A nursing case study is a written record to be used as a guide and caring for the patient. A case study is a written document concerning a patient, pertinent facts such as age, condition of the patient at the time of the latest incident or disease symptoms, etc. It begins with a plan, a pre-arranged set of specifics that will, most often, be from a template. The template will guide the nurse in how to be inclusive and what to look for, questions to ask, and how to care for the patient, and what to expect as a prognosis.
Generally, a care plan will begin with an introduction of the patient, the type of plan that is being written, the goal of the document. It’s simplicity, or its complexity, will depend on the nursing setting. Is this a care plan being written by a professional for a presentation to a group of students as a learning tool, or is it a basic care plan that all can follow from day to day as they go about tending to the needs of the patient, or is it intended as evidence that will presented in a courtroom?
Therefore, after the type of care plan has been decided upon, what next? It must be implemented, that is, it must be written. Possibly an instructor is teaching a class and the assignment is on how to write nursing care plans. These are varied. They may concern a real patient that the students are familiar with, a fictional list of patients, or it may concern a varied list of medical conditions and the students are to fill in the details and write a general care plan around each condition.
Real situations where care plans are, or should be mandatory, are home health care, public health nursing, and in all situations where the care is done without the immediate supervision, or near contact, of others who may be available for help and advice. Situations where traveling with a patient, caring for them in hotels, on cruises, and in settings outside of the institution, will need written instructions and notes on care. Records and care plans may be needed and are necessary as part of the plan for the patient, as well as protection for the caregiver, in all nursing situations.
Once the overall plan has been decided upon, it will be carefully evaluated. If it is for a student assignment, it will be read over, corrected for its grammar, its clarity, but most of all, for its content. Is it inclusive? Does it take in all aspects of the patient, their needs, their prior symptoms, the type of medical treatment sought previously to this present need for care, and overall, what is the expected outcome?
Where are case studies most often found? They are common in nursing schools and in teaching situations as an essay type document that stimulates thoughts and care for a particular diseased entity. They are designed to stimulate students to critical thinking, and to show them how to observe a patient, and what symptoms to watch out for out, and how to report these symptoms.
To make writing these care plans easier, it is best to follow an outline so that nothing will be left out. One online nursing education site recommended these five steps: Assessment, nursing problems or requirements, goals of care, how to begin the care, determination if the goals have been met.
Assessment will take in all aspects of the immediate care of the patient, their symptoms, their doctor’s orders, their laboratory findings, their history, their family’s disease history, their personal needs, their personality and how easy or how difficult it is to work with them. Their nutritional needs, the effects of the physical examination, how their general health is, and how well they communicate and how much care they can give themselves, is all part of the plan of care. In other words, how much help will they need.
Nursing problems or the exact reason they are being cared for, is the core of the plan. The incidents leading up to the present outcome, when did the symptoms start, what were the preliminary treatments, if any, and what led them to this particular hospital, clinic, nursing home, or whatever. What is the expected outcome?
Goals of care will specifically relate to what has been done, what is being done, and how well these treatment options are working. If they are seen as inadequate, then what are the suggested ways they can be improved upon. Steps four and five will be the actual beginning of the care plan and description and facts of how it is being carried out will be next, and after that, the goals and expectations that initiated the care plan, have they been met?
Typically, nursing care plans are tools of the nursing profession, and they are most often used in teaching situations. Yet, basically , in a more random form they are part of every patient’s chart. The difference is in the type of information needed: the write up about the reason for hospital admittance, the medical problem, the doctor’s order, the method of treatment, general notes on the condition of the patient are noted on a daily basis, and whatever else is needed.
The chart, as well as information from the patient, and the assessment by the nurse will be the source of most of the information that make up a care plan. Basically, in some form, care plans are necessary since so many varied individuals care for a patient. They must have some way of quickly assessing the problem, following through with the plan of care, and getting the patient the treatment needed.