Case Study Grid Essay Sample

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List five factors of the patient’s history that demonstrates nursing needs.
1. Limited social support in and out of the hospital
2. Weight loss
3. Lack of knowledge about the importance of self-breast examination
4. Smokes approximately two packs of cigarettes a day.
5. No emotional support from her spouse, and abusive spouse

Complete the table below with the following information:

Formulate three nursing diagnoses using the Problem, Etiology, and Signs and Symptoms (PES) format and the taxonomy of NANDA. The diagnoses must be based on the case study, be appropriate, be prioritized, and be formatted correctly.

For each nursing diagnosis, state two desired outcomes using NOC criteria. Desired outcomes must be patient-centered and measurable within an identified timeframe.

For each outcome, state two nursing interventions using NIC criteria as well as one evaluation method. Interventions and the evaluation method must be appropriate to the desired outcomes.

Provide rationale for each nursing diagnosis, and explain how PES, NANDA, NOC, and NIC apply to each diagnosis.

Use a minimum of three peer-reviewed resources, and create an APA formatted reference page.

Nursing Diagnosis 1: Acute pain related to radical hysterectomy as evidenced by report of 8/10 pain and grimacing

Desired Outcome 1
Patient will report minimal pain with minimal interference of ADLs by hospital day 2
Patient will demonstrate use of relaxation skills and diversional activities by the end of hospital day 3

Determine the location, frequency and duration of pain in a scale of 0-10 Provide non pharmacological activity measures like repositioning and offering comfort measures

Administer analgesics as indicated and also Inform patient of the expected therapeutic effects and discuss management of side effects Encourage use of stress management like music therapy, therapeutic touch Evaluation method

Asking the patient to rate the pain in a scale of 0-10
Patient is able to demonstrate

Provides baseline data to evaluate need for intervention and also provides realistic expectations. Promotes relaxation and refocus attention and also enables patient to participate in the care

Nursing Diagnosis 2: Imbalanced nutrition related to inadequate food intake as evidenced by loss of weight
Patient will demonstrate selection of foods that will help achieve cessation of weight loss by the end of day 2
Patient will gain lbs. per week for the next 2 weeks

Monitor laboratory values that indicate well-being e.g., total lymphocyte count, serum transferrin, and albumin/ prealbumin. Weigh patient weekly

Maintain strict input, output and caloric count
Explain importance of adequate nutrition
Evaluation method

Have the patient keep a daily diary
Patient is able to explain the importance of adequate nutrition Rationale

Provides objective data regarding nutrition
Necessary to make accurate nutritional assessment

Nursing Diagnosis Risk for infection related to invasive procedure and malnutrition
Patient will remain afebrile and achieve timely healing throughout the hospital stay
Patient will be able to identify and participate in interventions to prevent/reduce risk of infection Nursing Intervention 1

Monitor the patient temperature
Promote good hand washing procedures by staff and visitors. Screen/limit visitors who may have infections. Nursing Intervention 2

Administer antibiotics as indicated
Emphasize personal hygiene.
Evaluation method

Check the temperature every hours


Early identification of infectious process enables appropriate therapy to be started promptly. Limits potential sources of infection and/or secondary overgrowth.

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