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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.
- 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.

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