Case Study and Care Plan

Case Study and Care Plan


Assignment: Case Study and Care Plan

Assignment: Case Study and Care Plan

The purpose of a case study is to describe an individual situation/case in nursing that allows the student to identify key issues of the case, analyze the case using relevant theoretical concepts from nursing and psychiatric nursing and recommend a course of action for that case.

Students are presented with a case study and will work through the critical thinking exercises.

They will utilize the nursing process and present a plan of care that addresses the holistic needs of the client and the focuses on theoretical understandings of forensic psychiatric nursing care.

Develop a holistic care plan based on the “Incarcerated and Substance Use” Case Study. Using the Care Plan template as a guide and the resources presented in this course, create a care plan that utilizes each phase of the nursing process (ADPIE). Use APA format for your assignment, including a title and reference page.

Your Care Plan must include:

  1. Written assessment including subjective, objective and historical data – clear, concise and to the point.
  2. Written MSE from the information available.  Keep your report clear and concise.
  3. Create one 3-part Nursing Diagnosis following the guide described in the NANDA Nursing Diagnosis Guide – choose what you feel is a PRIORITY consideration for this client – think about what the most important consideration for this client at this time is.
  4. Develop one goal for your Nursing Diagnosis
  5. Create three interventions to support the client obtaining the goal (6 total)
  6. Scientific rationale/principle with references for each selected intervention (6 total)
  7. Evaluation of interventions selected (6 total)

Marking Guide:

Assessment: Includes subjective, objective, and historical data that support nursing diagnosis.
1 mark for subjective data. 1 mark for objective data. 1 mark for historical data to support the nursing diagnosis

1 mark for appearance. 1 mark for behaviour. 1 mark for affect and mood. 1 mark for thought process. 1 mark for thought content. 1 mark for speech. 1 mark for cognition. 1 mark for insight and judgment.

NANDA Nursing Diagnosis (2 ND)
4 marks for each complete NANDA diagnosis as per correct accuracy and priority sequence. 1 mark for including ‘as evidenced by’. 1 mark for including ‘related to’. 2 marks for appropriate choice of what is a priority for this client.

Goal/Outcome Criteria
2 Marks for the goal. 1 mark for a goal related to the diagnosis. 1 mark for use of evidence/ reference to support use of the goal.

Nursing Interventions 
1 mark for each intervention (3 in total). 1 mark for each use of evidence/ reference to support efficacy of the chosen interventions.

Evaluation of Interventions
2 mark for each method of evaluating the 3 interventions including use of literature/ evidence to support the evaluation process.

Medication Regimen
2 marks for identifying possible medications to benefit the client. 2 marks for evidence/ reference to support these choices.

Referrals to community supports
0.5 mark for each support identified (up to 4 services) including a description of the service. 1 mark for including supportive evidence for each service.

APA Reference Page
1 mark for including a reference page in APA formatting. 1 mark for completed reference list used in the care plan.

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