Case Study

Case Study

ASSIGNMENT – SCHOLARLY PAPER

Case Scenario and Questions:

Mr. Chestnut is an 89 year old client who has just had a big gathering of family members at his bedside
for a visit. The family members had just brought in drinks and snacks to celebrate Mr. Chestnut’s
birthday. He is quiet and staring out the window. You have to call his name out loudly before he hears
you. You take his vital signs: 38.0C, 22, 98, 138/96mmHg. He is comfortable in bed and reading his
newspaper.

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Based on the Case Study and assigned system given to the student, the student will create a SOAP note.
A SOAP note consists of subjective data, objective data, an assessment and a plan for your client.

SUBJECTIVE DATA
This portion of the SOAP note should include a statement (s), preferably in the patient’s own words
regarding the chief complaint or why the patient has presented to the health care facility – i.e. why
is he/she here?

The case study will provide you with some of the subjective data. When writing your SOAP note you also
need to include missing subjective date in the form of questions the nurse would ask to obtain
subjective data to complete the history.

OBJECTIVE DATA
This objective data should include information obtained via the physical exam, laboratory analysis, x-
rays, etc.

Your objective data will come from the physical examinations that you feel are necessary based on the
case study. Doing unnecessary exams on the patient will result in lost marks. This data needs to be
referenced.

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ASSESSMENT
Assessment is the nursing diagnosis portion of the SOAP note. Nursing diagnosis are actual or potential
problems this patient may have.
The student needs to prioritize the problems related to the Case Study and associated system assigned.
Through readings and further research, the student will provide their rationale for each of the
problems identified.

PLAN
Through readings and further research, the student will provide a plan.
The plan will include three nursing interventions along with their rationale (referenced). Each nursing
intervention will be based on the problems identified in the assessment portion of the assignment.
1. The due date for the submission of the assignment is at the beginning of class week 9. Anything else
is considered late without prior arrangements. (See student handbook)

2. Content for the assignment can include any topics/readings from the course outline.

3. The assignment criteria MUST include:
i. Demonstrate critical thinking about/analysis;
ii. Be written in scholarly format (Introduction, Body, and Conclusion)
iii. Be a minimum of 2 pages and a maximum of 4 pages, not including the title page or reference page;
iv. Be ‘original thought’, that is, the content must be your own ideas, and not repeat the thoughts or
wording of another;
v. Use references from credible resources (using course resources is allowed, e.g., Jarvis text other
texts and/or suggested reading materials, peer reviewed journals, topic of the week within online
weekly content on Evolve)
vi. Use scholarly language. No use of colloquial chat/texting terminology or abbreviations (e.g. LOL);
vii. Must utilize a minimum of two (2) credible references (1 must be from a peer reviewed journal) for
original posting
viii. Use APA – current edition;
ix. Use correct grammar and punctuation.
x. The Percentage, Summary, and Originality Report from Turnitin must all be included.
xi. Grading rubric attached

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4. Please see PN Handbook for details regarding late assignments.
5. Please see attached grading rubric for evaluation criteria for additional information.