I have attached what needs to be filled out for this care plan project
Please use the document below to complete the following activities:
You will complete a case study focused on one of the body systems we studied this semester.
This will not be a research paper on the disease. Instead, you will take the information that you have learned in this course, along with your own additional research, and apply it to a typical patient. This is the true meaning of applied science. You MUST use the form that is below. The form must be typed and not handwritten.
You will create an imaginary patient and produce a medical chart that reflects his/her condition, treatment, and outcomes. Why did they seek medical attention? What are the objective and subjective signs and symptoms? What are the medical history and the medical history(s) of his immediate family? What clues do the vital signs and physical exam provide? Which diagnostic studies will be ordered, and what results would be consistent with his condition? Anything necessary to diagnose and treat this patient must be documented. A detailed rubric has been provided and should be carefully reviewed and followed for the best results.
Tips for Success
1. Research your disease. Always try to look at this research as a living document, representing the experiences that a real-life patient would have.
2. Always look at your disease as being a link to a body system. If you are clear on how that system typically works, then you can quickly figure out what must go wrong for this disease to occur.
3. Once you know what has gone wrong in the body, you begin to see what those malfunctions would do to a patient.
What signs and symptoms would they have?
How would that patient know that something was wrong? This is usually what would bring them to the doctor.
Please describe your patient as you first encounter them, including signs/symptoms, general appearance & primary complaint. This is an excellent way to start a case study.
4. In studying your disease, you may notice that it is strongly linked to family history or social habits.
Bronchitis can be linked to smoking, cirrhosis can be linked to drinking, heart disease can be linked to poor diet or lack of exercise, and many diseases seem to run in the family, like cancer. Your imaginary patient might have some of these concerns. That is up to you. Listing them shows that you are thinking about every aspect of your disease.
5. Determine what your patient’s vital signs would be and what you might find in a physical exam (paying particular attention to a thorough inspection of the body system involved).
Complete a head-to-toe nursing assessment with typical assessment findings for this disease process.
This includes blood pressure, pulse, respiratory rate, oxygen saturation, and temperature. Once you familiarize yourself with normal measures, you can easily find approximate changes which would reflect the appropriate status of your patient.
Would the blood pressure or pulse rise or fall?
Would they have a fever? In other words, if their blood pressure reading would likely be higher than usual, give them a reading above the normal range. Note this on your report.
Any other unusual signs or complaints like pain or dizziness should also be noted.
Also, note any alterations from your head-to-toe physical examination or system-specific exam.
6. Write a narrative nurse’s note that includes all of your findings.
Summary of pertinent Health History and Review of Symptoms
Positive & Negative Physical Exam Findings
Diagnostic Findings
Medications
Complete a medication reconciliation by determining the medications this patient would be on before admission.
Determine what medications you would expect the provider to prescribe for this patient based on the disease process
7. Now comes the fun. You have your patient’s baseline information, such as vital signs, symptoms, and relevant history. You also have the findings from your own examinations.
Does this information guarantee that your patient will be diagnosed with your particular disease? Probably not. This is where a medical professional would pursue these “leads” and order diagnostic testing. Blood tests, x-rays, EKGs, etc. Whatever fits in your particular case. Nothing extravagant, but be realistic.
List these tests with normal results. What would you expect to see in the results? For example, would a particular lab value be higher or lower than the normal range?
For example, if your patient has pneumonia, a chest x-ray would probably be ordered and show a clouded area in the lung. Normal results would be a clear lung picture with no clouding. Any infection would increase the white blood cell count, etc. Numerous classroom and internet resources can help you find this information.
8. You now have enough information to create a care plan for your patient.
Develop the concept map with your assessment findings
Determine your priority nursing diagnosis for this patient.
Determine the resources you will need to provide for the patient
9. With the information you have about your patient and their disease process, create an educational handout for this patient about their disease process and medications.
10. Now you have done a complete clinical study on a patient. You will put all this information into the template provided in the case study packet provided in this assignment’s resources below.
You will submit your completed case study packet.
Please use the sheet as a general guide to complete this case study. Additionally, review the rubric and check-off sheets provided before turning in your case study/care plan.
Good luck and have fun!!
