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Subjective: What the patient says, the family, the doctor, a nurse/ Usually in quotations **Note if your patient is nonverbal, you can still have subjective data from other sources. Objective: (Note your Topics to the side) Start with a brief overview of the patient. Example: 78 yo white male admitted 6/12/09 with COPD exacerbation PMH: include a comprehensive past medical history of your pt Orders: orders that are specific to your ND or that may contribute to supporting your ND statement Interdisciplinary assistance such as PT, OT, RTDietActivityOxygenRadiology: report any radiological findings that may support or contribute to your ND statement Labs: what laboratory findings are pertinent to supporting your ND statement Medications: only medications that can support your ND statement Assessment findings: can include an array of things, but only if relevant to support Intake and Output: include if can support your NDVital Signs: usually a great inclusion to support most NDWound appearanceMobility performanceSystem Assessment: that is pertinent to your NDExample; Impaired Gas Exchange-do Resp assessment P= Problem E=Etiology **May use Secondary to a diagnosis after the etiology if it permits S=Signs and Symptoms ****Note that if it is a Risk for diagnosis you will only have a PE format without signs and symptoms PATIENT WILL..... This is what the nurse hopes to achieve by implementing the nursing interventions COMPONENTS Subject: PT will Verb: action patient is to perform Condition: explains how the behavior is to be performed Criteria: Time frame BE SPECIFIC Patient will increase mobility by the end of 3-11 shift as evidenced by independently ambulating to chair. NURSE WILL..... This is what the nurse will do to assist the patient in accomplishing the goal. COMPONENTS Subject: Nurse will Action verb: precision--educate, demonstrate administer Content: the what and where of the order Time Element: when, how long, or how often the action is to occur Rationale: Under each statement you must support this nursing intervention with a source as to why it is important Nurse will perform range of motion every 2 hours. Rationale: Exercise increases joint flexibility, stability, and range of motion. Sources: you must have at least 2 sources per care plan. We encourage use of articles and lectures as well. Format in APA. Goal Met... Goal partially met... Goal not met... This is merely reporting that the goal was accomplished or not. Goal partially met. Patient ambulated with assistance of 2 to the chair at 9:30 pm. ***Note that if your goal is met or not met, you need to state what you would expect to find or what you found.