1) Diagnosis - name and definition of the diagnosis 2) Three nursing diagnoses properly formatted - can only use ONE “risk for” Logical prioritization of the three nursing diagnoses 3) Pertinent assessment findings - are there any pertinent findings you would expect to find in your initial shift assessment? 4) Signs and symptoms - which s/s are typical for this disease process? Many of these may overlap with assessment findings, but also may include more chronic findings. Ex: with CHF the patient might not be experiencing SOB during your assessment, but that is a symptom they would have been experiencing prior to the hospitalization. 5) Pathophysiology 6) Labs and Diagnostics - you may only have labs OR diagnostics for this disease process, but which are typically ordered and why? 7) Medications - link to the nursing diagnoses if possible, but give me the top 3 meds typically ordered for this disease, using the same categories as your weekly write-up 8) Education - what education would a patient need for this disease process? 9) RN Interventions - five total (may overlap with nursing diagnosis), reminder that an assessment alone isn’t enough, you must act on the information. Tell me why that intervention is being used. 10) Causes/Risk Factors - at least three 11) Collaborative interventions and treatments - RT? PT? OT? Spiritual care? Social Work? Which ones and why?
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