Nursing Case Study: Importance of Patient History and Nursing Care Plan

Nursing Case Study
1

Table of Contents
INTRODUCTION.......................................................................................................................................................................................3
Patient situations......................................................................................................................................................................................3
Collection of informations relevant to the patient...................................................................................................................................4
Process informations of the patient..........................................................................................................................................................6
Nursing care plan.....................................................................................................................................................................................7
Reflection.................................................................................................................................................................................................9
CONCLUSION............................................................................................................................................................................................9
REFERENCES..........................................................................................................................................................................................11
2

INTRODUCTION
Nursing refers a collaborative care of people with different age. The main aim of nursing is to improve health of
people and make them healthy as well as disease free Butcher & et.al., (2018). This study is based on a case in which
patient Banu fell down from a tree root and injured her left leg. Due to this she is now suffering from the pain in her left leg.
She has overall a healthy life but takes contraceptive pills. This study is going to show importance of knowing patient
history as what she does daily, what is her family history, her medication, treatments, disease and diagnosis if happened.
By knowing all of these informations, nurses provide better treatment as per their present issue and situation. It will also
show some nursing problems as well as interventions for them Moskal, D. & et.al., (2018, p. 65).
Patient situations
In the case of Banu who fell over a tree roof stated pain in her left calf. Banu is a 28 years old lady. In the case, some
problems stated which shows her present situation.
Pathology of pulmonary embolism can be defined as a condition of sudden closure of pulmonary artery as well as
one of its branches which is mainly caused by a blood borne clot (Neto-Neves and et.al., 2017, p. 700-712).
Identification of problem: Banu is a healthy female as sudden she fell or tripped over a tree root on her daily run.
She stated that due to tree fall her left calf is swollen as well as painful. The right calf is absolutely normal. After 1-2 days
at the time of medication, she looked stressed, and she told that she is suffering from chest pain Gupta & et.al., (2018, p.
141-145). She was diagnosed with pulmonary embolism. This test is diagnosed and recommended when a patient has
pain in chest and feel like a blockage.
Medication: In the medication history, it is identified that she takes contraceptive pill as the only medicine.
Otherwise, she has a healthy lifestyle and there is no major issues Farquhar & et.al., (2017).
3

Collection of informations relevant to the patient
It is important for a nurse to collect several informations relevant to her disease. It includes: her family history, her
medication, her daily routine and other. There are several reasons of having a disease in an individual as it may be
genetic as if parents of an individual have some types of disease than there are chances of having disease in patient or
their children as well. Some reasons may related to their daily life as if an individual consume alcohol, smoking and other
drugs than it may also be the reason Moskal & et.al., (2018). One of the main aim of knowing patient history and collecting
all informations is to identify the reason and give treatments accordingly. For example: If an individual has some pain in
chest, and he/she use alcohol, drugs and other things which may cause pain in chest than nurses recommend them to not
use all those things. Nurses also treat them as per the reasons Khoo & et.al., (2019, p. 348).
In the case of Banu, as a nurse it is important to collect informations and from the informations' history of patients is
identified such as:
Age: Age of Banu is 28 years.
Lifestyle: Banu lives a healthy lifestyle and that is why she found a healthy female. She rides to Holmes glen institute
most of the days when she studies allied health. From this, it can be said that she knows how important it is to being
healthy and fit as well as ways of being healthy and fits. It equates to approximate 10 km/day. She also went for a trip to
London it also shows that she likes travelling and to be happy. She also loves to read books as well as partying with her
friends.
Medication: It is stated that Banu takes contraceptive pills as the only medication. She does not take other pills because
she is healthy and fit and founded disease free. She used to drink alcohol, but she had not been drinking when she fell
Curtis & et.al., (2016, p. 1-66).
Family history: She has a happy family in which she has 3 siblings. Her father and mother. She has 1 older brother age
of 30 and 2 younger sisters age of 26 and 24. It is also stated that her mother diagnosed with TIAs. TIAs (Transient
4