NURSING CASE STUDY: 1. Cover page 2. Table of Contents 3.

Rationale >must be 1 1/2 page >should give an overview of the rotation, case, patient >statistics of the case should be provided (international, national, local) >implications to Nursing Research, Practice & Education 4. Goal & Objectives >SMART >KSA >BLOOMS TAXONOMY 5. Data Base A. BIOGRAPHICAL DATA --Follow History form B. CLINICAL DATA i. chief complaint ii. date of admission iii. admitting dx iv. ward v. attending physician vi. date of discharge vii. final dx C. FAMILY HEALTH HISTORY i. Genogram

ii. Narrative D. PAST HEALTH HISTORY --Follow history form E. HISTORY OF PRESENT ILLNESS >should start from the 1st onset of manifestation >follow history form >narrative presentation F. DEVELOPMENTAL TASKS a. Psychosocial theory (Erikson) -brief discussion of the theory -tabular presentation of the tasks Stage Central task Actual Justification (Met or unmet)

b. developmental tasks theory (Havighurst) -brief discussion of the theory -tabular pres. of the tasks Developmental Tasks Actual Justification (Met or Unmet)

6. PHYSICAL ASSESSMENT/NEURO ASSESSMENT 7. DEFINITION OF DIAGNOSIS -must have minimum of 3 definitions from diff. book sources or electronic sources -complete statement of reference must be stated every after each definition 8. ANATOMY AND PHYSIOLOGY 9. PATHOHYSIOLOGY A. Etiology

i. Predisposing factors Present/Absent ii. Precipitating Factors Present/Absent Mechanism/Rationale Mechanism/Rationale

B. symptomatology Signs & Symptoms Manifestations Mechanism/Rationale

C. Schematic Tracing D. Narrative pres. 10. MEDICAL MANAGEMENT A. Diagnostic Exams (actual & possible) -tabular pres. Of all dx exams done -arrange accordingly -separate per type of procedure -if test is done >1, results should be tabulated as one -landscape format a. Actual 1. Laboratory tests Date Compone nt Definition & Normal Range Rationale Result Interpretati on & Significanc e Nursing responsibilit ies

2. Diagnostic exams Date Test Rationale Result Interpretati on & Significance Nsg resp.

b. Possible laboratory & diagnostics B. Medical Therapeutics (IVF, BT, Diet, Activity, Procedures) Date Order Rationale

c. Drug Studies 11. Nursing care A. NCP -5 NCPs -must have actual, risk/potential, and/or wellness potential problems B. Discharge Planning Medication -health teachings then rationale Exercise -health teachings then rationale Treatment -health teachings then rationale Hygiene -health teachings then rationale Outpatient -health teachings then rationale Diet -health teachings then rationale 12. Prognosis -good, poor, or fair -narrative

-supplement with related literature 13. References -arrange alphabetically -follow APA format