Case Report:
Based upon the Horizons Hospital & Health Service (HHHS) Mary Young, construct a case report. The case report will draw upon your knowledge of pathophysiology and relevant academic literature to support an evidence-based plan of care.
Headings and a description of the content for each section of the report have been provided. These serve as a guide for how you will present your case report; however, it is important that all sections of the report are conceptually connected. For example, your knowledge of pathophysiology and your understanding of this particular client should underpin the nursing problems that you identify which should, in turn, drive the nursing management that is relevant for this clinical situation.
The case report should include the following:
Introduction (150 words)
Introduce the client and provide a brief overview of their case. Provide an outline of the purpose and structure of the report.
You might like to think about the overview of the case study like a verbal clinical handover: what is the key information from the HHHS patient information, progress summary and medication chart that would be relevant for the plan of care for this client?
Primary admission diagnosis (200 words)
Identify the primary diagnosis for the client (i.e. the reason the client was admitted to the HHHS). Provide a brief description of the pathophysiology for the primary diagnosis.
As part of this discussion, it is important to relate the pathophysiology to client’s risk factors and relevant previous medical history.
Nursing problems (200 words)
Use your knowledge of pathophysiology and the subjective and objective data provided in the HHHS progress summary notes to identify five (5) nursing problems that may arise as a result of the client’s primary diagnosis. These problems may be actual or potential nursing problems. Provide a brief description for why these problems may arise for this client.
From these, select two (2) nursing problems as the focus for the remainder of the case report. Provide a rationale for your selection.
Nursing Management (600 words)
The nursing management should focus on the nursing assessment, nursing interventions and the role of the Registered Nurse (RN) related to medication management for this client and will address the two (2) selected nursing problems.
Nursing Problem 1: Nursing assessment, nursing intervention, medication management.
Discuss one (1) method of nursing assessment that would need to be performed related to the ongoing
nursing management of this nursing problem. Provide a rationale for this type of assessment and briefly
describe how this assessment would be conducted in this case.
Discuss one (1) nursing intervention that you would need to implement related to the ongoing nursing
management of this nursing problem. Provide a rationale for the intervention.
Discuss the role of the RN in the medication management related to the ongoing nursing management
of this nursing problem.
Nursing Problem 2: Nursing assessment, nursing intervention,medication management.
Discuss one (1) method of nursing assessment that would need to be performed related to this nursing problem. Provide a rationale for this type of assessment and briefly describe how this assessment would be conducted in this case.
Discuss one (1) nursing intervention that you would need to implement related to the ongoing nursing management of this nursing problem. Provide a rationale for the intervention.
Discuss the role of the RN in the medication management related to the ongoing nursing management of this nursing problem.
Discharge planning (250 words)
Identify five (5) issues/challenges that you may need to address for this client prior to discharge home. Discuss how you would facilitate discharge planning for this client, with consideration to two (2) of these concerns?
