Plan of care.

Nursing Plan of CareStudent name:
Patient initials:
Age:
Date of Care:
All material submitted must be typed in the space provided!
Patient’s Admitting Diagnosis:
List patient’s past medical history related to admission:
PATHOPHYSIOLOGY Provide brief/key aspects of pathophysiology related to your patient’s admitting diagnosis in the
space provided below.
Instructions for
assessment:
In the space below enter the subjective and objective data gathered during your patient
assessment based on systems, including laboratory and diagnostic assessments.
Subjective Data Entry
A
S
S
E
S
S
M
E
N
T
TIME OUT!
Objective Data Entry
To be sure your patient diagnostic statement written below is accurate, you need to review the
assessment data and determine if it is appropriate and relevant for the diagnostic statement
below. Do you have an accurate match or is additional data required or does another nursing
diagnosis need to be investigated? Have you appropriately categorized the subjective and
objective data? Have you prioritized and clustered your assessment data to formulate the
nursing diagnosis? List at least one (1) actual and one (1) at risk nursing diagnosis for your
patient.
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Nursing Diagnostic
Statement:
Nursing Diagnostic Label:
Related to:
As Evidenced By:
Nursing Diagnostic
Statement:
Nursing Diagnostic Label:
Related to:
As Evidenced By:
TIME OUT!
Expected
Goals/Outcomes:
TIME OUT!
I
N
T
E
R
V
E
N
T
I
O
N
The diagnostic label must be NANDA approved and describes the patient’s response to health
conditions. Is there a possibility that the diagnostic label can be misunderstood as a medical
diagnosis? Are the related factors displaying the reason why the patient is exhibiting the
diagnostic label? Are the defining characteristics (“as evidenced by”) show the evidence of the
problem? List two (2) short term goals (STG) for each nursing diagnosis.
Diagnosis A:
STG #1:
STG #2:
Diagnosis B:
STG #1:
STG #2:
The desired outcome must meet criteria to be accurate. The outcome must be specific, realistic,
measurable, and include a time frame for completion. Does the action verb describe the patient’s
behavior to be evaluated? Can the outcome be used in the evaluation step of the nursing process
to measure the patient’s response to the nursing interventions listed below? List at maximum of
three (3) interventions for each goal.
Interventions
Rationale for Selected Intervention Using
A1
Evidence-Based Practice (EBP) references
1.
A1
1.
2.
2.
3.
3.
A2
1.
A2
1.
2.
2.
3.
3.
B1
B1
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1.
1.
2.
2.
3.
3.
B2
TIME OUT!
B2
1.
1.
2.
2.
3.
3.
Do your interventions assist in achieving the desired outcome? Do your interventions address
further monitoring of the patient’s response to your interventions and to the achievement of the
desired outcome? Are qualifiers: when, how, amount, time, and frequency used? Is the focus of
the actions of the nurse and not on the patient? Do your rationales provide sufficient reason,
directions, and best evidence-based practice?
Was the desired outcome achieved? Include data and if not, or partially met, what revisions to
either the desired outcome, goals, or interventions would you make?
 Yes  No  Partially met
E
V
A
L
U
A
T
I
O
N
Complete this care plan using a minimum of four scholarly resources outside of your textbook and your ATI resources.
These resources must be easily available if requested. Attach a reference list using APA format on a separate sheet of
paper to this document. All resources must be current within the last 3-5 years.
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