Pertinent past medical history and current diagnosis

Apply the theoretical knowledge about medical surgical disorders and the drug treatment to actual clinical practice.Compare and contrast expected presentations of the disorder and use of pharma-cotherapeutics with the disease and the drug treatment used in an actual client case.Critically analyze the pathophysiologic and pharmacotherapeutic components of an actual clinical case presentation.Synthesize knowledge gained about disease and the drug treatment by creating an appropriate case study of a selected disease process and drug treatment.Improve critical thinking and communication skills through writing and developing a case study.
Guidelines for writing a case study: This must be done individually
Choose 1 area studied in this course from weeks 1 and two, write a case study based on an actual client you cared for during the adult health clinical rotation, or base it on a disease topic discussed in class.You must protect client confidentiality in the case study. Names or initials will not be used, nor will other identifying information such as the health care facility or city, among others. Client’s age, gender, and race may be included.The case study must be submitted through the course shell in the Drop Box labeled, “Missed Clinical Assignments”on or before the due date. NO EXCEPTIONS. The course coordinator will determine the due date for the case study.Students are required to support research material with appropriate citations using current APA format. Resources must include at least 3 nursing journals.Include a title page, table of contents, an abstract, and a reference page.The case study will include the following components:
Demographic data (protecting confidentiality)Pertinent past medical history and current diagnosisClinical presentation: Signs/symptoms, physical findings upon assessmentDescription of medical diagnosis (including pathophysiology & nursing needs)Lab and diagnostic test results with rationalePharmacotherapeutic treatment with rationaleA table listing expectedand actualpresentation findings, lab/diagnostic studies, drug treatment based on pertinent past medical history and current diagnosis.3 care plans which include:Prioritized nursing diagnoses (one diagnosis on each care plan; one must be psychosocial)Goal statements (short term and long term)Minimum of 6 nursing interventions with rationale statementsEvaluation statement of short term goalA minimum of 5-typed pages is required. This does not include the title page, table of contents, abstract, or reference page.If this assignment is not turned in by the due date or is incomplete, a clinical Unsatisfactory /“U” will be given and this may result in a clinical failure.A Satisfactory / “S” grade must be obtained to meet clinical competency for the day.
Grading Rubric for Clinical Make-Up AssignmentSatisfactory UnsatisfactoryContent: Clear presentation of Case StudyDemographic dataPertinent past medical history and current diagnosisClinical presentation: signs and symptoms, physical findingsDescription of medical diagnosis (including pathophysiology and nursing needs)Lab and diagnostic test results with rationalesPharmacotherapy treatment with rationaleTable comparing expected and actual presentation findings3 Care plans which include: nursing diagnoses (one psychosocial), goal (short term and long term), minimum of 6 nursing interventions with rationale statements, evaluation statement of short term goalMechanics· Minimum of 5 pages typed.· The paper, including tables and graphs, headings, title page, abstract, appendices, and reference page are consistent with current APA formatting guidelines.
· The introduction provides sufficient background on the topic and previews major points.
· Intellectual property is recognized with in-text citations and a reference page.
· The paper presents with effective use of level headings, font styles, and space.
· Rules of grammar, usage, and punctuation are followed; spelling is correct.
· Conclusion is logical, flows, and reviews the major points.

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