Subjective & objective data support the nursing diagnosis
Discuss the diagnostic tests to confirm, clarify, and direct patient care
Medication is listed including name, dose, class, indications, expected effect
2. Nursing Diagnosis

Ineffective gas exchange related to altered oxygen supply (obstruction of airways by secretion). Structure diagnosis in problem related to etiology (cause) as evidenced by sign and system framework.
Connect the diagnosis with clinical/assessment findings.
Discuss the prioritization of the selected diagnosis
3. Goal Statement and outcome criteria
Discuss the 2 most appropriate goals for the nursing diagnosis
Goal must be measurable with target dates and times
4. Planning
Consider observation you make to monitor the patient condition or progress
What would be done to prevent, repair or reduce the problem is included
How and what will you teach the patient
5. Intervention
Include actions that directly relate to the patient’s goal that are specific in action and frequency
Include rational for selecting the specific intervention
6. Evaluation
Discuss how you would evaluate the patient
Discuss the implication if the goals are fully, partially or not achieved and what action you would take


 

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