Diagnosis and Patient Goals

In order to write a Diagnosis and Patient Goals case study paper, you must carefully address a number of sections in a specific order, with specific information contained in each. The guideline below outlines each of those sections.

Section	Information to Include
Introduction (patient and problem)	Explain who the patient is (Age, gender, etc.) Explain the problem (What were they diagnosed with, or what happened?) Introduce your main argument (What should you as a nurse focus on or do?)
Pathophysiology	Explain the disease (What are the symptoms? What causes it?)
History	Explain the patient’s health problems (Have they been diagnosed with other diseases?) Detail any and all previous treatments (Have they had any prior surgeries or are they on medication?)
Nursing Physical Assessment	List all the patient’s health stats in sentences with specific numbers/levels (Blood pressure, bowel sounds, ambulation, etc.)
Related Treatments	Explain what treatments the patient is receiving because of their disease
Nursing Diagnosis & Patient Goal	Explain what your nursing diagnosis is (What is the main problem for this patient? What needs to be addressed?) Explain your goal for helping the patient recover (What do you want to change for the patient?)
Nursing Interventions	Explain how you will accomplish your nursing goals, and support this with citations (Reference the literature)
Evaluation	Explain the nursing intervention’s effectiveness (What happened after your nursing intervention? Did the patient get better?)
Recommendations	Explain what the patient or nurse should do in the future to continue recovery/improvement

Your paper should be 3-4 pages long and will be graded on how well you complete each of the above sections. You will also be graded on using APA Style and applying nursing journals to the treatments and interventions. For integrating nursing journals, remember the following:

Make sure to integrate citations into all of your paper
Support all claims of what the disease is, why it occurs and how to treat it with references to the literature on this disease
Always use citations for the information you learned from a book or article; if you do not cite it, you are telling your reader that YOU discovered that information (how to treat the disease, etc.)

Review the rubric for further information on how your assignment will be graded.

General Education Standardized Rubric: PATH 370 Signature Assignment (1)

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