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Nursing Diagnosis Assessment Data

Goals and Outcome

Nursing Interventions

Rationale

Outcome Evaluation and Re-planning

Include 3–5 pieces of data (subjective, objective, or a combination) that led to a nursing diagnosis.

Write two goal statements for each nursing diagnosis. Goals must be patient- and family-focused, measurable, attainable, reasonable, and time-specific.

List at least three nursing or collaborative interventions; provide the rationale for each goal and outcome.

Explain why each intervention is indicated or therapeutic; cite applicable references that support each intervention.

Were the goals met? How would you revise the plan of care according the patient’s response to the current plan of care? Support your conclusions with outcome measures and professional standards.