Student Name: _________________________________ Date: ______________Class: __________ Patient Initials: ___
A care plan should start with the major issues for that client. Write the top three priority nursing diagnosis for this client, with the highest priority first. Be sure to include “related to”, “as evidenced by”, or “risk factors” (if at risk diagnosis) for each medical diagnosis. Write at least one short term and one long term (“expected outcome”) measurable goal per nursing diagnosis stated in terms of client achievement (“the client will…”). List at least 3 specific nursing actions (interventions) for each nursing diagnosis and give the scientific rationale for selecting the action you will use to work toward that goal, along with the cited reference of that rationale. Evaluate if goal was met and list specific assessment data to support it (How did you know goal was met?)
NURSING DIAGNOSIS
(NANDA APPROVED)
EXPECTED OUTCOME
(Measurable Goal with dates)
ST: within time frame of clinical
LT: can be outside of time frame of clinical NURSING INTERVENTIONS
(What do you plan to do for the client to accomplish the goal? Be specific and include time frames) RATIONALE
(Why are you doing this?)
(Citation for each rationale) EVALUATION
(If goal not met, need to evaluate why? And what to do to meet goal?)
- ST: 1.
- ST:
2.
- ST:
4.
- 2.
- LT:
LT: - ST: 1.
- ST:
2. - LT: 3.
- LT:
4. - 5.
- ST:
- ST: 1.
- ST:
2. - LT: 3.
- LT:
4.- 5.
- ST:
