Section and Information to Include Introduction (patient and problem) Explain who the patient is (Age, gender, etc

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Section and Information to Include

Introduction (patient and problem)

• Explain who the patient is (Age, gender, etc.)
• Explain what the problem is (What were they 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 (Have they been diagnosed with other diseases?)
• Detail any and all previous treatments (Have they had any prior surgeries or are they 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 their 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