Identify expected outcomes and therapeutic nursing intervention, including early discharge planning.

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Introduction: (250 words)
Do not reveal the name of your institution/hospital
Maintain confidentiality (e.g. Mdm. X, Dr. Z,)
Age/gender/ race/ date of admission chief complaint
Assessment: Health Assessment in details (500 words)
Objective Data & Subjective Data
The Interview, The Complete Health History (medical,
surgical, social, mental), Chief Complaints, allergy, isolation (infectious
disease)
Assessment Techniques, the Clinical Setting, General Survey,
Measurement and Vital Signs
Assessment of Thorax and Lungs (breath sound, heart sound)
Assessment of Heart and Neck Vessels, Peripheral Vascular
System and Lymphatics
Assessment of Abdomen (Inspection, auscultation, palpation,
percussion), abdominal girth, Male Genitourinary System & Anus, Rectum, and
Prostate
Assessment of Neurologic System & Mental Status
Assessment of Head, Face, Neck and Regional Lymphatics &
Eyes, Ears, Nose, Mouth, and Throat
Lab Result Interpretation, X-ray, ECG (as applicable)
Identify patient at risk for complication

Medical Diagnosis: Pathophysiology of the disease in
details: Pathophysiology in details (500 words)Nursing Care Plan: Nursing
Diagnosis: medical surgical nursing (600 words)
Outline care plans, according to prioritize of patient’s
needs
Address the need patient safety
Identify appropriate nursing intervention
Identify strategies to assist patients in
achieving outcomes

Identify expected outcomes and therapeutic
nursing intervention, including early discharge planning

Intervention/Implementation:

Treatment (Medical, Pharmacological and Nursing
treatment – as applicable)

Outline care plans, according to prioritize of
patient’s needs

Address the need patient safety

Identify appropriate nursing intervention

Identify strategies to assist patients in
achieving outcomes

Evaluation:

Patient response/reaction to intervention/
implementation/ treatment

Evaluate effects of nursing intervention

Adjust care to potential problems

Document the plan of evaluation of the care

Conclusion: Summary (150 words)

References

Appendix (if applicable)

Resources:
Evidence Based, recent articles (within 5 years)

Wide and extensive reading is a key to success

Harvard’s referencing style

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