What are his objective and subjective signs and symptoms?
Instructions Please use the document below to complete the following activities: You will be asked to complete a case study focused on one of the body systems we study this semester. Due dates will be posted in advance. At the beginning of the course, your clinical team will be given a disease or disorder for which you will base your case study. This will not be a research paper on the disease. Instead, you will take the information that you are given on this condition, along with your own additional research, and apply it to a typical patient. This is the true meaning of applied science. You will be given an example of what type of information to include, and in what format to present it. Your clinical team will create an imaginary patient and produce a medical chart which reflects his/her condition, treatment and outcomes. Why did he seek medical attention? What are his objective and subjective signs and symptoms? What is his medical history and the medical history of his immediate family? What clues do his vital signs and physical exam provide? Which diagnostic studies will be ordered and what results would be consistent with his condition? Anything necessary to diagnose and treat this patient must be documented. A very detailed rubric has been provided and should be carefully reviewed and followed for the best results. Tips for Success Research your disease. Always try to look at this research as a living document, representing the experiences that a real-life patient would have. Always look at your disease as being a link to a body system. If you are clear on how that system normally works, then you can easily figure out what must go wrong for this disease to occur. Once you know what has gone wrong in the body, then you begin to see what those malfunctions would do to a patient. What signs and symptoms would they have? How would that patient know that something was wrong? This is usually what would bring them to the doctor. Please describe your patient as you would first encounter him/her, including signs/symptoms, general appearance & primary complaint. This is an excellent way to start a case study. In studying your disease, you may notice that it is strongly linked to family history or social habits. Bronchitis can be linked to smoking, cirrhosis can be linked to drinking, heart disease can be linked to poor diet or lack of exercise, and many diseases seem to run in the family, like cancer. Your imaginary patient might have some of these concerns. That is up to you. Listing them shows that you are thinking about every aspect of your disease. Determine what your patient’s vital signs would be and what you might find in a physical exam (paying special attention to a thorough inspection of the body system involved). Complete a head to toe nursing assessment with typical assessment findings for this disease process. This includes blood pressure, pulse, respiratory rate, oxygen saturation, and temperature. Once you familiarize yourself with normal measures, you can easily find approximate changes which would reflect the appropriate status of your patient. Would the blood pressure or pulse rise or fall? Would they have a fever? In other words, if their blood pressure reading would probably be higher than normal, give them a reading above the normal range. Note this on your report. Any other unusual signs or complaints like pain or dizziness should be noted also. Also, note any alterations from your head-to-toe physical examination or your system-specific exam. Write a narrative nurses note that includes all of your findings. Summary of pertinent Health History and Review of Symptoms Positive & Negative Physical Exam Findings Diagnostic Findings Medications Complete a medication reconciliation by determining the medications this patient would be on prior to admission Determine what medications you would expect the provider to prescribe for this patient based on the disease process Now comes the fun. You have your patient and his/her baseline information such as vital signs, symptoms and relevant history. You also have the findings from your own examinations. Does this information guarantee that your patient would be diagnosed with your particular disease? Probably not. This is where a medical professional would pursue these “leads” and order diagnostic testing. Blood tests, x-rays, EKGs, etc. Whatever fits in your particular case. Nothing extravagant, but be realistic. List these tests along with their results. Also include normal results so that someone reviewing your patient’s chart can appreciate the differences. Results do not have to be perfect but take what you learn about normal findings and alter them accordingly. For example, if your patient has pneumonia, a chest x-ray would probably be ordered and show a clouded area in the lung. Normal results would be a clear lung picture with no clouding. Any infection would increase the white blood cell count, etc. There are numerous classroom and internet resources which can help you find this information. You now have enough information to create a care plan for your patient. Develop the concept map with your assessment findings Determine your priority nursing diagnosis for this patient. Determine the resources you will need to provide for the patient With the information you have about your patient and their disease process create an educational handout for this patient about their disease process and medications. Now you have done a complete clinical study on a patient. You will put all of this information into templates provided in the case study packet found in Canvas. You will submit your completed case study packet and will also create a case presentation to share with the class. Reviewing cases of your peers will provide tremendous help as you begin to put all of the pieces together: anatomy, physiology and pathophysiology. Instructions for creating voice-over PowerPoints and uploading or sharing your presentations will be provided. Please use this sheet as a general guide to completing case studies. Additionally, review the rubric and check-off sheets provided before turning in your case study/care plan.