ASSESSMENT PLANNING AND IMPLEMENTATION EVALUATION

Data Collection and Nursing Diagnosis Expected Outcome Planning Nursing Rationale Evaluation of Goal Reassessment
Organization Interventions Attainment

Subjective and “P” = Problem Outcomes or Goals Must include A referenced rationale Remember you are If goal is MET, the
objective data should NANDA approved must be written in collaborative, must accompany each evaluating the patient’s plan should be
support your chosen language only “S.M.A.R.T” format: assessment, intervention Goals (Outcomes) and ongoing.
nursing diagnosis. (pp. 4, & 17-118) Technical, and NOT the interventions
(p. 3) Specific teaching (total of 10 rationales) If partially met or
“E” = Etiology or Measurable Interventions Should start with unmet, discuss what
Please be thorough “Related to” which is Attainable “Goal met”, you would do
here, this is your “as the cause of the Realistic “Goal partially met”, differently?
evidenced by” (AEB) problem. Timed or What would you revise
assessments (pp. 4-7) (p. 7-8) “Goal unmet” in the plan of care?

Supporting data should “S” = Symptoms also Provide 1 Short Term Provide 5 different Must explain with Consider revisiting the
be CLUSTERED to called “AEB” “as Goal (STG) in interventions for the rationales SMART goals.
your specific NANDA evidenced by” which SMART format. STG and list these in (p. 10) (p. 10)
are the defining order of priority.
characteristics or
symptoms the nurse AND AND
identified in the
assessment. Provide 1 Long Term Provide 5 different
(pp. 4-7) Goal (LTG) in interventions for the
SMART format. LTG and list these in
order of priority.

Risk Nursing
Diagnosis is a health
condition that has a
high probability of
developing. This is
only 2 parts (No AEB)
because the problem
has not happened yet.
(p. 4)

Ackley, B.J., & Ladwig, G.B. (2014). Nursing diagnosis handbook: An evidence-based guide to planning care (10th ed.). Maryland, MO: Mosby Elsevier.
 ASSESSMENT PLANNING AND IMPLEMENTATION EVALUATION
Data Collection and Nursing Diagnosis Expected Outcome Planning Nursing Rationale Evaluation of Goal Reassessment
Organization Interventions Attainment

Reference: