Nursing Care Plan Guidelines & Sample Nursing Care Plan Template
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3Nursing Care Plan Guidelines
Age: ______ Date Admitted: ________
Diagnosis: ____________________
Occupation: ________________
Religion/Culture/Ethnicity: _______________________________
Student: _______________________ Date of Care: ___________
Date: ____________
Nursing Diagnosis:
Interventions:
Assessment with subjective &
Patient goals & objectives
“I will……..” or “patient
I did……
Outcome/Evaluation
objective data
“Patient will………..”
will…….”
S.O.A.P. format
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•
•
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Prioritize nursing
This is what you want to
Number & list specific
Check list
Address same categories
diagnosis (dx)
happen to
actions you plan to help pt.
of items,
as in the goals &
•
resolve/prevent the stated
achieve goals
one for
objectives column
Give specific & complete
•
•
problem. Put in patient
each of the
subjective & objective data
Use active language
Ask yourself, was that
•
behavioral terms
intervention
that support nursing dx
goal met & indicate here.
Think about this in
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•
s listed
Goals help determine the
For example, goal was
Give a “picture” of patient
documentable terms
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nursing interventions
Place
that pt. would walk hall
with this problem you
Do no use “encouraging” or
necessary for the next
checkmark
length 3x/day. Put here
identified
“try” words that are vague
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•
column
s to
pt. walked hall 2x/day
Nursing Dx should be from
Use words like teach,
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indicated
(whatever the pt. really
Goals must be realistic,
NANDA and in 3 parts:
explain, provide, monitor,
that you did
did)
specific, measurable,
1-“potential/actual…,2-
administer, assess,
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it, and if
action oriented, & with a
This is the accountability
related to (r/t) _____, 3-as
consult/collaborate, report,
not, put in
time frame
area. If goal not met,
evidenced by (AEB) _____.
etc.
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evaluation
document new goal or
You must be able to
Many ways to prioritize –
These are client specific &
column
added time if that is
evaluate these goals (last
Maslows Hierarchy,
individualized
WHY you
•
necessary
column) so you must
functional level,
Consider needs,
did not
have criteria here than
pathophysiology
preferences, limitations of
•
can be measured in some
r/t—etiology, factors that
patient
•
way
cause or contribute to
Standardized care plans
•
Think of goals you as the
problem
are fine, but you must
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nurse can help patient
AEB – signs & symptoms
individualize
achieve with your
exhibited by THIS patient
interventions
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Parent category: Medical