Nursing Diagnosis: Statement of problem experienced by patient that can be helped by nursing intervention
R/T (cause of problem):
AEB:
Subjective Data:
Objective Data:
Expected Outcome: Patient centered, measureable/observable, realistic, time-limited
By (____________), the patient will:
Interventions: Actions of nurse to assist patient to achieve the
Rationales and Source: Evidence based explanation why each intervention
expected outcome (Minimum of 3)
will assist patient to achieve the expected outcome
Evaluation: Did the patient achieve the expected outcome? Was outcome fully, partially or not at all achieved? How do you know? Elaborate with
details.
Reflection on performance of interventions: Did nurse perform interventions effectively? Did patient tolerate the interventions? Did the
intervention assist patient to progress to outcome? Why or why not?
Revision of Plan: If outcome was partially or not at all achieved, what should be changed? Is outcome unrealistic? Are different interventions
needed?