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Background of self and current working area / department, introduce the case scenario.
Health Assessment – 1250 words*
. Subjective Data Chief complaint, Past medical history, Family history, Social/Spiritual history, Focused review of systems, Functional health, pattern assessment, Cluster the data and determine/modify.
. Objective Data Complete focused, physical exam including related systems. ldentification of diagnostic data.
. Assessment Determined nursing diagnosis(es) and collaborative problem(s).
Nursing Plan and Evaluation – 750 words” . Plan For each nursing diagnosis or collaborative problem, determined at least two specific measurable patient outcomes. The plan also includes nursing interventions that are evidence-based with rationale and target specific etiologies of illness or risk behaviors. lnterventions integrate the unique needs of the patient.
. Evaluation Describe the methods used to evaluate each of the patient outcomes.
Conclusion – 250 words* o Give an overall appraisal of what you have learned from this case study.
Presentation . lncludes sentence construction, word choice, spelling, punctuation, and grammar
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