Nursing

1. Subjective Data-What did the patient or family say?

(May obtain second hand from the chart)

5 pts.

2. Objective Data-Relevant data that collaborates diagnosis or what the patient/family said.

5 pts.

3. Analyze Data-additional relevant information (labs/test/social/medical/surgical/family history)

5 pts.

4. Nursing Diagnosis

a. must be a NANDA approved diagnosis- (5pt)

b. must contain all 3 parts (Diag, R/T, AEB)- (5pt)

c. must be relevant to the Patho.- (5pt)

15

5. Expected Outcomes/Goals

a. must be relevant to the diagnosis-(10 pt)

b. must be what you expect the patient to achieve; (5 pt)

i. Patient will remain free of

ii. Patient will be able to

iii. Patient will verbalize

c. must include at least 4 goals: (10 pt)

i. 2 short term-prior to discharge

ii. 1 long term-after discharge

iii. 1 collaborative-with another discipline:

(Dietary, Respiratory, Physical Therapy)

25

6. Interventions

a. Each goal must have at least 1 intervention. (10 pt)

b. Intervention must be relevant to the goal (5 pt)

c. If it’s something you (the nurse do) it’s a intervention: (5 pt)

i. assess, monitor, obtain, order or teach

ii. If the goal for the patient is increase in knowledge of something-your intervention should be teaching something.

20

7. Rationales

a. Must be relevant to the intervention (10 pt)

b. Each intervention must have at least 1 rationale (5 pt)

c. Each rationale must have a reference (5pt)

20

8. Evaluation

a. Did the patient achieve the goals?

5

Total