Patient initials, age, gender and admitting diagnosis

Nursing diagnosis

Related to

As Evidence by

Nursing diagnosis

Related to

As Evidence by

 

 

 

 

 

Outcomes

Assessment

Signs / Symptoms

Subjective / Objective

Outcomes

Assessment

Signs / Symptoms

Subjective / Objective

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Interventions

Interventions

 

 

Evaluation of Interventions / Outcomes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Medication	Dose, Route & Frequency	Classification	Purpose / Mechanism of Action	Significant Side Effects / Adverse Reactions	Nursing Implications

 

 

Pathophysiological Discussion

1. APA format (citations and references)

2. Discuss the disease process: etiology, epidemiology, and pathophysiologic mechanism

3. Identify common complications that may occur with the alterations or treatment modalities

4. Patient’s overall prognosis