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
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