Patho S/A

Section

Information to Include

Introduction (patient and problem)

· Explain who the patient is (Age, gender, 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?)

Pathophysiology

· Explain the disease (What are the symptoms? What causes it?)

History

· Explain what health problems the patient has (Has she/he been diagnosed with other diseases?)

· Detail any and all previous treatments (Has she/he had any prior surgeries or is he/she 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 his/her 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

· Explain what the patient or nurse should do in the future to continue recovery/improvement