Case Analysis: Scholarly Writing Assignment

Criteria for Evaluation
PLEASE READ ALL! PATENT MEDICAL INFORMATION IS ON OTHER PAPER AND PERSONAL IS BELOW.
Purpose:
The student will evaluate the nurse’s role in facilitating safe, quality outcomes for patient-centered care. The student will select a patient care assignment from the clinical practicum (not the same patient used for the case presentation) to complete the case analysis using the criteria stated below. The student must use at least 2 professional journal articles to supplement content from other recent nursing textbooks to provide the evidence for the care provided. Unless classic research, all references must be within 5 years of publication. The written assignment will conform to APA style for format of paper and citations of resources. The expected length of the paper is at least 8 pages.

Criteria Possible Points Comments/Earned Points
Introduce the background of the patient
Health history
Economic and social history
Spiritual and cultural considerations
Family members and relationships
Community of residence 10 /10
Comments:
Medical diagnoses
Discuss pathophysiology of disease or symptoms with focus on current health problem(s)
Analyze the risk factors and patient’s assessment findings that relate to the pathophysiology or disease conditions 30 /30
Comments:
Patient assessment
Discuss physical assessment findings including vital signs and allergies
Evaluate the medications including the reasons for patient taking each one.
Evaluate laboratory and diagnostic tests relevant to care of the patient
Emphasis should be on the analysis of assessment data to care for patient 30 /30
Comments:
Analyze the case and progress toward outcomes using the nursing process framework
Identify one priority diagnosis and two other nursing diagnoses and provide brief plan of care with rationales and interventions that are realistic and individualized to patient.
Evaluate the care provided to the patient and the patient’s achievement of care outcomes 40 /40
Comments:
Examine how a systems approach to collaboration with other members of the interdisciplinary team contributed to safe patient care. 10 /10
Comments:
Evaluate discharge planning goals or other long term planning goals for the patient. 15 /15
Comments:
Discuss how the nurse provided or could have provided for the spiritual and cultural needs of the patient. 10 /10
Comments:
Evaluate one or more of the agency specific policies and the impact on the provision of care for this patient.
Was policy a barrier or facilitator for care?
How does nursing leadership advocate for safe, quality care? 10 /10
Comments:
Analyze ethical and legal standards that impacted the care of the patient and family. Possible discussion topics include: ethical standards for professional nursing practice, end-of-life decisions and advanced directives, respect for ethical rights of patients (autonomy, beneficence, etc.) 15 /15
Comments:
Analyze ethical and legal standards that impacted the care of the patient and family. Possible discussion topics include: ethical standards for professional nursing practice, end-of-life decisions and advanced directives, respect for ethical rights of patients (autonomy, beneficence, etc.)Reflect on additional learning that you need to enhance your care of a similar patient care situation in the future. 10 /10
Comments:
Scholarly presentation of work
Uses textbooks and recent journal articles to support discussion points
APA format for style, grammar, in-text citations, and references
Absence of spelling errors 20 /20
Comments:
Total 200 /200

MM is an 83-year-old female who came in with a TIA. She is a retired Kroger worker and identifies herself as a Christian. She likes to read the bible every night before going to sleep so everyone taking care of her knows that for the fifteen minutes before she goes to bed not to bother her. Her daughter and son in law were present when I did my assessment. She lives with her daughter and explained how the house is very fitting for her.

PHYSICAL ASSESSMENT FINDINGS: She had a bruise on her arm she doesn’t recall how that happened. Her respirations are unlabored and normal. Heart rhythm is normal sinus. She has weakness and decreased movement in her left side could be because of the TIA. She is only able to get up with assistance and is using the bed side commode. Capillary refill less than 2 seconds. She is well groomed and Alert and oriented x 4.