Nursing Care Plan Guidelines & Sample Nursing Care Plan Template Page 3
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3Sample Nursing Care Plan 2
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)
• Assess patient’s pain
Objective:
1. patient will verbalize his
Yes/no for
1. Patient continues to
• patient requests pain
pain as less than 7/10
each
rate his pain as 8-9/10
level every shift and prn
• Educate patient
during therapy by the end
intervention
during and around therapy
meds for shoulder pain
of this week.
times, continue goal.
often
regarding when to
medicate for pain (i.e.
2. Patient demonstrates
2. Patient is
Subjective:
before therapy)
• “my pain is a 10/10”
• Educate patient about
ability to cope with
demonstrating some
unrelieved pain within two
coping but continues to
types of pain
weeks.
need assistance with
medications including
relaxation techniques.
action, duration, side
Interesting in massage
Diagnosis:
effects.
• Educate the patient
therapy, continue goal.
Chronic pain related to spinal
cord injury AEB patients
about types of pain
statements, request for pain
common after SCI and
meds and inability to finish
management techniques
therapy without complaints of
available.
• Administer pain
pain.
medications as needed
• Offer alternative
therapies including
acupuncture and
massage, once cleared
by MD
• Educate on relaxation
techniques, coping
strategies
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Parent category: Medical