Highlights
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Physiological problems.
These may be actual problems, potential problems, or one of each.
Do not select psychosocial problems as you will not be able to discuss the pathophysiology of these and they will not be marked.
For each of your chosen problems:
Nursing interventions may be
Independent interventions – nurse-led, nurse initiated
Collaborative interventions – with other members of the multidisciplinary team
Dependant interventions - for example, dependent on a doctors order
These interventions should focus just on interventions that will specifically treat or prevent your chosen problems. Please do not include general nursing care that would be applicable here or interventions that are required for all care (i.e. there is no need to identify obtaining consent, hand hygiene, etc. as this is required for all nursing interventions always). You do not need to describe the intervention, just state what you would do and why (not how you would do it).
Identify the intended goals of care and patient outcomes for your problem, considering how you would evaluate this. I.e. what do you want to achieve for your patient specifically, how will you measure the patient’s progression towards this goal and how often will you take these measurements?
Include specific outcomes here appropriate for your patient. The idea is that if someone were to read your plan of care without knowing the patient they would still be able to achieve patient specific goals. For example, your patient might have a history of COPD with CO2 retention and the target oxygen requirements would be 88-92%. Instead of your outcome being ‘satisfactory oxygen saturations’ you should specify ‘oxygen saturations of 88-92%’. Instead of saying “acceptable BP” as an outcome, identify what range you want the BP to be in for your patient.
As this is a formal academic report you should include
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