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Nursing Diagnoses

Use your Assessment data to ID clinical problems

Expected Outcomes (S.M.A.R.T.)

Specific, measurable, attainable, realistic,   & time-oriented (ID a future time or date for reassessment/evaluation) 

Nursing Interventions

What can you, the nurse, do to reach the goal and improve the problem? 

Rationale

Why are you doing the nursing intervention?

#1

 

 

R.T.

 

A.E.B.

Subjective Data:

Objective Data:

The patient will…

Short-term goal: 

 

 

Long-term goal: 

The nurse will…

1. 

 

 

2.

 

 

3.

 

4.

 

#2

 

 

R.T.

 

A.E.B.

Subjective Data:

Objective Data:

The patient will…

Short-term goal:

 

 

Long-term goal:

The nurse will…

1.

 

 

2.

 

 

3.

 

4.

 

 

 

#3

 

 

R.T.

 

A.E.B.

Subjective Data:

Objective Data:

The patient will…

Short-term goal:

 

 

Long-term goal:

The nurse will…

1.

 

 

2.

 

 

3.

 

4.

 

 

 

#4

 

 

R.T.

 

A.E.B.

Subjective Data:

Objective Data:

The patient will…

Short-term goal:

 

 

Long-term goal:

The nurse will…

1.

 

 

2.

 

 

3.

 

4.

 

 

 

Steps in the Nursing Process:

Assessment

Diagnosis

Planning/outcomes

Implementation

Evaluation

 

 

ATI Real Life Scenario- Newly Diagnosed Type 1 Diabetic with Hypoglycemia  

This scenario focuses on Skyler Hansen an 18- year-old female away at college, recently diagnosed with type 1 diabetes. She is living in the dorms and is away from home and her parents who were the main support system that helped her successfully control her diabetes. It addresses client-centered concepts related to glucose regulation, hypoglycemia, and diabetes education. Nursing-focused concepts include the use of SBAR, patient education, communication with the provider, prioritization of care for multiple clients, and discharge planning.  

 

 

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