Clinical Case Scenario- including VS, age, pertinent information (smoker or non-smoker), HPI
2 nursing diagnosis (1 risk, 1 primary nursing diagnosis)
Labs- Abnormal Lab values- How do they relate to the case
Medications- At least 3-5 per case (don’t forget to include class, adverse effects, and nursing considerations
3 Nursing Interventions- in order of importance
2 SMART goals for each intervention
Patient Education
Potential Discharge Planning
Evaluation