is. (What is the main problem for this patient? What need to be addressed?)
Explain what your goals are for helping the patient recover. (What do you want to change for the patient?) You must have a minimum of two goals.
Explain how you will accomplish your nursing goals, and support this with citations (reference the literature).
Be sure to include at least three interventions for each goal. Try to make the interventions patient-focused instead of nurse-focused (“Patient will…” instead of “I will…”)
Explain if the nursing intervention was effective. (What happened after your nursing intervention? Was there an improvement in the patient’s condition?)
Were the patient goals met? If not, how would you revise your goals or your interventions to ensure better success?
Explain what the patient or nurse should do in the future to continue recovery/improvement.
Include any important patient teaching that would help the patient continue to care for themselves going forward.
Your paper should be 3-4 pages in length and will be graded on how well you complete each of the above sections. You will also be graded on your use of APA style and on your application of nursing journals/literature into the treatments, interventions, pathophysiology, and discharge teaching. For integrating nursing journals and literature, remember the following:
Make sure to use in-text citations throughout your paper.
Support all claims of what the disease is, why it occurs, and how to treat it with references to the literature about 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.).