Is appropriate to the clientAddresses the nursing diagnosis and helps to resolve the symptomsIs specific (note the nurse may need to add the specifics of the goal, as the NCP text provides a basic guide)Is measurable (SMART)

Use the highest priority nursing problem, choose the most relevant nursing diagnoses using Ackley, or another NCP textInclude related to and as evidenced by information
Review the defining characteristics in the NCP text for the chosen nursing diagnosis, and ensure the Patient Assessment Form includes theseReview the definition of the diagnosesis this suitable to your patient?Transfer ONLY the group of manifestations that support the problem identified onto the Assessment column of the NCPWrite one client goal/outcome — Be sure it:

Write four nursing interventions with supported rationales Be sure the interventions:State specifically what the nurse will do (assume another nurse is looking at this NCP and will know exactly what to do to support the clients problem)Are appropriate to the clients age, status, and abilityHave supporting rationales supported by evidence and reputable referenceWrite the expected, or actual, evaluation of the clients progress towards the goal/outcomeIf the goal is in progress, indicate what progress has been madeIf the goal is unmet, indicate how the NCP would be revisPatient Information Form(Adapted from Canadian Neighbourhood)
Gender: F Age: 87 Admitting Diagnosis: Congestive heart failure, Shortness of breath, Atrial Fibrillation, Type2 Diabetes, Pulmonary edema
The patient came from home or LTC/ALC: From HomeIn-Patient Unit /hospital (the type of unit): Oncology unit Admission Date: 03/07/2018 Date of Assessment: 03/07/2018
Code Status: Full CPRAllergies: No known Allergies
Social History: Occasionally spends times with daughter and Son-in-law who visit twice a week
Supports (includes Church family, occupation, social supports/programs): Religious society visits daily to ensure meals are prepared, cleaning the house and keeping her company.
Presenting Problem: Shortness of Breath
History of presenting problem (signs, symptoms, onset, etc.): Fatigue, Dizziness, Fainting, Fever, Nausea, Leg Swelling, Dry CoughPast medical and surgical history (Include dates): Myocardia Infarction (2008), Hypertension, pacemaker in the chest, COPD, and SOB
Curre current Medications and Treatments (dose, route, times, and why the patient is ordered each med):Metformin: improves control of blood sugar in people with type 2 diabetes

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