Case report
Introduction: (200 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 case study 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 hospital). Provide a brief description of the pathophysiology of the disease and demonstrate how the presenting manifestations support the client’s primary diagnosis.Identify the complication experienced during admission. Provide a brief description of the pathophysiology of this complication in relation to the clients pre-existing medical conditions.
Nursing Problems (200 Words)
Using your knowledge of pathophysiology and the clinical manifestations of the client; identify two (2) nursing problems that arise as a result of the client’s complication developed during the admission. These problems may be actual or potential nursing problems. Provide a brief description for why these problems arise for this client. Support this discussion using current literature.
Nursing Management (800 Words)
The nursing management must focus on the inpatient 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) identified nursing problems. Support this discussion using the current literature.
(This section of the report focuses on assessments and interventions that the Registered Nurse conducts. So avoid reverting to simple referrals to other members of the health team. What does the nurse physically do to provide optimal person-centred care as part of the nursing management plan? You should also prioritise your care. What is the most pressing concern for the client at this stage?)
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 (400 Words)
The discharge plan must focus on the multidisciplinary management for this client and can refer to the nursing problems addressed throughout the paper.
Discuss the aim for discharge planning and the importance of using a multidisciplinary approach. Discuss the role of the Registered Nurse to facilitate the multidisciplinary discharge plan for this client. Identify the members of the multidisciplinary health care team and the role that they would play. You can include your identified nursing problems discussed in the paper.
(You may also like to discuss what socio-economic factors may impact your discharge planning.)
Conclusion (200 Words)
Summarise the major findings of this case report.
Please note the word limit in each section is provided as a guide to help you structure this assignment..
General information:
This assignment must be supported by at least 20 credible references presented in Harvard Style. These references should include course readings and the wider nursing academic literature.
