An introduction of the client including the patient demographics and background included any pertinent information. • Only Discuss 1 of your clients major PMHX. Briefly mention any comorbid illnesses that are relevant to the situation. For example if you are discussing Atrial fibrillation, a remote past history of hernia repair is not important whereas a clotting disorder would be. • For the Main disorder only, Include: o appropriate treatments o medications o diagnostics o nursing assessments o expected patient presentation § Identify all subjective and objective data • The care plan portion must be presented using a chart format. o It shall include: § 2 appropriate nursing diagnoses § 2 (S.M.A.R.T.) goals per diagnosis. § A minimum of 3 (S.M.A.R.T.) nursing interventions that directly apply to each nursing diagnosis & goal § Choose and identify one PRIORITY intervention for each goal based on what is relevant to the status of the client. § Interventions must be supported by scientific rationale that has come from an academic, reliable source. § Evaluate if the client was able to meet the goal based on the Nursing interventions that were chosen. _ minimum 3 academic reference not older than 5 years
