Students will build upon and apply previously acquired knowledge and skills from prior courses while integrating the pathophysiological concepts and nursing process for care provided to patients with health alterations and/or disorders related to current course content discussed. Students will present a case study of a patient, with health alterations and/or disorders related to current course content, they provided cared to during their clinical rotation. The case study should integrate concepts of health promotion, maintenance, and restoration as well as concepts of promoting patient- centered care, safety, interdisciplinary teamwork, communication, and evidence-based practice..
Rubric is the Grading Sheet attached.
Please enter the information in the attached Case study
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Pathophysiology: what brought the patient to the facility? What is their primary diagnosis of concern? All others will go under brief medical history, but be sure to tie any pertinent points in your verbal report. References for your information should be in APA format.
Expected Symptoms: Refer to rubric.
Targeted physical assessment: refer to rubric.
Actual findings: document actual physical assessment for each focus system to include a general survey. Refer rubric.
Nursing Diagnoses: Use 3 of your patient’s problems 2 actual and 1 at risk for issue.
Intervention: (3) Why are the interventions you selected most important? How are they patient-centered? Did you base them on your patient’s values, preferences and expressed needs? Was the family included in determining patient’s needs? Refer to rubric for further instructions.
Rationales: (3)Were your interventions individualized based on patient values, clinical expertise and evidence? How did you know you selected interventions that are supported by evidence-based practice? Be sure to cite resources using APA format with references listed on a separate sheet. Refer to rubric for further instructions.
Evaluation/Response: (3)Were outcomes or responses to care less-than-desired or resulted in an adverse event? If so, what would you do differently?
Teaching Plan: Refer to teaching requirement sheet. You will be responsible to teach a student, selected in your class, your teaching plan. Act as if this is your actual patient and go through the steps of the teaching process based on a knowledge deficit.
Resources: Who should be involved in the patient’s care? Who played a role in helping the patient/family achieve health goals? How did teamwork and collaboration promote the patient care and effect the outcome of care? How was this care communicated? Was the patient and family included as a core member of the health care team? Refer to sheet for further instructions. Medications: Refer to rubric if you need more room use another sheet of paper.
What was the most interesting thing you learned about this patient: Refer to rubric.
Safety: Describe factors that create a culture of safety. How were observations or concerns related to patient safety communicated to families and the health care team? Discuss any potential and/or actual impact of national patient safety resources, initiatives and regulations related to your patient and the care setting of your clinical rotation. Refer to the National Patient Safety Goals for your particular setting at http://www.jointcommission.org/standards_information/npsgs.aspx. Refer to case study rubric for further instructions.
Lab tests and treatments: Refer to rubric.
Report Sheet: Refer to rubric. May use a separate sheet of paper for this section.
All work is to be typed and required to be submitted to the grading instructor. For classroom presentation you are to verbally present in the order designated below.
I will complete the current orders, laboratory and diagnostic tests, head to toe assessment,
and medication list.
Patient history to be used for Case Study :
The patient was admitted for Acute Respiratory Failure with Hypoxia, Atrial Fibrillation, and
Stroke (CVA).
The patient is 77 year old veteran who was tranferred to Continue Care Hospital due to
acute respiratory failure with hypoxia requiring tracheostomy placement on 2/16/2024. The
patient initially was admitted to Prisma Health Hospital due to a fall in his bathtub where he was found unresponsive. The patient has a significant medical history of atrial fibrilliation
and is taking Xarelto. Due to the blood thinning effects of the medication, when the patient
fell it made it easier for him to develop a nontramatic intracerebral hemorrhage with
intraventricaular extension; which prevented the body from getting oxygen into blood or
getting carbon dioxide out of his blood resulting in acute respiratory failure with hypoxia.
Since the patient’s transfer to Continue Care Hospital on 3/1/2024; the medical staff has
consulted a pulmonary for airway placement and tach weaning.
