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Evaluation: Evaluation of the assessment and medical history is the basis for planning care.
• Is complete and accurate, containing pertinent subjective and objective data related to the patient’s problem and nursing diagnosis. All pertinent subjective and objective data related to the patient’s problem and nursing diagnosis is included.
Nursing Diagnosis: The nursing diagnosis provides the basis for the selection of nursing interventions to achieve short-term and long-term goals. The Nursing Diagnosis included all 3 components of:
• The three (3) nursing diagnoses (NANDA approved) • A diagnosis that correlates with the assessment data
• The “Related to” correlates with the patient’s data collected in the assessment and is not a medical diagnosis.
• The “As evidenced by” correlates with the assessment data documented on the assessment form (only if actual diagnosis)
Planning: The short-term and long-term goals assist the patient in achieving positive outcomes.
The Planning included all 28-30 components of 3 short-term goals
• Related to the nursing diagnosis
• Patient centered
• Realistic for patient situation
• Includes a time frame
• Is measurable 3 long-term goals
• Related to the nursing diagnosis
• Patient centered
• Realistic for patient situation
• Includes a time frame
• Is measurable
Nursing Intervention: Nursing Interventions assist the client in meeting short-term and long-term goals. The interventions section should include a minimum of 3 nursing interventions for each of the three nursing diagnosis.
The Interventions included all 6 components of:
• Minimum of 3 nursing interventions for each nursing diagnoses. Each intervention should:
• Contribute to the achievement of goals
• Be comprehensive (include specific action, frequency, healthcare member to perform, etc.)
• Be appropriate for the patient situation
• Have scientific rationale
• References cited in APA format
Evaluation: Evaluation of goals to make decisions and recommendations for continued patient care. The Evaluation included all 6 components of: Each short-term and long-term goal evaluated to determine
• If goals were met, partially met, or not met.
• Must be patient and/or family centered
• Must provide evidence
Development: The development of the diagram incorporates clinical judgement and critical thinking of patient care. The clinical impression of data is easily identified; sub concept problems are prioritized and branch appropriately. The development of the diagram is linked logically from the main idea.
Linking Data: Linking the data shows a connection between the nursing and medical diagnosis and care based on data.
The data is linked and interrelated between the nursing and medical diagnosis and the concepts related showing a holistic mindfulness.
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