"A" WORK IN 10 HOURS or LESS

ASSESSEMENT- RECOGNIZE CUES

(Subjective/Objective Data pertinent to this nursing diagnosis- problem

ANALYZE CUES

MEDICAL DIAGNOSIS NURSING DIAGNOSIS

NANDA diagnosis

3 part Actual Problem

2 part Risk Diagnosis

NURSING ACTIONS GENERATE SOLUTIONS

Administering, demonstrating, and performing treatments, & teachings pertinent to diagnosis)

List in order of priority

3 assessments are required---there is not a limit when caring for patients

EVIDENCE SUPPORTING

PRACTICE

(Rationale required for EACH assessment and intervention)

(Cite source: Author & Page # using APA format) List each reference separately.

IMPLEMENTATION TAKE ACTION

Were the interventions implemented? If not, why? Explain if there were any modifications to the interventions.

EVALUATION

EVALUATE PATIENT

OUTCOMES

State outcome achievement in behavioral terms. Note: Continue, Change (specify), Discontinue POC

Subjective:

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Objective:

· Medical Diagnosis

· Patient Age

· Include relevant medical orders, collaborative efforts to be included in the plan of care.

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Problem Nursing Diagnosis

· NANDA Label

· Cause

· Evidence

OR

Problem-Risk Nursing Diagnosis

· NANDA label

· List the risk factors.

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Medical Diagnosis:

Pathophysiological process causing the problem

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Outcome Statements- Generate Solutions

SMART: Specific, Measurable, Achievable, Realistic, Timed (Outcomes should be aimed toward correcting or improving the EVIDENCE of the problem listed in the nursing diagnostic

statement)

By (enter time) on (enter date) the patient will …. as evidenced by:

Must be Prioritized & Correlate with Outcome Statements

(i.e., 1A, 1B, 2A, etc.)

Ongoing Assessments: (verbs such as monitor, assess, observe or synonyms)

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Prioritized Interventions:

(relevant medical orders, comfort

measures, collaborative efforts with ancillary services)

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Assessments:

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Interventions:

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Overall goal was Choose an item. as evidenced by:

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Will you continue, discontinue, or modify the plan of care? Why?

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