I have to create a nursing case study. I have everything I need, but am not sure how to present it. Details: 67 year old causcasain male diagnosed with emphysema returns with shortness of breath, etc. supposedly associated with CHF. Have to have everything including ABCD Assessment as well as meds he is taking and 24 hour diet recall with my modification for health - All I want is an example of how to write it.
These sites seem to have what you need.
http://www.pasadena.edu/hstutoringlab/writing/writingcasestudy.cfm
http://www.referencepointsoftware.com/articles/article-write-a-nursing-case-study-paper/
http://www.ehow.com/how_5724629_present-nursing-case-study.html
Thank you so very much. These websites are a great help to me.
You're very welcome. :-)
When presenting a nursing case study, it is important to organize your information in a clear and concise manner. Here's an example of how you can structure your case study:
Title: Nursing Case Study: Management of Emphysema and Congestive Heart Failure (CHF) in a 67-Year-Old Caucasian Male
Introduction:
- Provide a brief overview of the patient's demographic information (age, gender, race).
- Mention the patient's primary diagnosis (emphysema) and the secondary condition (CHF).
- Highlight the main symptoms or presenting complaint (shortness of breath).
ABC Assessment:
- Airway: Describe the patient's respiratory status, including the presence of shortness of breath, use of accessory muscles, or any signs of airway obstruction.
- Breathing: Discuss the patient's oxygen saturation levels, respiratory rate, and lung sounds.
- Circulation: Address any cardiovascular issues such as edema, abnormal heart sounds, or chest pain.
- Disability: Assess the patient's level of consciousness, neurological status, and presence of any sensory deficits.
Diagnosis:
- Summarize the patient's medical history and diagnostic findings that led to the diagnosis of emphysema and CHF.
- Mention any relevant laboratory results or diagnostic tests, such as chest X-ray or echocardiogram.
Medical Management:
- List the medications the patient is currently taking, specifically targeting the management of emphysema and CHF.
- Provide the rationale for each medication, including the dosage, frequency, and possible side effects.
Dietary Modification:
- Describe the patient's 24-hour diet recall, focusing on the specific modifications made to promote health and manage emphysema and CHF.
- Mention any dietary restrictions or recommended nutritional changes.
- Discuss the patient's compliance with the modified diet and any potential barriers encountered.
Interventions and Nursing Care:
- Outline specific nursing interventions implemented to manage the patient's symptoms and overall care.
- Include any respiratory treatments (nebulizer use, oxygen therapy), education provided, or support measures undertaken.
- Emphasize the collaborative approach (involvement of other healthcare professionals) in achieving patient outcomes.
Evaluation:
- Assess the patient's response to the interventions implemented.
- Discuss any improvements or complications observed since the initiation of care.
- Provide measurable outcomes to showcase the effectiveness of the nursing interventions.
Conclusion:
- Summarize the key points from the case study, including the patient's demographic information, medical diagnosis, and nursing interventions.
- Emphasize the importance of a holistic and interdisciplinary approach in managing patients with multiple comorbidities.
Remember to use appropriate medical terminology, provide evidence-based rationale for your interventions, and maintain patient confidentiality throughout the case study. Good luck with your assignment!