Medical History – Medical Problems
Practicum Case Scenario/ Study The following outlines general instructions for the case scenario. Please remember not to include any HIPPA information. Concerns and questions related to care should be included. Include references to treatment plans using APA format. Case studies are expected to be a minimum of 500 words, detailed and comprehensive.
Plagiarism receipt requires
Please follow the outline as below when submitting your case study:
Case Scenario/Study
Student Name:
Submission Date:
Case Study: (GERD)
Patient Initials, Age, Gender
Subjective information from the patient (History of Present Illness/Symptoms)
Current Medications
Medical History – Medical Problems
Objective findings from physical examination
Vital Signs, Weight, Height, BMI
Focused examination findings based on diagnoses being addressed.
Assessment
ICD-10 Diagnosis (include ICD-10 code)
Nursing Diagnoses https://nurse.org/resources/nursing-diagnosis-guide/
Plan
Care Plan based on the diagnosis. (Use Nurses lab for care plan)
Include specific nursing care planning for patients to include.
Potential issues with achieving quality, comprehensive care.
Information on best practice care considerations.
Care outcomes from current treatment
Possible side effects of medications or treatments
Patient education planning/instructions
Care outcomes
Plans for the follow-up to review response to treatment.
References:
