In the process of becoming a nurse the prospective nurse will need to learn how to write a nursing case study. A nursing case study begins with gathering information on a patient and ends with a conclusion that gives a prognosis based on medical intervention and education of the patient.
Nursing case studies are used as a training tool as well as a means of communicating between nurses and other medical professionals involved in a patient’s care. In addition nursing case studies can be used for research, nursing education up gradation and education for new equipment or techniques. A nursing case study is comprised of the following:
Introduction: The introduction is comprised of data collected concerning the patient’s personal life and physical complaint. The patient’s confidentiality most be maintained and the patient is identified by his or her first name or a fictional name.
Items that are included in a case study would be the age, sex, and ethnicity of the patient as well as his or her economical and living conditions. The patients work history and history of alcohol, tobacco, prescription and non-prescription drug uses are also important.
While the first part of the introduction is comprised of interviewing the patient, the second part lists the nurse’s personal observations of the patient’s condition. These observations may include the manner of the patient as they answer questions, their breathing, mental state, pallor etc.
Finally the introduction will detail the tests ordered by the patient’s physician, the results of those tests and a diagnoses.
It is important to remember that in order for a case study to be released for publication written permission from either the patient and/ or the patient’s family is necessary.
Problem diagnosis/decision: After the diagnosis has been made, an explanation of the diagnosis and what it means as well as the details of the possible causes of the patient’s condition are given. How the diagnosed condition affects the patient and the secondary results of the diagnoses are explained (i.e. affects of symptoms produced by the patient’s condition) and how the symptoms affect the well being of the patient.
This section will also delve into how specific aspects of the patient’s lifestyle or over all physical and mental condition contribute to the patient’s condition or may hinder recovery. For instance, a patient diagnoses with asthma may have their condition worsened by smoking or living with someone who smokes or by anxiety over having an asthmatic episode.
Nursing interventions: This is where the nurse explains the treatment prescribed for the patient’s condition and how the patient needs to be educated about their condition in order to be able to assist in their own treatment.
A list is made of actions the patient can take or circumstances in their lives that they can alter to help alleviate symptoms or improve their condition as well as what medical staff and family can do to help the patient. The list would include where applicable: medication, therapy, treatment and rehabilitation.
Perhaps the patient needs to change his diet or get more exercise, the nurse will need an explanation to give the patient for how and why this will benefit him as it relates to his ailment and also address any obstacles to making the necessary changes in his lifestyle.
It is important that this section address not only the physical but also the mental condition of the patient. It is also important to realize that each patient is an individual and thus will have different needs; differing needs will necessitate tailoring nursing care to the individual patient and not to a archetype for the condition.
Conclusion: The conclusion gives the best hopeful prognoses for both the short and long term. It will review what measures will need to be taken by the medical staff and the patient to insure the best outcome.
A nursing case study is a way of formally putting together what a given patient is suffering from, how the patient’s condition presented itself and what can be done by everyone involved to best help the patient.
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Sources:
http://casestudiessamples.blogspot.com/2009/02/sample-nursing-copd-case-study.html
http://www.bestcertifiednursingassistant.com/nursing/guidelines-nursing-case-study-preparation/
