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2 Nursing Diagnosis
(Problem identified in assessment)
Impaction; obstipation r/t pregnancy d/t decreased
mobility and use of opioid analgesics. Reference w/page #s: Nursing Care Plan pg 46-48 Old’s
pg 1045
3 Outcomes (Specific to client & Nsg Dx, realistic, measurable, and time limited with baseline 6 Evaluation (Were outcomes accomplished? If not, why)
data in Assessment) Date & Time:
Client will verbalize at least 3 means of promoting peristalsis by end of shift On 4/16/10 at 0830, Client met outcome by stating “drinking plenty of water,
4/16/10. eating foods high in fiber, and getting out of bed and moving around”
Criteria for Nursing Process Assignment
1. Assessment
1. Is subjective data in the client’s or significant other’s own words or accurately paraphrased?
2. Is objective data in the form of specific measurements from student’s assessment (ie, resp rate, breath
sounds, wound measurement, etc) and diagnostic information from the chart? Are dates included? Subjective
3. Does data relate ONLY to the problem identified in nursing diagnosis?
4. Does data adequately support the nursing diagnosis or is additional data needed? Objective
2. Nursing Diagnosis
1. Does the nursing diagnosis accurately describe the problem or risk identified in the assessment? Nursing Diagnosis
2. Is the nursing diagnosis NANDA?
3. Does the “related to” section describe the etiology (cause) of the problem (in physiological terms)?
4. If “high risk for” diagnosis, are the risk factors listed instead of “related to” section?
3. Outcomes (Use action verbs only. You must be able to use outcomes in the evaluation step to measure
client’s response to nursing interventions.)
1. Are outcomes specific, realistic, measurable and have an appropriate and realistic time limit? Outcomes
2. Are there baseline measurements for all outcomes in the assessment?
3. Do outcomes demonstrate improvement or at least no worsening of the problems?
4. Do outcomes reflect changes expected as the result of nursing interventions?
4. Interventions: List references (Text & page#)
1. Do nursing interventions address the identified problem?
2. Do interventions help resolve the problem? Interventions
3. Do interventions best accomplish the outcomes?
4. Are interventions individualized to client (“O2 as ordered” would not be individualized but “O2 at 2L
per NC” would be.)
5. Are interventions specific enough? (“Increased activity” would not be specific but “Walk length of
hallway qid” would be.)
6. Are references listed?
7. Have interventions been done? Date when done added to intervention?
5. Rationales
1. Do rationales explain why the intervention is appropriate to resolve the problem? Rationales
2. Do rationales explain what the rationale accomplishes?
6. Evaluation (Determines effectiveness of plan of care and addresses outcomes.
1. Were outcomes evaluated by reassessment? Evaluation
2. Were specific findings reassessed and listed?
3. Did the outcome (change) occur? Were outcomes met? If not, why?