Name of Pt.

:
Age/Sex:

Date:

Assessment

Nursing Diagnosis

Goal

SUBJECTIVE
Hindi ko alam ang
sakit ko as
verbalized

Knowledge deficit
regarding condition
prognosis
treatment r/t
educational
background

At the end of
nursing
intervention the
client will
verbalized
understanding on
disease state and
need for treatment

OBJECTIVE
>Teary eyed
>Irritable at times
>restless
>with guarding
behaviors

Nursing Intervention
Assessed client level of
understanding
Reviewed
specific
pathology
and
anticipated procedure.
Verify correct client
procedure.
Determined
clients
ability, readiness and
barriers to learning
Provided
information
relevant only to the
situation
Provided
positive
reinforcement
Provided mutual goal
setting and learning
contracts
Provided active role for
client in learning process

Provide
information
about additional learning
resources
Provide
access
information for contact
person

Rationale

To have baseline data

To have baseline data

Individual may not be

physically, emotionally,
mentally, capable at this
time
To prevent overload

Can encourage
continuation of efforts
Clarifies expectation of
the learners

Promote sense of
control over situation
and is mean for
determining that client is
assimilating
May assist further
learning and promote
learning at own pace
To answer question and
validate information post
discharge

Evaluation
>client verbalized
understand the given
health teaching
regarding his/her
condition

Dx: