Abstract (maximum of 150 words) Case Presentation – This should be thorough, and
Abstract (maximum of 150 words)
Case Presentation – This should be thorough, and professionally written describing the patient and the problem(s) they are having. Include descriptions of the environment, patient actions, family involvement, communication, etc.
Items to include:
1. Introductory sentence: e.g. This ____ year old ______ (profession, or retired etc. e.g. office worker – retired secretary — farmer) presented for the treatment of ______________.
2. Describe the essential nature of the complaint, including location, intensity and associated symptoms, vital signs; e.g. Her headaches are primarily in the suboccipital region, bilaterally but worse on the right. Sometimes there is radiation towards the right temple…..
3. Further development of history including details of time and circumstances of onset, and the evolution of the complaint: e.g. This problem began to develop three years ago when….
4. Describe relieving and aggravating factors, including responses to other treatment: e.g. The pain seems to be worse towards the end of the work day and is aggravated by…. __________ provides some relief
5. Include other health history (medical and surgical) (What other co-morbidities or other coexisting problems would a patient with your diagnosis have?)
6. Include family history, if relevant (Are there any genetic or familial tendencies a patient with your diagnosis would have?)
7. Objective data based on your scenario
a. Complete assessment including each body system (Use medical terminology with only accepted abbreviations, do not document by exception)
8. Subjective data based upon your scenario (Include any appropriate quotes from the patient)
a. Identify associated pathophysiology related to the topic.
b. Appearance (posture, body movements, dress, grooming)
c. Cognition (orientation, concentration, recent and remote memory, judgment, insight)
d. Thought processes (content, process, perception)
9. The patient presented with (chief complaint) and was admitted for (medical diagnosis)
Diagnostic, Management and Outcome
1. Describe as specifically as possible the diagnostic methods for diagnosing your patient’s condition
2. Describe as specifically as possible any laboratory tests including expected values expected to be found with the diagnosis of your patient
3. Describe as specifically as possible the treatment provided, including the nature of the treatment, and the frequency and duration of care. This will include any medications, treatments, therapies, adjunctive disciplines.
4. Where indicated, include an objective measure of the patient’s progress: e.g. The patient maintained a blood pressure diary indicating that she was able to….
5. Describe the resolution of care: e.g. Based on the patient’s report of decreased pain upon ambulation during physical therapy treatments, she received an additional two weeks of physical therapy on an outpatient basis. Following a total of four days care, she was discharged.
Develop the Plan of Care (YOU MAY USE THE FORMAT BELOW – use one for each of the three diagnosis)
1. Nursing diagnosis: Provide three correctly written priority nursing diagnosis including supporting data from your assessment.
2. Goals: Develop three goals for each nursing diagnosis above.
3. Interventions: Develop three interventions you will implement to meet each goal
4. Rational: Include EBP rationales for each intervention (cite all sources*)
a. *Sources: You must use a different source for each intervention rationale per goal. For example, for one goal with three interventions you can use (1) your textbook, (2) evidence-based article, and/or (3) the Internet. Sources must be scholarly and published within the past five years.
5. Teaching points: Include all appropriate teaching for patient and caregivers
NURSING DIAGNOSIS: _______________________________
Interventions Rationale Source
NCLEX Questions with Rationale:
Develop three exam questions based upon your scenario. DO NOT copy an exam question from a NCLEX book or your textbook. Your questions should be specific to your scenario (the answer should be discernible from your assessment data, nursing diagnosis goals, interventions, or rationale). *Include the correct answer and the rationale for the correct answer (including a source) after each question you develop.
Recorded verbal SBAR – Utilizing Canvas Studio, record and upload appropriate SBAR handoff report as though you are exchanging information with the nurse who will be assuming care from you
S : Situation – State Name, Unit, Patient, Problem
B : Background – Admission Diagnosis, Pertinent history, Current treatments
A : Assessment – Current VS, Physical assessment, Test results
R : Request – Needs MD/MLP evaluation, Further testing, Transfer to higher level of care
S: This is Jane Doe, 78 year old female under Dr. So-And-So. A/O x 3 but forgetful. No allergies, No isolation, full code.
B: She came in with pneumonia. Her past medical history includes COPD and diabetes. She came in yesterday (blah blah blah)…
A: (Vital signs) Her vital signs are stable. Afebrile. No pain.
(Activity) She can get out of bed to chair with 1 assist.
(IVs) She has 2 peripheral IVs in the right AC from two days ago. No drips but gets IV antibiotics.
(Skin) Her skin is intact. Palpable pulses.
(Lungs) She’s on 2 L nasal cannula sating 95%. Lungs diminished bilaterally.
(GI) Active bowel sounds. Regular diet. Last bowel movement was today.
(GU) Voids. Good urine output.
(Glucometer) No fingerstick.
(Labs) She needs a CBC and BMP in the morning.
Current labs Her WBC is elevated.
R: I recommend ID (infectious disease) consult on her.
APA Reference page