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During clinical placements, students are to select a patient in their care and to undertake a thorough clinical assessment and case study. Students must discuss their choice of patient with their facilitator and should also obtain appropriate consent prior to assessment and use non identifying information in the case study submission. Patient Information Name (pseudonym):- _____________________________________ Age:- ___________ Gender:- _________ Admission Diagnosis:- _____________________________________ Past Medical History:- _________________________ _______________________________________________ Past Surgical History:- _____________________________________ _______________________________________________ __________________________________________________________ __________________________________________________________ Current Medications:- __________________________ ________________________________________________ Immunisation status:- _____________________________________ ________________________________________________ Allergies:- _____________________________________ ________________________________________________ Next of kin:- _____________________________________ General Appearance :- __________________________ Nursing Observations: - ________________________________________________ Temperature: - ______ Pulse: - _______ Respirations: - _______ Brief overview of patient: ____________________________ BP: - _________ Weight: - _________ Height/Length:- _________ Urinalysis: - Interpretation of nursing observations: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Anatomy, physiology and pathophysiology of admission diagnosis:- ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Diagnostics:- Pathology:- Reason(s) for particular tests ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________Findings: ___________________________________________________________________________________________________________________Radiology: - Reason(s) for particular tests _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________Findings: ___________________________________________________________________________________________________________________Other: - Reason(s) for particular tests _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________Findings: __________________________________________________________________________________________________________________IDENTIFY 6 FUNCTIONAL HEALTH PATTERNS IN PRIORIY ORDER (with 1 the most important) THAT HAVE BEED AFFECTED BY THE CURRENT (or past) DIAGNOSIS. Include the reason why each functional health pattern has been affected and was given a 1-6 priority order 1.0 _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________2.0 ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________3.0 ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________4.0 _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________5.0 _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________6.0 _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Provision and coordination of care: Nursing Care Plan Complete the following Nursing Care Plan related to the first 3 functional health patterns that were affected. Nursing Diagnosis: NANDA Approved Manifested by (Presenting symptoms) Management strategies and rationales 1. Related to (Aetiology): 2. Related to (Aetiology): 3. Related to (Aetiology):- Prepare a brief handover report for your patient using ISBAR. References Marking criteria: Adherence to case study criteria : Linked to the provision and co-ordination of care for a patient requiring acute med/surg care. All areas addressed in-depth Evidence of consolidation of learning.Analysis, critique and synthesis The case study was articulate, logical, balanced and convincing. A diverse range of perspectives was offered. All important aspects are covered demonstrating comprehensive knowledge of the key areas Evidence to support the analysis An extensive range of relevant literature utilised with sophisticated interpretation and analysis Organisation, Presentation and ReferencingFlawless presentation.
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