Use your own words and make sure to describe how this relates to your patient’s findings. Include the reference(s) in APA format.
1. What is the primary problem that your patient is most likely presenting with?
2. What is the disease process for this problem:
3. What are the signs and symptoms the patient is exhibiting.
4. What pre-disposed the patient to this disease/condition?
5. How is/was this disease/condition diagnosed? (Include information regarding labs and diagnostic tests that would/have/should be performed)
6. What is the course of treatment for the care of this disease/condition?
7. If left untreated, what would happen to the patient? (The disease progression- do not say death)
8. What nursing priority(s) will guide your plan of care? (Nursing diagnosis AKA Patient problem)
Problem-Focused Diagnosis related to __Related Factors__ As evidenced by __This is your evidence____
Risk For Diagnosis _______ As evidenced by __This is your evidence____
Patient Problem #1: Use your patho data above and your H2T assessment to determine the PRIORITY patient problem
SMART Goal: (Specific, Measurable, Attainable, Relatable, Timely)- Patient problem focused
Intervention #1: (What can “I” as in the Interdisciplinary team- do to help meet that goal?)
Rationale: Why did you decide this intervention as the first thing to help meet the goal?
Intervention #2: (What can “I” as in the Interdisciplinary team- do to help meet that goal?)
Rationale: Why did you decide this intervention as the first thing to help meet the goal?
Intervention #3: (What can “I” as in the Interdisciplinary team- do to help meet that goal?)
Rationale: Why did you decide this intervention as the first thing to help meet the goal?
9. What body systems will you most thoroughly assess based on your patient problem #1?
10. What is the worst possible/most likely complication to anticipate? (don’t say “death”)
11. What nursing assessments will identify this complication EARLY if it develops?
12. What nursing interventions will you initiate if this complication develops?
13. What nursing priority(s) will guide your plan of care? (Nursing diagnosis AKA Patient problem)
Problem-Focused Diagnosis related to __Related Factors__ As evidenced by __This is your evidence____
Risk For Diagnosis _______ As evidenced by __This is your evidence____
Patient Problem #2: Use your patho data above and your H2T assessment to determine the PRIORITY patient problem
SMART Goal: (Specific, Measurable, Attainable, Relatable, Timely)- Patient problem focused
Intervention #1: (What can “I” as in the Interdisciplinary team- do to help meet that goal?)
Rationale: Why did you decide this intervention as the first thing to help meet the goal?
Intervention #2: (What can “I” as in the Interdisciplinary team- do to help meet that goal?)
Rationale: Why did you decide this intervention as the first thing to help meet the goal?
Intervention #3: (What can “I” as in the Interdisciplinary team- do to help meet that goal?)
Rationale: Why did you decide this intervention as the first thing to help meet the goal?
14. What body systems will you most thoroughly assess based on your patient problem #2?
15. What is the worst possible/most likely complication to anticipate? (Don’t say “Death”)
16. What nursing assessments will identify this complication EARLY if it develops?
17. What nursing interventions will you initiate if this complication develops?