Create a Case Study

History of Present Problem:

What data from the PRESENT PROBLEM are RELEVANT and must be interpreted as clinically significant?

RELEVANT Data from Present Problem:Clinical Significance:

Patient Care Begins:

?

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Current VS:P-Q-R-S-T Pain Assessment (5th VS):
T:Provoking/Palliative:
P:Quality:
R:Region/Radiation:
BP:Severity:
O2 sat:Timing:

What VS data are RELEVANT and must be interpreted as clinically significant by the nurse?

RELEVANT VS Data:Clinical Significance:
Current Assessment:
GENERAL APPEARANCE:
RESP:
CARDIAC:
NEURO:
GI:
GU:
SKIN:

What assessment data are RELEVANT and must be interpreted as clinically significant by the nurse?

RELEVANT Assessment Data:Clinical Significance:

Lab Results:

Basic Metabolic Panel (BMP:)Current:High/Low/WNL?Prior:
Sodium (135–145 mEq/L)
Potassium (3.5–5.0 mEq/L)
Glucose (70–110 mg/dL)
Creatinine (0.6–1.2 mg/dL)

What lab results are RELEVANT and must be interpreted as clinically significant by the nurse?

RELEVANT Lab(s):Clinical Significance:TREND:
Complete Blood Count (CBC:)Current:High/Low/WNL?Prior:
WBC (4.5–11.0 mm 3)
Neutrophil % (42–72)
Hgb (12–16 g/dL)
Platelets (150-450 x103/µl)

What lab results are RELEVANT and must be interpreted as clinically significant by the nurse?

RELEVANT Lab(s):Clinical Significance:TREND:
Misc. Labs:Current:High/Low/WNL?Prior:

What lab results are RELEVANT and must be interpreted as clinically significant by the nurse?

RELEVANT Lab(s):Clinical Significance:TREND:

Put it All Together and THINK Like a Nurse!

  1. What is the primary problem that your patient is most likely presenting?
  1. What nursing priority(ies) will guide your plan of care? (if more than one-list in order of PRIORITY)
  1. What interventions will you initiate based on this priority?
Nursing Interventions:Rationale:Expected Outcome:
  1. What is the rationale for treatment and expected outcomes for medical management of the priority problem?
Care Provider Orders:Rationale:Expected Outcome:

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