The seven sections instructors expect, a filled-in example, and a faster way to write yours.
In the order most rubrics grade them. Rename or reorder to match yours.
Age, history and reason for admission, with nothing that identifies the patient.
Subjective and objective data: what the patient says, what you measure.
Prioritized, in NANDA-I format, each tied to assessment data.
One measurable, time-bound outcome for each diagnosis.
Each nursing action, and the evidence behind it, cited.
Whether each goal was met, and what changes if not.
What you learned and what you'd do differently.
A fictional patient with a COPD exacerbation, written into the template. Targets follow the GOLD 2025 report; diagnoses use NANDA-I labels.
A 68-year-old man was admitted from the emergency department with an acute exacerbation of COPD after three days of worsening shortness of breath and productive cough.
History: COPD for 9 years, hypertension. Former smoker, 40 pack-years, quit 5 years ago. Home medications: tiotropium inhaler daily, lisinopril 10 mg daily. No known allergies.
Subjective: "I can't catch my breath walking to the bathroom." Reports thick yellow sputum.
Objective: RR 28, HR 104, BP 142/86, T 37.9 °C, SpO₂ 86% on room air. Tripod positioning, accessory muscle use, coarse crackles at both bases. WBC 12.8 × 10⁹/L.
1. Impaired gas exchange related to ventilation-perfusion imbalance as evidenced by SpO₂ 86% on room air and dyspnea at rest.
2. Ineffective airway clearance related to excessive, thick secretions as evidenced by coarse crackles and an ineffective cough.
3. Activity intolerance related to imbalance between oxygen supply and demand as evidenced by dyspnea walking 10 meters.
1. SpO₂ stays between 88% and 92% on the lowest oxygen flow within 24 hours.
2. The patient clears secretions with an effective cough, and crackles decrease within 48 hours.
3. The patient walks to the bathroom with SpO₂ at or above 88% within 48 hours.
Titrate oxygen to a target SpO₂ of 88–92%. Rationale: controlled oxygen corrects hypoxemia while limiting the risk of hypercapnia in COPD exacerbations (Global Initiative for Chronic Obstructive Lung Disease [GOLD], 2025).
Give prescribed short-acting bronchodilators and reassess breath sounds and work of breathing after each dose. Rationale: short-acting bronchodilators are the first-line treatment for an exacerbation (GOLD, 2025).
Teach pursed-lip breathing and huff coughing before activity. Rationale: slower exhalation reduces air trapping and dyspnea, and huff coughing moves secretions with less fatigue (Hinkle et al., 2022).
Refer to pulmonary rehabilitation before discharge. Rationale: rehabilitation started soon after a hospital stay improves exercise capacity and quality of life (GOLD, 2025).
Goal 1 met: SpO₂ 90% on 1 L/min nasal cannula at 20 hours.
Goal 2 partly met: productive cough improved, crackles persist at the right base. Continue huff coughing every 2 hours while awake.
Goal 3 met on day 2: walked to the bathroom with SpO₂ 89% using pursed-lip breathing.
I expected to give more oxygen, not less. Learning why the target is 88–92% in COPD changed how I read a "low" saturation. Next time I would teach pursed-lip breathing on admission instead of day 2.
Global Initiative for Chronic Obstructive Lung Disease. (2025). Global strategy for prevention, diagnosis and management of COPD: 2025 report. https://goldcopd.org/2025-gold-report/
Herdman, T. H., Kamitsuru, S., & Takáo Lopes, C. (Eds.). (2024). NANDA International nursing diagnoses: Definitions and classification, 2024–2026 (13th ed.). Thieme.
Hinkle, J. L., Cheever, K. H., & Overbaugh, K. J. (2022). Brunner & Suddarth's textbook of medical-surgical nursing (15th ed.). Wolters Kluwer.
Describe the patient scenario. Thezis opens a case study with these sections, ready for your assessment data and sources, and helps you write one section at a time.
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Use a de-identified or fictional patient. Remove names, dates, room numbers and anything else that could identify them, and follow your program's privacy rules.
Your instructor's rubric comes first. This template covers the sections most nursing programs ask for; rename or reorder them to match yours.
It's a learning example built on the GOLD 2025 report and NANDA-I diagnosis labels. Always follow your clinical instructor and facility policy for real patient care.
It helps you draft one section at a time from your scenario and your sources. The clinical reasoning is yours, and you check every citation before you keep it.
The template is free to download. Thezis is free to start with 10 AI requests, and writing, citations and exports stay free.
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