Case study nursing (comprehensive health assessment)

Presenting condition and symptoms
Richard Cheng is a 65-year-old man who has worked as a high-school teacher for the past 30 years and has decided to enter semi-retirement by working two days per week. He has moved into a smaller house with his wife and is considering going on a world trip within the next few years. Although he enjoys relatively good health, his doctor has been concerned about his smoking habit, stressing that Mr Cheng should quit given his age and the associated health risks. Mr Cheng has been a chronic smoker for many years and, although he has tried to quit several times without much success, he has managed to reduce the number of cigarettes he smokes per day from 20 to about 12. Recently, after a serious bout of flu, he developed a moist cough, but Mrs Cheng became concerned when he began wheezing, gurgling and struggling for breath during the night. In a panic, she drove him immediately to the hospital emergency department, where he underwent a physical assessment.

This assessment item requires you to undertake a
comprehensive health assessment of a patient in your
specialty area. You should choose a case that will allow you to
critically reflect on the care of that patient. If you are not
currently working clinically, it is your responsibility to contact
the unit coordinator to agree on a suitable case study.
You need to: (1) provide a comprehensive case description
including the salient patient history, physical assessment data
and any relevant investigations using an appropriate
assessment framework; (2) justify the clinical priorities in the
management of this patient. The clinical priorities are the most
important or pressing patient problems or issues based on the
assessment data collected.
Part 1 and 2 should be approximately equal in word count.
PART 1
• Apply an assessment framework that suits the needs of
your patient and/or speciality area of clinical practice
• Briefly justify your choice of framework with literature.
• Select a patient (either upon admission or an in-patient for
whom you care over a single shift). Identify at what stage
of the patient’s admission your health assessment was
undertaken in the introduction of your assessment item.
• Gain consent and then perform a thorough health
assessment.
• Present the patient’s subjective and objective data
logically and clearly. You may present this section under
key areas/headings of your framework and then in bullet
point form.
• Your assessment data should identify normal ranges and
highlight pertinent findings (use italics to highlight).

PART 2

• Based on part 1, identify all the clinical priorities in the management of this patient. The clinical priorities are the most important or pressing patient problems or issues based on the assessment data collected.

• Justify and explain why these are priorities for the patient, using the data you have collected and evidence-based literature.

• Critically reflect on the implications of this learning experience for your future nursing practice.

 

 

 

Sample Solution

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