Case Study Presentation


This assignment is a presentation, please put this as a power point presentation form. The rubric and patient information is listed below. please let me know if you have any questions

CASE STUDY PRESENTATION (Template)

  1. Data Collection
    History of Present Problem:

Personal/Social History:

What data from the histories is important & RELEVANT; therefore it has clinical significance to the nurse?

RELEVANT Data from Present Problem:

Clinical Significance:

RELEVANT Data from Social History:

Clinical Significance:


What is the RELATIONSHIP of your patients past medical history (PMH) and current meds?

(Which medications treat which conditions? Draw lines to connect)

PMH:

Home Meds:

Lab/diagnostic Results:

Basic Metabolic Panel (BMP)

Current

High/Low/WNL?

Most Recent:

Sodium (135-145 mEq/L)

Potassium (3.5-5.0 mEq/L)

Glucose (70-110 mg/dL)

Creatinine (0.6-1.2 mg/dL)

Misc. Chemistries:

What lab results are RELEVANT that must be recognized as clinically significant to the nurse?

RELEVANT Lab(s):

Clinical Significance:

TREND: Improve/Worsening/Stable:

Complete Blood Count (CBC)

Current

High/Low/WNL?

Most Recent:

WBC (4.5-11.0 mm 3)

Hgb (12-16 g/dL)

Platelets(150-450x 103/l)

Neutrophil % (42-72)

What lab results are RELEVANT that must be recognized as clinically significant to the nurse?

RELEVANT Lab(s):

Clinical Significance:

TREND: Improve/Worsening/Stable:

  1. Patient Care Begins:

Current VS:

WILDA Pain Scale (5th VS)

T:

Words:

P:

Intensity:

R:

Location:

BP:

Duration:

O2 sat:

Aggreviate:

Alleviate:

What VS data is RELEVANT that must be recognized as clinically significant?

RELEVANT VS Data:

Clinical Significance:

Current Assessment: ( Sample Assessment- Please include critical elements for recording assessment)

GENERAL APPEARANCE:

Resting comfortably, appears in no acute distress

RESP:

Breath sounds clear with equal aeration bilaterally, nonlabored respiratory effort

CARDIAC:

Pink, warm & dry, no edema, heart sounds regular with no abnormal beats, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks

NEURO:

Alert & oriented to person, place, time, and situation

GI:

Abdomen soft/nontender, bowel sounds audible per auscultation in all four quadrants

GU:

Voiding without difficulty, urine clear/yellow

SKIN:

Skin integrity intact

What assessment data is RELEVANT that must be recognized as clinically significant?

RELEVANT Assessment Data:

Clinical Significance:

  1. Clinical Reasoning Begins

  1. What is the primary problem that your patient is most likely presenting with?

  1. What is the underlying cause/pathophysiology of this concern?

  1. What nursing priority(s) will guide your plan of care?(if more than one-list in order of PRIORITY)
  1. What interventions will you initiate based on this priority? (List at least 3 interventions)

RELEVANT Assessment Data:

Clinical Significance:

  1. What body system(s) will you most thoroughly assess based on the primary/priority concern?
  1. What is the worst possible/worst possible complication to anticipate?
  1. What nursing assessment(s) will you need to initiate to identify this complication if it develops?

Nursing Role in Implementation of Orders and Expected Outcomes

Care Provider Orders:

Reason for order/Nursing role in implementation of orders:

Expected Outcome:

PRIORITY Setting: Which Orders Do You Implement First and Why?

Care Provider Orders:

Order of Priority:

Rationale:

Medication Dosage Calculation:

Medication/Dose:

Mechanism of Action:

Volume/time frame to Safely Administer:

Nursing Assessment/Considerations:

Normal Range:

(High/low/avg?)

Hourly rate IVPB:

IV Push Rate Every

15-30 Seconds?

  1. What educational/discharge priorities have you identified and how will you address them?

It is now the end of your shift. Effective and concise handoffs are essential to excellent care and if not done well can adversely impact the care of this patient. You have done an excellent job to this point, now finish strong and give the following SBAR report to the nurse who will be caring for this patient:

Situation:

Background:

Assessment:

Recommendation:

Caring & the Art of Nursing

  1. What is the patient likely experiencing/feeling right now in this situation?

  1. What can I do to engage myself with this patients experience, and show that he/she matters to me as a person?

Rubric

CASE STUDY PRESENTATION RUBRIC

CASE STUDY PRESENTATION RUBRIC

Criteria Ratings Pts

This criterion is linked to a Learning OutcomeContext and Background Informationa. Relevant Data from Present Problem
b. Relevant Data from Social History
c. Clinical Significance

10 pts

Excellent

Identifies all relevant data related to present problem, social history, and clinical significance

7.5 pts

Good

Identifies most relevant data related to present problem, social history, and clinical significance

5 pts

Average

Identifies some relevant data related to present problem, social history, and clinical significance

2.5 pts

Poor

Did not identify relevant data related to present problem, social history, and clinical significance

10 pts

This criterion is linked to a Learning OutcomeII. Critical Thinkinga. Relationship of past medical history and current medication
b. Clinical significance of lab/diagnostic results

10 pts

Excellent

Demonstrates a clear and deep understanding of patient medical history, current medication and clinical significance of lab and diagnostic test

7.5 pts

Good

Demonstrates a general understanding of patient medical history, current medication and clinical significance of lab and diagnostic test

5 pts

Average

Demonstrates some understanding of patient medical history, current medication and clinical significance of lab and diagnostic test.

2.5 pts

Poor

Demonstrates little understanding of patient medical history, current medication and clinical significance of lab and diagnostic test

10 pts

This criterion is linked to a Learning OutcomePhysical AssessmentData and Vital signs

10 pts

Excellent

Accurately documents all relevant data physical assessment, vital signs, and clinical significance

7.5 pts

Good

Accurately documents most relevant data physical assessment, vital signs, and clinical significance

5 pts

Average

Accurately documents some relevant data physical assessment, vital signs, and clinical significance

2.5 pts

Poor

Accurately documents few relevant data physical assessment, vital signs, and clinical significance

10 pts

This criterion is linked to a Learning OutcomeIdentifies Main Problem/sa. Discuss patients primary problem

10 pts

Excellent

Identifies and understands all of the patients primary problem

7.5 pts

Good

Identifies and understands most of the patients primary problem

5 pts

Average

Identifies and understands some of the patients primary problem

2.5 pts

Poor

Poor understanding of the patients primary problem

10 pts

This criterion is linked to a Learning OutcomeDescription of PathophysiologyDescribe and demonstrates a clear and deep understanding of underlying pathophysiology of patients primary problem

10 pts

Excellent

Describe and demonstrates a clear and deep understanding of underlying pathophysiology of patients primary problem

7.5 pts

Good

Describe and demonstrates a general understanding of underlying pathophysiology of patients primary problem

5 pts

Average

Describe and demonstrates some understanding of underlying pathophysiology of patients primary problem

2.5 pts

Poor

Provide a little understanding of underlying pathophysiology of patients primary problem

10 pts

This criterion is linked to a Learning OutcomeIdentifies Nursing Priority ,Interventions, and Rationale

10 pts

Excellent

Identify and explain nursing priority and 3 nursing interventions, and rationale

7.5 pts

Good

Identify and explain nursing priority and 2 nursing interventions, and rationale

5 pts

Average

Identify and explain nursing priority and 1 nursing interventions, and rationale

2.5 pts

Poor

Nursing priority, interventions, and rationale are inappropriate and irrelevant to patients primary problem

10 pts

This criterion is linked to a Learning OutcomeCase Study Analysis

10 pts

Excellent

Clearly provide an excellent and insightful analysis of patients current medical management/ priority setting, educational/ discharge priorities and integration of theory of caring

7.5 pts

Good

Clearly provide an thorough analysis of patients current medical management/ priority setting, educational/ discharge priorities and integration of theory of caring

5 pts

Average

Clearly provide a superficial analysis of patients current medical management/ priority setting, educational/ discharge priorities and integration of theory of caring

2.5 pts

Poor

Lack insights of patients current medical management/ priority setting, educational/ discharge priorities and integration of theory of caring

10 pts

This criterion is linked to a Learning OutcomePresentation

10 pts

Excellent

Speaker makes eye contact with all individuals.

7.5 pts

Good

Speaker makes eye contact with most of audience.

5 pts

Average

Speaker looks at only one portion of the audience.

2.5 pts

No Marks

Speaker makes little or no eye contact.

10 pts

This criterion is linked to a Learning OutcomeVocal Delivery

10 pts

Excellent

Clear articulation of words demonstrated

7.5 pts

Good

Speaker has difficulty enunciating one or two words.

5 pts

Average

Speaker slurs word endings.

2.5 pts

Poor

Speakers words are garbled.

10 pts

This criterion is linked to a Learning OutcomeUtilization of EBP

10 pts

Excellent

Utilized recent EBP articles to discuss the case study Submission of 3 articles (within 5 yrs)

7.5 pts

Good

Utilized recent EBP articles to discuss the case study Submission of 2 articles (within 5 yrs)

5 pts

Average

Utilized recent EBP articles to discuss the case study Submission of 1 article (within 5 yrs)

2.5 pts

No Marks

Discussion is not based on EBP

10 pts

Total Points: 100

Patient: J. T.

Age: 71 y.o.

Sex: Male

Allergies: NKA

Code: DNR

Weight: 253 lbs

Height: 71 inches

DX: Hemiplegia and hemiparesis following cerebral infarction affecting left nondominant side

Diet?

Medical Hx:

Cellulitis of unspecified toe

Cataract

Edema

Hypertensive heart disease with heart failure

MDD (Major Depressive Disorder)

BPDC (Bipolar Disorder)

Generalized anxiety disorder

Labs:

AST 17 IU/L

ALT 14 IU/L

ALK Phosphates 39 IU/L

Bilirubin 0.3 mg/dL

Albumin 3.4 g/dL

Protein 6.3 g/dL

Globulin 2.9 g/dL

WBC 8.60

RBC 3.71

HGB 10.8

HCT 36.3

Platelets 207

Lymphocytes 43.1

Monocytes 10.6

Neutrophils 41.1

Eosinophils 2.8

Basophils 0.7

Medications:

Betadine External Solution 10% (Povidone/Iodine)

Fluocinonide External Cream 0.1% Fluocinonide

Ketoconazole External Cream 2% (Ketoconazole Topical)

Mupirocin External Ointment 2% (mupirocin)

Clopidogrel Bisulfate Oral tab 75 Mg

Give 1 tab PO 1x/day for DVT prophylaxis

Dapagliflozin Propanediol Oral tab 10 mg

Give 10 mg DO 1x/day for HF

Lexapro 10mg PO 1x/day for M/b verbalizing hopelessness

Lasix 40mg 1 tab 2x/day for BLE edema; Hold if SBP < 110

Spironolactone 12.5 mg PO 1x/day for CHF

Give 0.5 mg