In order to write a case study paper, you must carefully address a number of sections in a specific order with specific information contained in each.The guideline below outlines each of those sections:
Introduction (patient and problem): Explain who the patient is (Age, gender, etc.), Explain what the problem is (What was he/she diagnosed with, or what happened?), Introduce your main argument (What should you as a nurse focus on or do?)
Pathophysiology: Explain the disease (What are the symptoms? What causes it?)
History: Explain what health problems the patient has (Has she/he been diagnosed with other diseases?), Detail any and all previous treatments (Has she/he had any prior surgeries or is he/she on medication?)
Nursing Physical Assessment: List all the patientâ€™s health stats in sentences with specific numbers/levels (Blood pressure, bowel sounds, ambulation, etc.)
Related Treatments: Explain what treatments the patient is receiving because of his/her disease
Nursing Diagnosis & Patient Goal: Explain what your nursing diagnosis is (What is the main problem for this patient? What need to be addressed?), Explain what your goal is for helping the patient recover (What do you want to change for the patient?)
Nursing Interventions: Explain how you will accomplish your nursing goals, and support this with citations (Reference the literature)
Evaluation: Explain how effective the nursing intervention was (What happened after your nursing intervention? Did the patient get better?)
Recommendations: Explain what the patient or nurse should do in the future to continue recovery/improvement
Clinical History and Presentation:
A 2-year-old Latino male presented to the primary care office with a one-day complaint of irritability and penile swelling. A Spanish translator was obtained for the parent interview. The patient had no recent illness, changes in appetite, or recent fevers. There was no known trauma to the abdomen or genitals.
The child’s medical history was unremarkable, with an uncomplicated term pregnancy and no history of chronic illness, previous surgeries, or hospitalizations. The child lived at home with his parents and two school-aged sisters. His parents were poor historians and were unable to provide a family history. The child’s immunizations were up to date. He had no known allergies and was on no routine medications. The review of systems was negative except as noted above. His growth and development were normal for age. His height was 34.25 inches, weight was 26.9 pounds (12.2 kg), and body mass index (BMI) was 16.1 kg/m2 (37th percentile). His vital signs were within normal for age: temperature 36.8Â° Celsius axillary, blood pressure 84/58, pulse 120 beats per minute, and respirations 24 breaths per minute.
On examination, the child appeared in no acute distress. He had no skin rash or lymphadenopathy. His abdomen was soft, non-tender, and non-distended with no hepatosplenomegaly. There was no ecchymosis noted to the abdomen or the genitals. The child was uncircumcised, with both testicles descended. The foreskin was semi-mobile with moderate erythema and swelling (ballooning) of the prepuce; the meatus was barely visible. The glans penis was moderately erythematous and edematous with the appearance of phimosis. Upon gentle palpation of the penile shaft, a large amount of mucopurulent discharge was easily expressed from the urethra and from under the foreskin. The child did not complain of pain with palpation of the penis or expression of discharge. The remainder of the physical exam was unremarkable.
Clinical Evaluation and Intervention:
Based on the history and the physical examination, the differential diagnoses included balanoposthitis, balanitis, urinary tract infection (UTI), sexually transmitted infection (STI) secondary to possible abuse, hair tourniquet, and foreign body. A sample of the discharge was sent for bacterial culture and sensitivity.
For integrating nursing journals, remember the following:
Make sure to integrate citations into all of your paper
Support all claims of what the disease is, why it occurs and how to treat it with references to the literature on this disease
Always use citations for information that you learned from a book or article; if you do not cite it, you are telling your reader that YOU discovered that information (how to treat the disease, etc.)