Introduction (patient and problem) ? Outline the case Explain who the patient is (Age, gender, marital
status, occupation, roles in life …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?)
? Rationale for selection of this topic.
? Include brief literature and general statistics on the topic.
Pathophysiology ? Explain the disease (What are the symptoms? What causes it?)
History ? Past history of illnesses
? Explain what health problems the patient has (she/he been diagnosed with other diseases?
? Consider medications, allergies, behaviors, and habits which may have impacted upon their health.
? Detail any and all previous treatments (Has she/he had any prior surgeries?)
? Maintenance practices ( immunization, screening, lifestyle)
? Family health history, for example, heart disease, high blood pressure, stroke, diabetes
? Family and other support provided.
? The source of information (patient, relative, other health care professional).
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 Care Plan
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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