Nursing Case Study

Choose a clinical case they have encountered in your clinical areas/work, gather relevant clinical data associated with the pathophysiology, document the information in a SOAP note format, and relate the clinical data to the pathophysiological process. References for case studies should be in APA format.

Use the Independent Case Study Template provide for this assignment.


Consider the SOAP note format for clinical documentation.

S- Subjective
Subjective information obtained from the patient/caretaker.

Objective information obtained during a thorough physical exam and diagnostics completed prior to the exam. Must include lab values.

A-Assessment (or Diagnosis)

Name the pathophysiological condition(s).

P-for this course, the P will stand for Pathophysiology

Students will thoroughly discuss the pathophysiology from cellular to tissue to system to whole being effects.
Relationship between the pathophysiological symptoms and signs/diagnostic results presented in the subjective and objective sections, respectively, are thoroughly discussed.
If co-morbid conditions exist, students must discuss the interaction of these pathophysiological processes.
Use the questions below to guide the discussion.
Questions to answer for the Pathophysiology Section

As with our case studies in class, these may be bulleted. However, be sure to clearly link the information to the pathophysiology.

Describe the pathophysiology. Consider cellular, tissue, organ, system, whole being responses. (Etiology)
What is the incidence and prevalence of this pathophysiology?
Prevalence is a statistical concept referring to the number of cases of a disease that are present in a particular population at a given time.

Incidence refers to the number of new cases that develop in a given period of time.

How do the symptoms, signs, and diagnostic studies of this specific case relate to the pathophysiology of the diagnosis indicated in the Assessment section?
Not all cases of a given pathophysiology present in an identical manner. When discussing symptoms and signs of your patient, be sure to explain how the symptoms or signs occur given the specific pathophysiology.

When discussing diagnostics, clearly link the diagnostic to the pathophysiology. Explain the diagnostic, what the results mean, and its relationship to the specific pathophysiology.

Are there any nonpharmacological interventions that may assist with the pathophysiological condition?
If so, describe how the intervention would benefit the patient with this specific pathophysiology.

Sample Solution