1. Use diagnosis related to patient
(1) wandering (potential safety risk, also going into other Pt rooms reaching their privacy).
(2) Hygiene (Pt refuses to shower).
(3) incontinence/ age related (social) diagnosis. Diagnosis must be NANDA diagnosis.
2. You may type in the textboxes by saving the document and then double clicking in the text boxes. It is okay to use 2 pages You need to follow the general format but can create your own document if you want.
3. Appropriately group assessment data together. Assessment data will be different for each diagnosis. Do not just make a laundry list of all your data.
4. Assessment data leads you to a nursing diagnosis-develop nursing diagnoses based on data. Develop 3 nursing diagnoses. (see 1).
5. Draw arrows to demonstrate relationships. Draw arrows from data to the appropriate nursing diagnosis.
6. Think of priorities and number the diagnosis. Consider Maslow’s Hierarchy of Needs as you prioritize.
7. Draw arrows to demonstrate relationships among diagnoses if appropriate.
8. Develop specific, measurable patient outcomes with a time frame. There must be one outcome for each diagnosis.
9. Complete interventions (3-5 for each outcome). You may add an additional text box and add interventions as needed. Identify which dx/goal the intervention relates to by the priority #. For example, interventions relating to priority dx #2 would include (#2) after so that the instructor knows which one/ones they go with.
10. Complete evaluations. You may list evaluations based on the priority number of the diagnosis (for example, priority dx #1 would be referred to under evaluations as #1).