Nursing essay paper

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

(May obtain second hand from the chart) Nursing

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

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

1. Nursing Diagnosis
   1. must be a NANDA approved diagnosis- (5pt)
   2. must contain all 3 parts (Diag, R/T, AEB)- (5pt)
   3. must be relevant to the Patho.- (5pt)

1. Expected Outcomes/Goals
   1. must be relevant to the diagnosis-(10 pt)
   2. must be what you expect the patient to achieve; (5 pt)
      1. Patient will remain free of
      2. Patient will be able to
      3. Patient will verbalize
   3. must include at least 4 goals: (10 pt)
      1. 2 short term-prior to discharge
      2. 1 long term-after discharge
      3. 1 collaborative-with another discipline:

(Dietary, Respiratory, Physical Therapy)

1. Interventions
   1. Each goal must have at least 1 intervention. (10 pt)
   2. Intervention must be relevant to the goal (5 pt)
   3. 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 Nursing teaching something.

1. Rationales
   1. Must be relevant to the intervention (10 pt)
   2. Each intervention must have at least 1 rationale (5 pt)
   3. Each rationale must have a reference (5pt)

1. Evaluation
   1. Did the patient achieve the goals? Nursing