Page 11 - Advanced Communication in Nursing

Assessment, Diagnosis, Goals and
A.

Outcomes

Getting Started

Are you familiar with this table? Fill in the blanks with the correct terms.

a. Nursing diagnosis b. Evaluation c. Assessment d. Intervention e. Planning (goals and outcomes)

NURSING CARE PLAN

Patient’s Name : Mr. Joe Sidabutar

Age : 25
Gender : Male
Address : Komplek Margasari No 5
Room : Aster 225

1. ________ 2. _________ 3. ________ 4. _______ 5. _______

Subjective: “Today, Diarrhea related to After 4 hours of • Observe and After 4 hours of
I defecate more presence of toxins. nursing record stool nursing
often than interventions, the frequency, interventions, the

yesterday” as patient will report characteristics, patient was able to
verbalized by reduction in amount and report reduction in

patient. frequency of precipitating frequency of
stools. factors. stools.
Objective: • Promote bed
• Increased rest.
peristalsis
• Frequent
watery stool
• Abdominal
pain
• V/S taken as

follows:
T: 36.6
P: 80
R: 18
Bp: 110/90

pg. 3