Once the treatment has been implemented, it will be your job to document each treatment activity – time, dose, etc.
– and then track the improvement that does or does not occur.
In this case, you may very well recommend this new treatment plan.
Just remember, you must justify any recommendation you make, and usually this comes from medical research literature.
It will require lots of planning of methodology, literature reviews, and careful documentation as the case study proceeds.
There are three large sections – Information about the Patient; The Nurse’s Assessment of the Patient’s Status; and the Treatment Plan, along with Recommendations. Section 1 – Patient Status This section includes demographic information, the patient’s medical history, and the current patient’s diagnosis, condition, and treatment.
Here you will obviously speak about the patient – and you will commit all of this information to writing.
Do not rely on your memory – write everything down.
For example, suppose a patient has a diagnosis of cancer.
One of the symptom presentations is difficulty in urination.