During clinical placements, students are to select a patient in their care and to undertake a thorough clinical assessment and case study. Students must discuss their choice of patient with their facilitator and should also obtain appropriate consent prior to assessment and use non identifying information in the case study submission. 
Patient Information 

Name (pseudonym):- _____________________________________ Age:- ___________ Gender:- _________ 

Admission Diagnosis:- _____________________________________ Past Medical History:- _________________________ 
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Past Surgical History:- _____________________________________ 
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__________________________________________________________ Current Medications:- __________________________ 

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Immunisation status:- _____________________________________ 
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Allergies:- _____________________________________ ________________________________________________ 


Next of kin:- _____________________________________ General Appearance :- __________________________ 

Nursing Observations: - ________________________________________________ 

Temperature: - ______ Pulse: - _______ Respirations: - _______ Brief overview of patient: ____________________________
BP: - _________ Weight: - _________ Height/Length:- _________
Urinalysis: - 

Interpretation of nursing observations: 

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Anatomy, physiology and pathophysiology of admission diagnosis:- 

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Diagnostics:- 

Pathology:- 
Reason(s) for particular tests 
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Findings: 

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Radiology: - 
Reason(s) for particular tests 

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Findings: 

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Other: - 
Reason(s) for particular tests 
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Findings: __________________________________________________________________________________________________________________

IDENTIFY 6 FUNCTIONAL HEALTH PATTERNS IN PRIORIY ORDER (with 1 the most important) THAT HAVE BEED AFFECTED BY THE CURRENT (or past) DIAGNOSIS. Include the reason why each functional health pattern has been affected and was given a 1-6 priority order 

1.0 ___________________________________________________________________________________________________________________

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2.0 ___________________________________________________________________________________________________________________

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3.0 ___________________________________________________________________________________________________________________

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4.0 

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5.0 

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6.0 

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Provision and coordination of care: Nursing Care Plan 
Complete the following Nursing Care Plan related to the first 3 functional health patterns that were affected. 

Nursing Diagnosis: NANDA Approved 
Manifested by (Presenting symptoms) Management strategies and rationales 

1. 

Related to (Aetiology): 

2. 

Related to (Aetiology): 

3. 

Related to (Aetiology):- 

Prepare a brief handover report for your patient using ISBAR. 

References 

Marking criteria: 

Adherence to case study criteria : Linked to the provision and co-ordination of care for a patient requiring acute med/surg care. 
All areas addressed in-depth 

Evidence of consolidation of learning.Analysis, critique and synthesis The case study was articulate, logical, balanced and convincing. A diverse range of perspectives was offered. All important aspects are covered demonstrating comprehensive knowledge of the key areas 

Evidence to support the analysis An extensive range of relevant literature utilised with sophisticated interpretation and analysis 

Organisation, 
Presentation and 
ReferencingFlawless presentation.