Clinical Case Study
Instructions
Purpose
As you are learning this semester, the role of the nurse is to integrate and apply knowledge from your general education background, health-related sciences, and evidence-based nursing science in the application of the nursing process to the nursing care of patients in the acute care setting. The nurse uses knowledge from pharmacology, anatomy and physiology, pathophysiology, microbiology, nutrition, psychology, and other sciences to build a plan of care according to the health assessment findings generated by the nurse. Nursing is practiced within an interdisciplinary health care system, and it is important for the nurse to understand the perspectives of other disciplines in their contribution to the patient plan of care. For this assignment, you will use the case study provided or choose a client from your clinical rotation. You will complete an in-depth analysis of the nature of their health alterations, the pathophysiological and psychosocial aspects of their health needs and how the interdisciplinary team contributes to the treatment plan while the patient is in the hospital and has plans for discharge are put into action.
Directions
1. Read the information about the case study with the chart materials provided or gather the necessary information from one of your patients.
2. Review the patient assessment information. What other assessments might you do in addition to those provided? What findings would you anticipate with this patient? Develop a care plan (use the template provided) based on the highest priority problem (1 nursing diagnosis, 2 goals, 3 interventions for each goal, 2 rationales for each intervention and evaluation for each goal). Complete an in-depth analysis reflecting your ability to prepare a case study based on principles derived from pharmacology, pathophysiology, psychology, nutrition, and evidence-based nursing practice guidelines. Remember to include an introduction to the patient, pathophysiology, history, nursing assessment (given and any additional), and related treatments.
3. Include selected references for your case study paper/care plan and use APA format.
4. A specific grading rubric is attached.
Criteria
A case study is specific, analytical, conceptually sound and based on scientific principles and application of knowledge, reflects evidence-based nursing care approaches and science, and is holistic in its approach to understanding the patient and his/her nursing care needs.
Assignment File(s)
Rubric
NU 448 - Case Study Rubric
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NU 448 - Case Study Rubric
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Criteria
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Ratings
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Pts
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This criterion is linked to a Learning OutcomeIntroduction to patient
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10 to >9.0 pts
High Proficiency (Level 5)
clearly explains who the patient is (age, gender, etc.), what the problem is, and what you are focusing on regarding care of this patient
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9 to >8.0 pts
Moderately High Proficiency (Level 4)
Contains both elements of High Proficiency and Moderate Proficiency
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8 to >6.0 pts
Moderate Proficiency (Level 3)
vaguely explains who the patient is, what the problem is, and what you are focusing on regarding care of this patient; missing 1 of above areas
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6 to >4.0 pts
Low Level Proficiency (Level 2)
Contains both elements of Moderate Proficiency and Non- Proficient
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4 to >0.0 pts
Non- Proficient (Level 1)
lack of introduction to the patient; missing 2 or more areas in first 2 columns of this row
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0 pts
Non- Performing (Level 0)
Not attempted/not submitted
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10 pts
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This criterion is linked to a Learning OutcomePathophysiology
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10 to >9.0 pts
High Proficiency (Level 5)
Clearly and concisely discusses the disease, manifestations, and causes
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9 to >8.0 pts
Moderately High Proficiency (Level 4)
Contains both elements of High Proficiency and Moderate Proficiency
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8 to >6.0 pts
Moderate Proficiency (Level 3)
vaguely or missing minimal information regarding the disease, manifestations, and causes
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6 to >4.0 pts
Low Level Proficiency (Level 2)
Contains both elements of Moderate Proficiency and Non- Proficient
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4 to >0.0 pts
Non- Proficient (Level 1)
Missing important information regarding the disease, manifestations, and causes
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0 pts
Non- Performing (Level 0)
Not attempted/not submitted
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10 pts
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This criterion is linked to a Learning OutcomeHistory
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10 to >9.0 pts
High Proficiency (Level 5)
Clearly and concisely discusses patient’s health history & past treatments including prior surgeries and prescribed medications
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9 to >8.0 pts
Moderately High Proficiency (Level 4)
Contains both elements of High Proficiency and Moderate Proficiency
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8 to >6.0 pts
Moderate Proficiency (Level 3)
Vaguely discusses patient’s health history & past treatments including prior surgeries and prescribed medications
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6 to >4.0 pts
Low Level Proficiency (Level 2)
Contains both elements of Moderate Proficiency and Non- Proficient
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4 to >0.0 pts
Non- Proficient (Level 1)
Missing important information regarding the patient’s health history & past treatments including prior surgeries and prescribed medications
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0 pts
Non- Performing (Level 0)
Not attempted/not submitted
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10 pts
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This criterion is linked to a Learning OutcomeNursing Physical Assessment
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20 to >18.0 pts
High Proficiency (Level 5)
Clearly and concisely lists all patient’s assessment data in sentences with specific numbers/levels
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18 to >16.0 pts
Moderately High Proficiency (Level 4)
Contains both elements of High Proficiency and Moderate Proficiency
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16 to >14.0 pts
Moderate Proficiency (Level 3)
Vaguely lists all patient’s assessment data; lacking some sentences; lacking some specific numbers/levels
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14 to >9.0 pts
Low Level Proficiency (Level 2)
Contains both elements of Moderate Proficiency and Non- Proficient
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9 to >0.0 pts
Non- Proficient (Level 1)
Missing important assessment data; lacking sentences and specific numbers/levels
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0 pts
Non- Performing (Level 0)
Not attempted/not submitted
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20 pts
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This criterion is linked to a Learning OutcomeRelated Treatments Criteria
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20 to >18.0 pts
High Proficiency (Level 5)
Clearly and concisely explains what treatments the patient is receiving because of his/her disease
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18 to >16.0 pts
Moderately High Proficiency (Level 4)
Contains both elements of High Proficiency and Moderate Proficiency
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16 to >14.0 pts
Moderate Proficiency (Level 3)
Vaguely explains what treatments the patient is receiving because of his/her disease
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14 to >9.0 pts
Low Level Proficiency (Level 2)
Contains both elements of Moderate Proficiency and Non- Proficient
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9 to >0.0 pts
Non- Proficient (Level 1)
No explanation of treatment(s) patients is receiving because of his/her disease
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0 pts
Non- Performing (Level 0)
Not attempted/not submitted
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20 pts
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This criterion is linked to a Learning OutcomeCare plan
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20 to >18.0 pts
High Proficiency (Level 5)
Contains nursing diagnosis, 1 SMART outcome, 3 SMART interventions, and evaluation
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18 to >16.0 pts
Moderately High Proficiency (Level 4)
Contains both elements of High Proficiency and Moderate Proficiency
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16 to >14.0 pts
Moderate Proficiency (Level 3)
Missing 1 part of diagnosis or 1-2 SMART outcomes and interventions; may not be the best nursing diagnosis
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14 to >9.0 pts
Low Level Proficiency (Level 2)
Contains both elements of Moderate Proficiency and Non- Proficient
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9 to >0.0 pts
Non- Proficient (Level 1)
Inappropriate nursing diagnosis; lacking SMART outcomes and interventions
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0 pts
Non- Performing (Level 0)
Not attempted/not submitted
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20 pts
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This criterion is linked to a Learning OutcomeAPA formatting and references
PRICE-I
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10 to >9.0 pts
High Proficiency (Level 5)
Utilizes 1st and 2nd level headings appropriately; at least 3 pages long; 2 credible resources; appropriate in text citations
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9 to >8.0 pts
Moderately High Proficiency (Level 4)
Contains both elements of High Proficiency and Moderate Proficiency
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8 to >6.0 pts
Moderate Proficiency (Level 3)
Utilizes headings but not accurately placed; minor errors in citations and referencing
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6 to >4.0 pts
Low Level Proficiency (Level 2)
Contains both elements of Moderate Proficiency and Non- Proficient
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4 to >0.0 pts
Non- Proficient (Level 1)
Lacks headings; < 3 pages long; lacks references and in text citations
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0 pts
Non- Performing (Level 0)
Not attempted/not submitted
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deji247
ClinicalCaseStudy.docx
