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Clinical Document

#1 Nursing Problem & RT with AEB:

#2 Nursing Problem & RT with AEB:

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Reason for Health Care (Medical Dx/Surgery)


Key Assessments: (S/O) Nursing Problem & RT with AEB
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#3 Nursing Problem & RT with AEB:


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#5 Nursing Problem & RT with AEB:

#4 Nursing Problem & RT with AEB:

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PROBLEM NO. 1: (Nursing diagnosis, related to, and as evidenced by


subjective/objective data (from Step 1) with medical pathophysiology in APA format.)
Behavioral Outcome Objective(s)/Goals(s): The client will:
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2- Click here to enter text.
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Nursing Interventions, Rationales (with APA in-text citation)
and Delegation (minimum of 5)
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2- Click here to enter text.
3- Click here to enter text.
4- Click here to enter text.
5- Click here to enter text.
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Summary of Outcome/Goal
State whether each goal was met, unmet, or partially met, with supporting subjective /
objective data. If goal was not met or partially met include recommendations or revision
to achieve the goal.
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2- Click here to enter text.
3- Click here to enter text.
PROBLEM NO. 2: (Nursing diagnosis, related to, and as evidenced by
subjective/objective data (from Step 1) with medical pathophysiology in APA format.)
Behavioral Outcome Objective(s)/Goals(s): The client will:
1- Click here to enter text.
2- Click here to enter text.

3- Click here to enter text.


Nursing Interventions, Rationales (with APA in-text citation)
and Delegation (minimum of 5)
1- Click here to enter text.
2- Click here to enter text.
3- Click here to enter text.
4- Click here to enter text.
5- Click here to enter text.
6- Click here to enter text.
Summary of Outcome/Goal
State whether each goal was met, unmet, or partially met, with supporting subjective /
objective data. If goal was not met or partially met include recommendations or revision
to achieve the goal.
1- Click here to enter text.
2- Click here to enter text.
3- Click here to enter text.
PROBLEM NO. 3: (Nursing diagnosis, related to, and as evidenced by
subjective/objective data (from Step 1) with medical pathophysiology in APA format.)
Behavioral Outcome Objective(s)/Goals(s): The client will:
1- Click here to enter text.
2- Click here to enter text.
3- Click here to enter text.
Nursing Interventions, Rationales (with APA in-text citation)
and Delegation (minimum of 5)
1- Click here to enter text.
2- Click here to enter text.

3- Click here to enter text.


4- Click here to enter text.
5- Click here to enter text.
6- Click here to enter text.
Summary of Outcome/Goal
State whether each goal was met, unmet, or partially met, with supporting subjective /
objective data. If goal was not met or partially met include recommendations or revision
to achieve the goal.
1- Click here to enter text.
2- Click here to enter text.
3- Click here to enter text.