Ideally what are the next nursing steps you would take for the nursing management of your patient?
GUIDELINES FOR COMPREHENSIVE PATIENT ASSESSMENT
Each student will develop a case study (no more than 8 pages excluding the title and reference pages) on a patient you cared for in the medical-surgical environment. References for this paper must be recent (within the past 5 years).
Purpose: The purpose of this paper is to promote scholarly thought and writing. Writing this paper will increase your critical thinking skills, writing abilities, and will encourage you to incorporate published evidence based literature into your nursing practice. This paper will allow you to examine the patient management process based on a real person you have had the privilege of interacting with in the clinical setting.
SECTION I: INTRODUCTION
Introduction of the client (anonymous name) and medical diagnosis (provide detailed synopsis of the client and the client’s context).
Short paragraph written identifying the purpose of the paper. Describe pathophysiology of admitting diagnosis and comment on the burden of the disease on the health care system and its effect on the population in the U.S.
SECTION II: SOAP NOTED
Brief description of the pathophysiology of diagnosis clearly stated in the student’s own words with reference(s) from a textbook or journal.
DETAILED and COMPLETE SOAP NOTE:
a. Chief Complaint
b. History of Presenting Illness (OPQRST/OLDCARTS)
c. Complete Health History
d. Complete Review of Systems highlighting all pertinent positives
a. Vital Signs
b. Complete Physical Assessment highlighting all abnormalities
c. Laboratory Data
d. Imaging Data
e. Other Diagnostic Data
a. List diagnosis in order of importance
b. Provide a rationale for each of your diagnosis and why
ASSOCIATE DEGREE IN NURSING – LEVEL I SYLLABUS
RNSG 1330 Nursing Clinical I Created: February 2019
prioritized as you did.
a. List your nursing care plans in order of importance and reference your interventions
b. Ideally what are the next nursing steps you would take for the nursing management of your patient?
i. Additional testing
c. Identify patient education needs and reference your teaching points.
SECTION III: APA FORMAT
Followed APA format for the layout of the paper
1. Paper typed and double spaced with appropriate margins
2. Pages of paper are numbered
3. Title page includes title of paper, name, course number, and name of clinical facility
Followed APA format for all citations
Followed APA format for reference page