Your paper must follow APA guidelines
Title slide: please include title of RUA, your name, name of school, number and name of course, instructor
name, due date or session.
All information should be on its own line and centered.-FOLLOW APA GUIDELINES!
Please delete the highlighted areas when submitting, this is only for your reference.
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Reserved.
Assessment
Highlight key areas of concern
General appearance:
Vitals:
Neuro:
HEENT:
Cardiac:
Respiratory:
GI:
GU/Elimination:
Integumentary:
Musculoskeletal:
Psychosocial:
Labs/Diagnostics:
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Pathophysiology (include what functional changes are occurring and what processes or issues initiated, lead, and are
maintaining the disorder/disease)
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Reserved.
Pertinent Medical diagnoses/Reason for
hospitalization:
Client initials:__________ Age: ________________
Student name: ______________________
Male/Female/Nonbinary
Date: ______________________
High priority NANDA diagnosis
Psychosocial NANDA diagnosis
NANDA diagnosis
Short term (ST) goal:
Short term (ST) goal:
Short term(ST) goal:
Long term (LT) goal:
Long term (LT) goal:
Long term (LT) goal:
ST interventions
LT interventions
ST interventions
1.
1.
1.
2.
2.
3.
3.
Evaluation
LT interventions
ST interventions
LT interventions
1.
1.
1.
2.
2.
2.
2.
3.
3.
3.
3.
Evaluation
Evaluation
Linkages and Rationale of Diagnosis
Short summary rationale for why these diagnosis were chosen and how they connect to the client’s current situation/condition
Rationale for why goals were selected
Should have a rationale for each short- and long-term goal. Provide references as applicable
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Infection control:
Safety:
Communication:
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.
References:
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