Nursing diagnosis

1. Use critical thinking and diagnostic reasoning skills to formulate differential diagnoses, medical diagnoses, and an evidence-based action plan.

Assessment

A: Differential Diagnosis (include rationales and cite sources)

1.

2.

3.

B: Nursing Diagnosis

1.

C: Medical Diagnosis

VI. PLAN

A: Orders

Prescriptions with dosage, route, duration, and amount prescribed and if refills provided

Diagnostic testing

Problem oriented education

Health promotion/maintenance needs

B: Follow-up plans (When will you schedule a follow-up appointment and what will you address in the subsequent visit — F/U in 2 weeks; plan to check annual labs on RTC (return to clinic).

VII. Nursing theory and application: Select a nursing theory and apply this to your patient’s plan and evaluation (brief statement).

VIII. Developmental stage: Identify the developmental state and provide rationales to support acquisition of skills in the stage (brief statement).

IX. Cultural characteristics, diversity, sensitivity, and ethical considerations

Discuss culturally diverse considerations you identified for this patient. Cultural diversity is a general term that can include gender, religious beliefs, culture, race, economic status, age, etc. Discuss one ethical standard relevant to the care of this patient.

X. Evaluation of care: Provide a brief statement sharing your thoughts about the visit and/or patient. Please share what you should have done differently.

References: Please include a minimum of three references. The reference list must be in APA format. All sources must be within 5 years of publication.