Abstract
This article discusses the nursing process in action. For best development of a plan with practical interventions for Mr. D. M., the admitting nurse completed a comprehensive assessment and used the home health agency's (HHA) checklist to assess for risk factors associated with rehospitalization. After Mr. D. M. was found to have met the criteria (5 or more risk factors), nursing diagnoses were identified and a high-risk clinical pathway was initiated. Interventions including patient education were implemented and evaluated at subsequent home visits.