|
Section
|
Information to Include
|
|
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?)
|
|
Pathogenesis
|
- Explain the development or evolution of the disease, from the initial stimulus (how etiologic factors alter physiologic function) to ultimate expression of manifestations of the disease and related complications.
|
| 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 patients 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/
| Section |
Information to Include |
| 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?)
|
| Pathogenesis |
- Explain the development or evolution of the disease, from the initial stimulus (how etiologic factors alter physiologic function) to ultimate expression of manifestations of the disease and related complications.
|
| 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 patients 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
|
|
Leave a Reply
You must be logged in to post a comment.