VOCATIONAL NURSING PROGRAM
Level II
Focused Nursing Case Study I & II
Required Work
During this summer you will complete two (2) Focused Case Studies:
Med/Surg; or OB/Newborn or Pediatric) on patients you have cared for; the goal of this activity
is to assist you to integrate classroom theory and the Nursing Process.
Case Study I will be evaluated as follows:
1 points
References (Minimum 4)
5 points
Punctuality
1 points
Neatness, clarity of data
2 points
Grammar and spelling
4 points
Assessment
5 points
Nursing Process
(Problem, Plan, Implementation, Evaluation) (4 Nursing Dx plus 1
Knowledge Deficit)
18 points total
You are also expected to document any references you used in preparing your paper, using APA
format.
You will need to get the assistance of the primary RN, Charge Nurse, or Instructor to receive a
Nursing Diagnosis. Please use the Assessment Guide and the Focused Nursing Care Plan Form
provided.
If each Focused Nursing Case Study is not complete or has a grade of less than 13, the student
must make corrections before a passing grade for the semester will be given (the original grade
will count towards the course grade).
v:\word\syllabus\vocation\level ii\clinical\nursing care plan
03/2013
VOCATIONAL NURSING PROGRAM
Level II
Focused Case Study I & II
The goal of this activity is to assist you in integrating classroom theory and nursing process.
SHOULD INCLUDE:
1. A list of patient’s medications, action, side effects and nursing implications.
2. Written pathophysiology of disease process or surgical procedures.
3. At least 4 references.
4. Must be submitted in bound folder.
WRITE OUT:
5. Background information: What brought patient to hospital, good narrative head-to-toe
physical assessment.
6. Data: Must document whether subjective or objective.
EXAMPLE:
Obj. - T 98.6 R16
Subj. - "I feel dizzy when I get up"
7. One NRSG Dx per page with rest of data taking etc. as many pages as needed. Must do 4
NRSG Dx (by priority) and one Teaching (knowledge deficit) care plans.
8. Goals - must document time frame as well as state whether LTG or STG.
STG EX: Patient will void 30cc/hr. this 8 hour shift. One STG & one LTG is sufficient.
9. Interventions - Must include whether these are dependent or independent actions. Must have
at least 6 actions per Nursing Diagnosis
10. Rationale - Why, what are you looking for, what will this action help/prevent, etc.
References and page numbers go here too.
11. Conclusion or Evaluation Column: Look at goal - was it met or not met?
What happened with patient after actions were implemented?
This should flow across page to document whether actions were effective.
v:word\syllabus\vocation\level ii\clinical\nursing care plan
03/2013
VOCATIONAL NURSING
FOCUSED NURSING CASE STUDY I
GUIDE SHEET
_____
1
References (Minimum 4)
_____
5
Punctuality
_____
1
Neatness, clarity of data
_____
2
Grammar and spelling
_____
4
Assessment
_____
5
Nursing Process
(problem, plan, intervention, evaluation) (4 Nursing Dx + 1
Knowledge deficit)
_____
18
Total points
Comments:
Student Name
Instructor Signature
Date
v:\word\syllabus\vocation\level ii\clinical\nursing care plan
03/2013
VOCATIONAL NURSING
FOCUSED NURSING CASE STUDY II
GUIDE SHEET
_____
1
References (Minimum 4)
_____
5
Punctuality
_____
1
Neatness, clarity of data
_____
2
Grammar and spelling
_____
4
Assessment
_____
5
Nursing Process
(problem, plan, intervention, evaluation) (4 Nursing Dx + 1
Knowledge deficit)
_____
18
Total points
Comments:
Student Name
Instructor Signature
Date
v:\word\syllabus\vocation\level ii\clinical\nursing care plan
03/2013