Planning Prioritized Independent and Evaluation Prioritized (outcome/goal) collaborative nursing Goal Met, Gordon’s Nursing Diagnosis Measureable goal interventions; include Rationale Partially Met, Functional Health (at least 2) during your shift further assessment, (use APA citations) or Not Met Care Patterns (at least 1 per intervention and teaching & Explanation Nursing diagnosis) (at least 4 per goal) Current Medications Nursing Medications Dose (& Mechanism of Common side considerations (with APA Class/Purpose Route Frequency If out of range, action effects specific to this citations why? of action client
Prioritized Gordon’s Functional Health Care Patterns Nursing Diagnosis (at least 2) Planning (outcome/goal) Measureable goal during your shift (at least 1 per Nursing diagnosis) Prioritized Independent and collaborative nursing interventions; include further assessment, intervention and teaching (at least 4 per goal) Rationale (use APA citations) Evaluation Goal Met, Partially Met, or Not Met & Explanation Current Medications Medications (with APA citations Class/Purpose Route Frequency Dose (& If out of range, why? Mechanism of action of action Common side effects Nursing considerations specific to this client