Nursing Care Plan Guidelines & Sample Nursing Care Plan Template Page 2
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3Sample Nursing Care Plan 1
Nursing Diagnosis:
Patient goals & objectives
Interventions with rationale
Assessment with subjective &
(patient-centered,
(what you’ll do and why)
Implemented
Outcome/Evaluation
objective data
measurable and timed)
(yes/no)
• Identify self and patient
Objective:
1. Patient will be oriented
Yes/no for
1. No measurable
• Patient not oriented to
to self within three weeks.
each
change yet, patient still
by name at beginning of
intervention
confused and
place or time
each interaction.
• Patient unable to
2. Patient will be oriented
disoriented, continue
(consistent orientation
to person, place and time
goal
may help memory)
concentrate
• Maintain calm
by discharge.
2. same as above,
Subjective:
environment (decreases
• Patient non-verbal, uses
3. Patient will be able to
continue goal
anxiety, promotes rest)
• When patient
perform basic ADLs by
nonsensical words
discharge independently.
perseverates, redirect
3. patient performing
Diagnosis:
attention to another topic
some ADLs with physical
Chronic confusion related to
(decreases anxiety and
assistance and verbal
traumatic brain injury AEB
improves self-esteem)
• Speak slowly and clearly
cues, continue goal.
disorientation and cognitive
dysfunction.
in simple sentences
(allows time for
information processing)
• Consult Speech Therapy
• Educate patient and
family regarding patho of
injury and resulting
cognitive dysfunction
(assists in understanding
of behavior)
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Parent category: Medical