How to Write a Clinical Case Study

 A nursing case study paper contains several sections that fall into three categories:

1. The status of the patient

• Demographic data
• Medical History
• Current diagnosis and treatment

2. The nursing assessment of the patient

• Vital signs(ABCDE) and laboratory results
• Nursing observations(AVPU, mental state)

3. Current Care Plan and Recommendations

• Details of the nursing care plan(including nursing goals and interventions)
• Evaluation of the current care plan
• Recommendations for changes in the current care plan (if required)

Patient Status

The first portion of the case study paper will talk about the patient — who they are, why they are being included in the study, their demographic data (i.e., age, race), the reason(s) they sought medical attention and the subsequent diagnosis. It will also discuss the role that nursing plays in the care of this patient.

Next, thoroughly discuss any disease process. Make sure you outline causes, symptoms, observations, and how preferred treatments can affect nursing care. Also, describe the history and progression of the disease.

Some important questions for you to answer are:

• What were the first indications that there was something wrong?
• What symptoms convinced the patient to seek help?

Nursing Assessment

• When you are discussing the nursing assessment of the patient, describe the patient’s problems in terms of nursing diagnoses.
• Be specific as to why you have identified a particular diagnosis. For example, is frequent urination causing an alteration in the patients sleep patterns?
• The nursing diagnoses you identify in your assessment will help form the nursing care plan.

Current Care Plan and Recommendations for Improvement

• Describe the nursing care plan and goals and explain how the nursing care plan improves the quality of the patient’s life.
• What positive changes does the nursing care plan hope to achieve in the patient’s life?
• How will the care plan be executed?
• Who will be responsible for the delivery of the care plan?
• What measurable goals will they track to determine the success of the plan?

Discussion

• The final discussion should be your personal recommendations. Based on the current status of the patient, the diagnosis, prognosis, and the nursing care plan, what other actions do you recommend can be taken to improve the patient’s chances of recovery?
• You must support your recommendations with authoritative sources and cite appropriately

Clinical Case Study and Reflection

Word Limit: 4000.

The purpose of this case study is the integration of nursing theory and practice in the context of the care of a patient with complex health conditions.

The focus of this assignment is the formulation of a plan of care taking this complexity into consideration.

The case study will have the following components:

Introduction including the context of the case and a statement confirming written consent was received for the collection of de-identified clinical information for the purpose of education; a pseudonym must be used and stated as such, with all other potentially identifying patient data anonymised at source.

A comprehensive health assessment, incorporating the underlying pathophysiology should be documented and include assessment tools and diagnostic results used (e.g. falls risk assessment, x-rays, pathology results etc.).

A plan for the care of the patient which details at least four identified problems and SMART goals of care related to your assessment, and the interventions (with rationale) that follow from these established goals.

Expected outcomes resulting from the interventions:

A comprehensive discussion of the care planned following from the psychosocial assessment – relating this to both person-centred care and strength-based nursing theories.

Presentation of medications used in the pharmacological therapy for the patient and nursing considerations noted from this patient in regard to these therapies.

Critical thinking should be indicated by the use of best practice guidelines documented where appropriate and the application of current and relevant references.

The purpose of this critical reflective practice section is the development of deeper understanding, professional judgement and clinical skill. The focus of this section is the exploration and examination of an experience from clinical practice that resulted in new learning and development of professional actions.

The critical reflective essay will have the following components:

Introduction including a statement of the discrete event or experience and the identification of a selected reflective framework and theorist such as Gibbs (1988), Johns (2000), Driscoll (1994), Atkins and Murphy (1994) GIBBS ONE IS EASIER

An account of the clinical event (patient/s and staff must be de-identified)

Examination of professional behaviour, thoughts, and feelings in response to the event, key influencing factors and relevant professional ethics

Connections to relevant literature and theory

Clinical reasoning informed by evidence, theory, research and broader professional perspective

Demonstration of progression of thoughts, knowledge and skills within clinical practice.

CONTENT: Comprehensive demonstration and understanding of the underlying pathophysiology of the complex conditions and how the comprehensive health assessment results relate to this, is evident. Identifies four nursing diagnoses and goals of care with extensive, and appropriate interventions (with rationale) based on these goals for this individual with complex needs . Extensive in-depth discussion around the expected outcomes resulting from the above interventions is comprehensively supported by literature. An informed and comprehensive discussion related to person centred care and strengths-based nursing theory on the planned care. Concise synthesis and analysis of the pharmacological therapy used for the patient and extensive discussion of the nursing considerations in regard to these therapies. Concise synthesis and analysis of the clinical event (ensuring confidentiality). Clear integration of clinical reasoning to inform the discussion of evidence, theory, research and the broader professional perspective in relation to the chosen clinical event. Extensive and appropriate understanding of the chosen theorist and reflective framework.

COGNITIVE SKILLS: Comprehensive and extensive analysis of the material and its relevance to the topic. Concise synthesis and analysis of best practice guidelines related to the identified goals and plan of care. An in-depth analysis of the relevant material and demonstrates its relevance to the topic. Provided an in-depth evaluation of best practice guidelines related to the identified goals and plan of care. Critically analyses the relevant material and demonstrates its relevance to the topic. Where appropriate has critically evaluated best practice guidelines related to the identified goals and plan of care. Introduction orientates to topic and conclusion provides overview of findings. Critical analyses of the relevant material is not evident and limited demonstration of its relevance to the topic. No demonstration of critical evaluation of best practice guidelines related to the identified goals and plan of care. 21 Extensive, and appropriate discussion of the chosen clinical event in relation to professional behaviour, thoughts and feelings in a way that develops clear integration of relevant literature and theory. The introduction is comprehensive and identifies the line of reasoning which is structured and clearly articulated. The conclusion identifies key findings and may also provide recommendations for consideration.

PRESENTATION: The assignment is scholarly, there are few errors in grammar, spelling or referencing. Within word limit..

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