SCHOOL OF HEALTH SCIENCES, NGEE ANN POLYTECHNIC Diploma in Health Sciences (Nu sin!

" CLINICAL ATTACH#ENT #OD$LE CASE%ST$DY& Stan'a ' Template (o Yea ), * + , INST-$CTIONS& 1. You are required to do ONE case-study on a patient during: a. CA 1.2a, 1.2b b. CA 2.1a, 2.1b c. CA 2.2a, 2.2b d. CA 3.2a, 3.2b e. PRCP 2. Your CF/C !i"" ad#ise you regarding presentation/sub$ission o% t&e case-study. 3. You !i"" be assessed under Assess$ent co$ponents: a. No 7: Displays critical thinking & clinical reasoning b. No. 14: Reflects on learning experiences & applies theoretical knowledge to clinical practice. '. n addition to t&e Case-(tudy (tandard )e$p"ate, use t&e %o""o!ing docu$ents under t&e Appendix to co$p"ete your case-study: a. Appendix A: edication !nfor"ation & anage"ent

b. Appendix #: $ist of N%rsing Diagnosis c. Appendix &: N%rsing &are 'lan '. Appendix D: GI//S -e(lecti0e C1cle *. (e"ect patient type as indicated be"o! %or your case-study: a. CA ).*a& (e"ect any patient under your c&arge. Focus: Introduction to doing case-study & fulfill medication information for Pharmacology 1. b. CA ).*2& (e"ect an e"der"y patient age +* , abo#e. Focus: Fulfill gerontology component learnt in FON 2. c. CA *.)2& (e"ect a patient !it& speci%ic disease process "earnt at -e#e" 2.1. Focus: fulfill medication information & management for Pharmacology 2. d. CA *.*a + *.*2& (e"ect a patient !it& t&e di%%erent needs "earnt at -e#e" 2.2: Paediatrics, .bstetrics//ynaeco"ogy and 0enta" 1ea"t&. Focus: fulfill Ethics !a" & #ealthcare module. e. CA ,.*a + ,.*2& (e"ect any patient under your c&arge. Focus: holistic patient care & management %. P-CP& (e"ect any patient under your c&arge. Focus: holistic patient care & management

Note: $u%mit case study "ith documents in the &ppendi'(s) for rele*ant modules as ad*ised %y your !ecturer.
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). PATIENT3S DE#OG-APHIC DATA Name 6initials):0.P Date o( /i th& 4+/47/15*1 Gen'e & Fe$a"e #a ital Status& (ing"e #ain Lan!ua!e o( Communication& )a$i" and 8ng"is& *. PAST HISTO-Y #e'ical& sc&e$ic &eart disease 1ypertension 3ys"ipide$ia (pina" stenosis Pri$ary C:( "y$p&o$a on c&e$ot&erapy, acco$panied by sei;ure Famil1& :i" Social& :i" Su !ical (nature & date of operation if applica%le): Carpa" tunne" op recent"y Date o( A'mission& 2+/47/2413 A!e& +2yo -ace& ndian -eli!ion& 1induis$ Occupation& 9ne$p"oyed

,. C$--ENT HOSPITALI4ATION -eason (o Hospitali5ation& Patient used to ad$it on 24/4+/2413 , disc&arge on 22/4+/2413 < =ard '7, C"ass C, under 3 0 %or abdo$ina" pain Partia" sei;ures 6(i$p"e partia" sei;ures> < 111*&r in 2+/47/2413, !&ic& noted by son (een ?er@ing rig&t upper "i$b 9pon arri#a" by (C3F, patient sti"" a"ert , responsi#e, &o!e#er rapid"y beco$e unresponsi#e !it& /)C /i#en recta" dia;epa$ by (C3F :oted to be sei;ing < 83 , gi#en A dia;epa$ #e'ical T eatment Plan (see ,r-s orders): 1. Para$eters ' &our"y 2. 2 &our"y C-C 3. P. c&arting '. C"ood in#estigations 61b, =CC, P"ate"ets *. 9rgent neuro"ogy re%erra" +. 3ai"y &ypocount 6)3( D14p$>
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Pathoph1siolo!1 (applica%le to !e*el 2 & +) Partia" sei;ures occur !&en t&ere is eBcessi#e e"ectrica" disc&arge is "i$ited to one part o% t&e brain, a sing"e &e$isp&ere or part o% t&e "obe. )&e sy$pto$s o% sei;ures !i"" #ary depending upon speci%ic "ocation in t&e brain !&ere t&e %oca" sei;ures originates or spread to.

!it& abortion o% sei;ures #e'ical Dia!nosis& (ei;ures 9nder $edica" onco"ogy

E. Reta@e a"" o"d $edications 7. 0R brain In0esti!ations (la% radiological etc): 9rea: +.4 (odiu$: 13* 8"ectro"ytes: 3.5 Ca"ciu$: 143 Cicarbonate: 1'5 :F3A D u! Alle !1 (type & allergy symptoms if applica%le):

6. #EDICATION LIST (.o record medication information & management / use template in Appendix A( 1 2 3 ' * + #e'ication(s" (enna 1tab .: (i$#astatin 24$g .: :o#e$iB 7 units pre dinner -e#etiraceta$ 1*4$g C3 Ca"ciu$ ca"binate 2 tabs .: A$"odipine *$g .0 In'ications&

7. ASSESS#ENT DATA (-e0ie8 o( S1stems" 1 :eurosensory 6cogniti#e %unction, $e$ory , reasoning>: 3ro!sy Ci"atera" pupi"s di"ate Ab"e to recogni;e p"ace, person but not ti$e

Respiration 6rate, patterns, nor$a"/abnor$a" breat& sounds, (P.2>: Respiratory rate: 1+ breat&s/$in Creat&ing pattern: Regu"ar :or$a" breat& sounds (p.2 144G

Circu"ation 6pu"se rate, b"ood pressure, apeB beat> Pu"se rate: 14* beats/$in C"ood pressure: 13+/EE

'

(1(2 c"ear /astrointestina" 6abdo$ina" assess$ent H pa"pation, percussion>:

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nspection Abdo$ina": F"at, no signs o% distention

(@in 6inc"udes &air , nai"sI co"or, teBture, "esions, integrity>:

0out& , )&roat 6inc"ude "ips , tongue H $oist/dry, condition o% teet&, dentures>:

:utrition 6eating patterns, appetite>:

8"i$ination: 9rinary 6patterns, incontinence, dribb"ing>:

8"i$ination: Co!e"s 6patters, incontinence>:

14

Co$%ort 6pain assess$ent H use .-3CAR), pain score>:

11

("eep 6patterns>:

12

0obi"ity , Acti#ity 6gait, ba"ance, ?oints>:

13

Psyc&osocia" , econo$ic 66&ousing, education>:

1'

(piritua"ity 6re"igion, re"igious practices>:

1*

Ris@ Assess$ent 6%a"" , pressure u"cer ris@>:

1+

.t&ers:

9. #ASTE- P-O/LE# LIST (N$-SING" (!ist in order of priority / at least + nursing diagnoses / select from list of Nursing ,iagnoses in Appendix #) Nu sin! Dia!nosis& Actual 1
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Nu sin! Dia!nosis& Potential

2 3

:. N$-SING CA-E PLAN (,e*elop 0 nursing care plans from the master pro%lem list / use template in Appendix &) ;. DISCHA-GE PLANNING #ain Ca e!i0e & Discha !e Placement (home community hospital etc): Home e<uipment=consuma2les (specify if re1uired): Discha !e Nee's=Conce ns (financial psychosocial etc): Ca e!i0e T ainin!=Teachin! (specify if re1uired):

>. SELF E?AL$ATION (2eflect on ho" you ha*e cared for the patient & areas "here you can impro*e / use 3I44$ cycle in Appendix D)

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