Care plan template for 1st semester students
This is the care plan template that 1st semester nursing students will use to gather/analyze and plan for care.
Nursing Care Plan Template (based on ANA Scope and Standards of Practice, 2015 and NANDA-I, 2018-2020)
| Clinically Relevant Assessment Data
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| Cluster of Assessment Data for Nursing Diagnosis #1 | Cluster of Assessment Data for Nursing Diagnosis #2
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Implemented Fundamentals SP 2023 LEP
| Nursing Diagnosis #1
The actual Problem OR Risk for developing a problem:
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Related Factors
What is the cause/Etiology of this problem?
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| Defining Characteristics
What are the patient’s signs and symptoms of this problem? OR why are they at risk for developing this problem?
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| Overall Goal Short or long-term, broad goal: What do you want to accomplish? What is the normal condition if the PROBLEM is resolved or controlled? | Expected Outcomes
SPECIFIC. MEASURABLE. ACHIEVABLE. REALISTIC. TIMEFRAME. How will you know when the goal is achieved? A statement of the resolution of the defining characteristics. Format: “The patient will…”
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| Nursing Interventions SPECIFIC nursing actions to accomplish the expected outcomes. For actual problems, should be directed at Related Factors when possible.
Format: “The nurse will …” 1.
2.
3.
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Rationale State WHY the nursing intervention will assist patient to reach the
goal. Cite an evidence-based resource for interventions.
1.
2.
3.
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| Evaluation
Identify the degree to which the Expected Outcomes have been met. g Met g Partially Met g Not Met State re-assessment data to support your analysis. |
Revision
If the goal was PARTIALLY MET or NOT MET, identify 2 new interventions based on your analysis. 1.
2.
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| Nursing Diagnosis #2
The actual Problem OR Risk for developing a problem:
|
Related Factors
What is the cause/Etiology of this problem?
|
| Defining Characteristics
What are the patient’s signs and symptoms of this problem? OR why are they at risk for developing this problem?
|
|
| Overall Goal Short or long-term, broad goal: What do you want to accomplish? What is the normal condition if the PROBLEM is resolved or controlled? | Expected Outcomes
SPECIFIC. MEASURABLE. ACHIEVABLE. REALISTIC. TIMELY. How will you know when the goal is achieved? A statement of the resolution of the defining characteristics. Format: “The patient will…” |
| Nursing Interventions SPECIFIC nursing actions to accomplish the expected outcomes. For actual problems should be directed at Related Factors when possible. Format: “The nurse will …”
1.
2.
3.
|
Rationale State WHY the nursing intervention will assist patient to reach the
goal. Cite an evidence-based resource for interventions.
1.
2.
3.
|
| Evaluation
Identify the degree to which the Expected Outcomes have been met. g Met g Partially Met g Not Met State re-assessment data to support your analysis. |
Revision If the goal was PARTIALLY MET or NOT MET, identify 2 new
interventions based on your analysis. 1.
2.
|
