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Nursing Diagnosis

Patient Goals Intervention: Rationale Implementation

(Yes or No)

Evaluation

Outcome

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EXAMPLE:

Nursing Diagnosis

Patient Goals Intervention:

Rationale

Implementation

(Yes or No)

Evaluation

Outcome

Diagnosis:

High risk for falls related

to confusion as

evidenced by

disorientation to place,

time, situation, unsteady

gait, generalized

weakness

Subjective Data:

Patient asking, “who are

you again?”

Multiple family stated,

“he doesn’t seem right”

Patient stated, “I feel

weak when I get up”

Objective Data: History of dementia

Set off bed alarm

continually during night

Requires walker for

ambulation

Patient will remain free

from injury during this

admission.

Patient will remain free

from falls during this

admission.

Patient will wear non-

skid socks when out of

bed: to provide stability

during ambulation

Patient’s bed alarm will

be on at all times: to

alert staff if patient is

attempting to get out of

bed independently

Patient will be relocated

to a room closer to the

RN station: to enable

staff to visualize patient

on a more frequent

basis

Nurse will increase

frequency of rounding:

to assess needs more

frequently, toilet more

often, reorient.

Yes

Yes

No

Yes

Patient utilized non-skid socks during all periods of ambulation, did need to be

continually reminded, as he does not like socks, per his report. Will continue to promote. Patient’s bed alarm was on consistently throughout shift and patient did set alarm off approximately 4-6 times. Will continue to have bed alarm on. Another confused patient

occupied the room closest to RN station; will move if room becomes available. Patient rounded on q 30 min or q 1 hour. Noted that patient became agitated when he had to use the bathroom during first rounding, therefore offered toileting with each visit and noted decrease in agitation. Will continue to round

frequently. Patient remained injury and fall free during this shift. Goals progressing.

1. Fill In:

Collaboration for Improving Outcomes - Family Support Assessment

Description: Identify the determinants of health and illness of individuals and families using

multiple sources of data.

Course Competencies: 2) Develop a holistic case management plan for a specified disease or

population that incorporates the role of insurance, health care finance, and utilization of

community resources. 4) Coordinate the care of individuals across the lifespan utilizing

principles and knowledge of interdisciplinary models of care delivery and case management.

QSEN Competencies: 1) Patient-Centered Care 2) Teamwork and Collaboration 3) Evidence-

Based Practice 5) Safety

BSN Essential VII

Area Gold

Mastery

Silver

Proficient

Bronze

Acceptable

Acceptable

Mastery not

Demonstrated

Data Includes detailed

objective and

subjective data

Lists objective

and subjective

data

Identifies only

subjective or

objective data

Does not

address section

Nursing Diagnosis Develops a

nursing

diagnosis (using

NANDA) for an

individual in the

family unit

Outlines a

nursing

diagnosis (using

NANDA) for an

individual in the

family unit but

some elements

are missing

Defines a

nursing

diagnosis for an

individual in the

family unit but is

not appropriate

for family

member

Does not

address section

Community

Health Nursing

Diagnosis

Develops a

properly

formatted

community

health nursing

diagnosis

Outlines a

community

health nursing

diagnosis but

some elements

are missing

Defines a

community

health nursing

diagnosis that is

not appropriate

Does not

address section

Plan of Care Designs a plan

of care that is

relevant to

identified

problems, issues,

or concerns

Prepares a plan

of care that

addresses some

of the problems,

issues, or

concerns.

Infers a plan of

care that is not

relevant to

identified

problems, issues,

or concerns.

Does not

address section

SMART Goal

Statements

Develops 3 clear

SMART goal

statements

(Specific,

Measurable,

Achievable,

Relevant, Time-

Bound [realistic

deadlines to

Develops 2 clear

SMART goal

statements

(Specific,

Measurable,

Achievable,

Relevant, Time-

Bound [realistic

deadlines to

Develops 1 clear

SMART goal

statement and/or

elements of the

goal statement

are missing or

not clear

Does not

address section

meet

goals/outcomes])

meet

goals/outcomes])

Evidence-based

Rationale

Illustrates

evidence-based

rationale to

support nursing

actions that

address

identified

problem, issues,

or concerns

Lists evidence-

based rationale

with minimal

explanation for

support of

nursing actions

r/t problem,

issues, or

concerns

Mentions

evidence-based

rationale with no

support for

nursing actions

addressing

problem, issues,

or concerns

Does not

address section

Evaluation Plan Designs an

evaluation plan

addressing each

goal statement

Provides an

evaluation plan

addressing some

of the goal

statements

Names an

evaluation plan

that doesn’t

address each

goal statement

Does not

address section

APA, Grammar,

Spelling, and

Punctuation

No errors in

APA, Spelling,

and Punctuation.

One to three

errors in APA,

Spelling, and

Punctuation.

Four to six

errors in APA,

Spelling, and

Punctuation.

Seven or more

errors in APA,

Spelling, and

Punctuation.

References Provides two or

more references.

Provides two

references.

Provides one

references.

Provides no

references.