Aultman College Pathophysiology Patient Diagnosis Case Study My school runs plagiarism check. I also attached a word doc of the rubric with all the info an

Aultman College Pathophysiology Patient Diagnosis Case Study My school runs plagiarism check. I also attached a word doc of the rubric with all the info and instructions needed for the case study.

This is what I am looking for:

Create a patient. Give background of patient based on what you would learn from the a patient intake. In other words age, lifestyle, general well-being. Put in some information about diet exercise just how the individual treats themselves. Please include past medical history and previous treatments (ex: medications) Don’t get too carried away, in real life patients do not always give much detail here.

So with patient background you will put together a SOAP note:

Quick physical assessment will be done: Height, weight, BP, Resp rate, Temp. Duration.

S – subjective. This is what the patient tells you. Why they are there (if they are able to, sometimes they are not conscious and you have to rely on who came in with them) This is symptoms.

O – objective. This is what you see and what you test for. Rashes, labored breathing, blood test imaging any study results.

A – assessment. This is your diagnosis. What you feel the patient has. Might be more then one condition. (put in why you selected this) Put in ICD-10 codes.

P- Plan. What is your treatment for this or these conditions. Expected outcomes, problems reaching this outcome, follow up care. Treatment includes medication and therapy. Include CPT codes.

You have a lot of leeway with this project.

Realize you are writing this with not a lot of time. You need to be precise and to the point. Insurance uses this to justify payment. This is important but you have a lot of patients and not a lot of time. Welcome to medicine. n order to write a case study paper, you must carefully address a number of sections in
a specific order with specific information contained in each. The guideline below outlines
each of those sections.
Section
Information to Include
• Explain who the patient is (Age, gender, etc.)
Introduction (patient and problem)
• Explain what the problem is (What were they diagnosed with, or what happened?)
• Introduce your main argument (What should you as a nurse focus on or do?)
Pathophysiology
•
Explain the disease (What are the symptoms? What causes it?)
History
•
•
Explain what health problems the patient has (Have they been diagnosed with other disea
Detail any and all previous treatments (Have they had any prior surgeries or are they on m
•
List all the patient’s health stats in sentences with specific numbers/levels (Blood pressur
ambulation, etc.)
•
Explain what treatments the patient is receiving because of their disease
Nursing Physical Assessment
Related Treatments
•
Nursing Diagnosis & Patient Goal
•
Explain what your nursing diagnosis is (What is the main problem for this patient? What n
addressed?)
Explain what your goal is for helping the patient recover (What do you want to change for
•
Explain how you will accomplish your nursing goals, and support this with citations (Refe
•
Explain how effective the nursing intervention was (What happened after your nursing in
patient get better?)
•
Explain what the patient or nurse should do in the future to continue recovery/improvem
Nursing Interventions
Evaluation
Recommendations
Your paper should be 3-4 pages in length and will be graded on how well you complete
each of the above sections. You will also be graded on your use of APA Style and on
your application of nursing journals into the treatments and interventions. For integrating
nursing journals, remember the following:
•
•
•
Make sure to integrate citations into all of your paper
Support all claims of what the disease is, why it occurs and how to treat it with references to the literature on
this disease
Always use citations for information that you learned from a book or article; if you do not cite it, you are
telling your reader that YOU discovered that information (how to treat the disease, etc.)

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