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Introduction (patient and problem) Explain who the patient is (Age, gender, etc

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Introduction (patient and problem)

• Explain who the patient is (Age, gender, etc.)
• Explain what the problem is (What was he/she diagnosed with, or what happened?)
• Introduce your main argument (What should you as a nurse focus on or do?)

Pathophysiology

• Explain the disease (What are the symptoms? What causes it?)

History

• Explain what health problems the patient has (Has she/he been diagnosed with other diseases?)
• Detail any and all previous treatments (Has she/he had any prior surgeries or is he/she on medication?)

Nursing Physical Assessment

• List all the patient’s health stats in sentences with specific numbers/levels (Blood pressure, bowel sounds, ambulation, etc.)

Related Treatments

• Explain what treatments  the patient is receiving because of his/her disease

Nursing Diagnosis & Patient Goal

• Explain what your nursing diagnosis is (What is the main problem for this patient? What need to be addressed?)
• Explain what your goal is for helping the patient recover (What do you want to change for the patient?)

Nursing Interventions

• Explain how you will accomplish your nursing goals, and support this with citations (Reference the literature)

Evaluation

• Explain how effective the nursing intervention was (What happened after your nursing intervention? Did the patient get better?)

Recommendations

• Explain what the patient or nurse should do in the future to continue recovery/improvement