Discussion post

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Student Name __________________ Clinical Instructor ________________ Date ______________

Unit _________________ Pt Initials _________ Age/Race/Gender ___________

Primary Medical Dx and definition (1-2 sentences):

Etiologies: What causes this pathology?

Asterisk (*) those specific to this patient.

List Meds used to manage this primary

pathology. Asterisk (*) those specific to

this patient.

Diagram and discuss the Pathophysiology of

the primary Medical Dx of the patient.

Signs & Symptoms: Asterisk (*)

those that are present in this patient.

List diagnostic tests used to manage

this pathology: Asterisk (*) those that

are actual in the patient.

Include APA Reference List and in-text citations.

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Initial Assessment Data r/t Priority Nsg Dx:

Highest Priority Nursing Dx:

Plan: S/T Goal:

Interventions:

Rationale for Nsg Dx #1 (number items to correspond

with interventions; cite/quote references and page

numbers):

Evaluation::

Skills Used for this Nsg Dx:

Explore potential Legal/Ethical Issues r/t caring for patient:

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Use back of page as necessary for all sections.

Initial Assessment Data for 2nd Highest Nsg Dx:

Nsg Dx #2:

Plan: S/T Goal:

Interventions: Cite reference with item.

Rationale for Nsg Dx #2 (number items to correspond

with interventions; cite/quote references and page

numbers):

Evaluation:

Skills Used for this Nsg Dx:

Safety Concerns when caring for this patient:

APA Reference List on back of page:

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Date Progress Notes