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Section and Information to Include

Introduction (patient and problem)

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  • 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

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