Specifically, what part of dx are you having problems with? Definately ask your instructor what you can do to improve.
In our careplans we have to use only NANDA approved dx. Hoolahans example is much like ours. The NANDA dx, "related to"..., "as evidenced by".... If it is an at risk for dx, then we skip the "as evidenced by" part, since the pt is at risk for, and wouldn't have specific symptoms.
Ex. Fluid volume deficit, related to decreased fluid intake due to nausea and vomiting, as evidenced by: pt states "I can not eat or drink because I feel nauseous", pt vomited 100 cc clear liquid after attempting to drink water, pt dry heaving when food is brought into room, pt has poor skin turgor - skin tents when pinched lightly between two fingers, urine is dark amber colored.
The outcome/goal has to be measurable, have a specified time limit and be classified as long or short term. Ex. Short term: Pt will display adequate fluid intake within two days as evidenced by pt drinking at least 1 glass (8oz) fluid per hour 10 times/day and voiding light yellow urine at a rate of at least 30ml/hr.
Actions or implementation and rationales (for our class) have to be found in a published reference and cited. The first action is usually some type of assesssment, so you have a baseline to measure the interventions against. We usually use actions that are diagnostic, educative, therapeutic, or referrals with docs or to other depts.
Ex. Assess causitive/precipitating factors, and evaluate degree of fluid volume deficit: (in this case) nausea and vomiting may be causative, skin tenting and concentrated urine are physical indicators.
Then what actions can you take to correct these factors and deficits:
Ex. Referral: Collaborate with MD to get IV order for fluid replacement, order for antiemitics. Rationale: to assist in rehydration and decrease s/s of nausea.
Diagnostic: maintain accurate I&O, monitor urine specific gravity. Rationale: Accurate I&O shows hydration status by measuring total daily intake and output, specific gravity determines hydration.
Therapeutic: Note pt preferences re fluids and foods with high fluid content and encourage intake. Rationale: Pt may be more cooperative if provided with fluids and foods that are appealing to sense of taste.
Educative: Discuss factors related to fluid deficit, identify actions pt may take to correct deficiencies (sucking on ice chips or taking sips of water instead of large amount of fluid at one time). Rationale: Educating pt on problem/treatment empowers pt to maintain healthy behaviors.
(Usually our actions are more specific and basically spell out exactly what we are going to do)
Then we document responses to the actions, and at the end of the time limit, evaluate the outcome. Evaluation should include whether the goal was met, partially met, or not met. Include the evidence documented in the outcome, like: Goal met, pt drinks 10 eight oz glasses of fluid per day and voids light straw colored urine, amt 100ml/hr. Then we can also say, continue with actions #1 to #5 (if they have been effective) or we can revise actions if needed.
Sorry this is so lengthy, hope it helps!