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1. Introduction introduces/outlines/situates the topic of the essay clearly describes the way in which the essay will proceed the essay is structured in a logical sequence so that the content flows (headings may be used to develop the structure of the paper) 2. Content a) Consideration of facts from the patient or situation Consider the case scenario of your choosing based on your clinical elective as per assessment Choose the one that best reflects your specialty placement this is where you determine what information should be collected and how information is going to be collected. b) Collection of information You need to discuss the type of information collected and why this information was collected based on the scenario for the clinical elective. For instance, the type of information collected should consider and include the history, current presenting issues and treatment plan, observations, results of investigations done medical records etc. c) Processing gathered information (analysing and interpreting) The most important thing is to analyse the information that you have collected and identify areas of nursing care needs and problems. In this section, your discussion should reflect analysis and interpretation of the patients current health status using your established knowledge of physiology, pharmacology, pathology, culture, and ethics to establish needs and issues drawn from the information. This stage allows you to demonstrate synthesis of theory and experience acquired in previousand concurrent nursing units. d) Identify the problem Identify and state the problems/needs or issues you have identified. It is important to identify the problems/needs/issues and the potential cause to determine the reason behind the patients current issue. Examples: Dehydration as a result of loose bowel motion x 4 and vomiting x 2 during am shift Falls risk as a result of confusion and unsteady gait Loss of weight as a result of poor oral intake for one week Pain due to post -operative procedure laparotomy Hyperglycaemia due to poor diet and lack of knowledge on diabetes Please note these are examples only, the nature of the problems you identify will depend on the nature of the case study and your analysis and interpretation of the situation. e) Establish goals Here, you determine the nursing goals for the patients situation. Identify and prioritise at least three (3) nursing problems/issues based on your assessment and collected data. f) Take action Here you discuss the nursing interventions or measures you will undertake in order to address the three nursing issues or problems. These measures should take in consideration the ethical, legal, evidence based, holistic -person-centred approach. g) Evaluation and Reflection Evaluate the effectiveness of the nursing interventions you have discussed (presumably which could havebeen carried out or actually carried out) and reflect on how the interventions could have been improved or done better- State the potential measures that could have been considered or could have been carried out to address the problem. This phase allows you to critically analyse what has been done and how best the care was carried out or could have been improved. 3. Conclusion the essays ends with a cogent, defendable conclusion that summarises the discussion 4. References Provide a list of references used in your discussion
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