This case study is a typed (APA format) paper on a patient that the PN student took care of in clinical (or a simulation scenario given to the student by an instructor if applicable). The project must include all of the following:
Patient’s current/admitting medical diagnosis. (If not included, the paper will be returned. Points will be deducted for each day late if it is resubmitted past the assigned due date. See syllabus for policy.)
A summarized patient past medical history. Include past medical history, past family history, past social history and any allergies. Describe what each diagnosis means in this section in your own words.
Describe what signs and symptoms are typically present with the patient’s admission diagnosis, even if they are not seen in your patient. Describe what this diagnosis means in your own words, and what typical treatment entails. Describe the patient’s presenting signs and symptoms, and what signs and symptoms they currently have, if developed or changed after admission.
Explain patient’s full list of prescribed medications (both scheduled and PRN). Include all pertinent information in your own words such as brand and generic names, dosage, route, time and frequency of administration. The patient selected must have at least 5 medications Do NOT include discontinued medications. Citations and references should be included as appropriate.
Provide a detailed interpretation of each medication prescribed. Include indication for use in your patient, action and expected outcome from use of each medication, the most common and most concerning adverse effects that nurses should monitor for, and any nursing assessments that are required before or after administration of the medications. What assessments/observations did you perform/see for your patient that indicated each medication was having the intended effect? If you didn’t see any of these effects, at least describe what would tell you they were working (for example, an antihypertensive drug should be lowering or keeping the blood pressure normal). Name assessment findings that would have prevented you from administering specific medications to this patient and why. Citations and references should be included as appropriate.
Describe patient’s pertinent lab values to their condition. Indicate the reason that these labs are pertinent to the patient. Provide and interpretation of how these values relate to the patient’s current medical condition and/or medication regimen. Provide both your patients lab results, as well as normal lab values. This needs to be cited and referenced.
Summarize patient teaching required for the medications that the patient is on. Include an assessment of the topics that are necessary to include for the patient, the rationale for why those topics need to be taught to the patient, and the approach that would be most effective for the patient. Includes non-pharmacologic methods that could be utilized to enhance the action of the patient’s medications. Citations and references included as appropriate.
There is not a number of pages specified and I already have a patient and their medical history and medication. I can forward all this information upon request.
