2021

 

The case study assignment will be based on a patient (case study provided) and will include the application of the nursing process.  Review the patient data provided to develop a comprehensive case study database.

In this assignment, students are expected to explore a patient’s presentation, history and diagnostic investigations in relation to the underlying pathophysiological process.  Evidence from scientific peer-reviewed literature as well as your course textbooks must be included to demonstrate the appropriateness of the diagnosis in relation to the patient’s clinical manifestations.  The paper must present a thorough description in order to demonstrate an understanding of how the disease is affecting the patient and how that disease is being managed.

This understanding will assist you in developing a comprehensive plan of care. Guided by the nursing process, you will demonstrate pattern recognition and the ability to interpret and analyze all data to identify the priority nursing diagnoses. Using clinical judgment skills, patient priorities and critical decision-making, your will plan of care will address the highest priority nursing diagnosis.

It is understood that the plan of care cannot be implemented by the learner considering it is  a case scenario; however, the patient goals (short-and long-term) and nursing interventions (supported by referenced rationale) must be congruent with the case study. Relevant evaluation criteria for the goals and interventions must also be included.

Overall Assignment Components/Criteria

Part A: BSN2107

Introduction

Provide a brief introduction for your paper. This introduction should include what you intend to present in both Part A and Part B of the paper. Only 1 introduction is needed as this is considered 1 paper.

Patient Presentation

Provide a brief summary of the relevant patient information:

  • Include important demographics such as age. Clearly identify the main health challenge. Then describe the patient’s clinical presentation on admission – what brought the patient to seek medical attention? What were the clinical manifestations exhibited by the patient on admission?
  • Signs and Symptoms: Identify the significant signs and symptoms presented by the patient on the clinical day.
  • Past Medical History: Describe findings in the past medical history which are relevant to the patient’s clinical presentation (e.g. co-morbid conditions, previous injury, relevant family history)
  • Treatments: List current medications and relevant treatments (include in Data Collection Template: Appendix 1).

Theoretical Discussion of Disease Process

Provide an in-depth analysis of the disease process:

  • Provide a definition for the disease process and its Canadian epidemiology.
  • Discuss the disease process’ pathophysiology. Explain the alterations from normal cell/organ/body functioning that are seen in this disease process.
  • Discuss the risk factors and causative factors for the disease process as it relates to the patient.
  • Based on your examination of relevant literature pertaining to the pathophysiologic process, identify all assessment data (subjective, objective, diagnostic tests) that should be collected and monitored by a nurse who is caring for a general patient with this disease process.

Analysis

Provide an in-depth analysis of the patient presentation (deviations from the expected normal findings):

  • Detail how the pathophysiology lends itself to the patient presentation.
  • Discuss/explain assessment data (both objective and subjective) (Every symptom and abnormal diagnostic test should be linked to the pathophysiology or otherwise addressed).
  • Were the usual diagnostic tests ordered for this patient? If not, why not? If so, what do the results reveal? What other diagnostic tests were performed on this patient? Discuss why the lab/diagnostic test would be ordered for this patient.
  • What evidence of the disease process is found in the diagnostic test information for the patient?
  • Include lab work/lab tests performed and results using the Lab form from clinical. You are not expected to fill this in. You can only input the lab values provided in the case study (available on Moodle: Appendix 2).
  • Use evidence from the literature to demonstrate that the patient’s presentation is a result of the pathophysiologic processes.

Nursing Implications 

Based on your knowledge and examination of relevant literature pertaining to the pathophysiologic process, explain how this information informs your practice. Identify all assessment data (subjective, objective, diagnostic tests) that should have been collected and monitored by the nurse who is caring for this specific patient. Provide rationale for why this information is relevant. Include how writing this paper can inform your future practice.

Part A: counts towards the BSN2107 grade.  The value is 10%

Maximum length of this section of the paper is to be 4 pages (12-point font) (not including title page, reference page or appendices).

All papers and submissions are to be formatted and references according to the most recent APA manual.

Part B: BSN2144

Case Study Analysis

  • Using the Data Collection Template (Appendix 1) as your source to gather and store information, analyze the data and identify relevant patterns and clusters within the data. Use a concept map to aid in clustering (Appendix 3).
  • On the concept map: include relevant data from the interview, physical assessment, diagnostic tests, current medications, relevant pathophysiology, medical treatments, and changes in status identified in the data collection tool that explain the general health challenge. All abnormal and other relevant data must be reflected on the concept map.
  • In your paper, include additional symptom analysis data for abnormal data collected.
  • Continue to analyze the data presented on the concept map by explaining your diagnostic reasoning (assessment and establishing nursing diagnoses). Explore how you recognized cues/clusters in order to determine nursing diagnoses.
  • From your data analysis, identify and list all pertinent nursing diagnoses – stated according to NANDA.
  • Actual nursing diagnostic labels (as per NANDA) must be indicated on the concept map (Appendix 3) and linked with the appropriate data / clusters.
  • List all complete actual and potential nursing diagnostic statements that apply to the patient: (Appendix 4).
  • Refer to the literature to support the analysis.

Nursing Diagnosis Priority Rationale

  • From the list of all nursing diagnoses, choose the top three priority nursing diagnoses and provide rationale for hierarchy (use at least one actual and one potential/risk diagnosis). This discussion must be supported by both the literature AND based on patient need.
  • Discuss the diagnostic reasoning used to determine the top 3 priority (actual and potential/risk nursing diagnoses listed). For example, relate to knowledge of pathophysiology (patient who is neutropenic is at risk for infection); or to a treatment the patient is receiving (patient receiving a heparin infusion is at risk for bleeding); etc.
  • Refer to your care plan table where appropriate.

Care Plan

  • Complete one care plan for the highest priority nursing diagnosis (use the clinical placement portfolio Plan of Care template: Appendix 5).
  • The care plan must include a short-term and a long-term SMART outcome relevant to the nursing diagnosis and patient.
  • Indicate all relevant interventions. Interventions must relate to the outcome and relevant to the patient. Interventions should be specific rather than broad – e.g. if your patient is hypoxic – rather than having a general intervention “Monitor vital signs q4h and PRN”; be specific “Monitor SpO2, respiratory rate and heart rate q4h and PRN”. If your intervention includes administering medications – the medication must be ordered for the patient and the specific name provided in the intervention.
  • Identify how interventions and outcomes will be evaluated, including pertinent follow-up.

 

Relevance of Care Plan

  • Discuss how the patient care plan is relevant and individualized for the patient.
  • Refer to care plan (Appendix 5) where appropriate.

 

Conclusion

Provide a brief conclusion to your paper. Include a restatement of what the intent of the paper was and summarize your main points. Only 1 conclusion is needed as this is considered 1 paper.

 

Part B: Counts towards the BSN2144 grade.  The value is 20%

Maximum length of this section is to be 6 pages (12-point font) (not including title page, reference page or appendices).

All papers and submissions are to be formatted and references according to the most recent APA manual.

Appendices:

  1. Data Collection Form
  2. Lab/Diagnostic Results
  3. Concept Map
  4. List of all relevant Nursing Diagnoses
  5. Care plan

Note: These Appendices will be graded.

Technical Aspects:

  • This is a formal paper and must follow APA formatting, be written using paragraphs, and have an introduction and a conclusion.
  • The paper is not to exceed 10 pages of text in total (excludes title page, appendices and reference list).
  • A minimum of 5 peer-reviewed references (all to be more recent than 2015) are required and must support the analysis of the case. Please DO NOT ATTACH ARTICLES.
  • An electronic copy must be submitted onto the Moodle drop box by the posted due date.
  • All appendices must be submitted in PDF format and as separate documents for the online submission.
  • Program policies will be followed for late papers.