You are required to discuss evidenced based nursing practice for TWO patients, with chronic health problems, you cared for during your professional practice.
You will be required to access the patient’s medical records to prepare for your case report for both patients.
Please maintain patient’s anonymity at all times
Use a pseudonym name for the patients that is not identifiable and state this in your case report
Be careful not to include any information that my identify the patient including places, dates, time, events
The case report should include information related to only ONE patient (word limit less than 70 words each):
1. Brief introduction (one paragraph)
2. Presenting complaint, assessment data and diagnosis
3. Past medical and health history including medications
4. Discuss the clinical manifestations of the chronic health problems on the body systems
5. Identify two (2) actual and two (2) potential health issues of the patient
6. Explain current treatments for the identified chronic problems. Name and explain a few resources and support services which can be utilised to meet patient’s care needs.
7. Answer following:
a. Identify two (2) nursing interventions you performed based on the patient’s needs according to continuum of chronic disease
b. Discuss the patient’s (as appropriate, with family or carer to confirm their) understanding of the conditions and its impact.
c. List other agencies and interdisciplinary team members involved in supporting patient’s care.
8. Formulate an action plan for the patient which includes referral to community support services or rehabilitation services or other support services as needed
9. Explain how you actively involved the patient in the development of strategies to manage their condition. Write what progress notes documentation you did for this patient.
10. Explain how did you identify and meet own role and responsibilities in communicating and reporting the person’s response to nursing interventions.
11. Enlist at least any two variations in person’s needs and explain your response to these variations in the context of a coordinated service approach.
12. Explain what and how you identified the level and type of contribution and support made by family or carer.
Support your case report with reference to current literature. (Minimum 2 literature and maximum of 4 literature).