Guidelines for Nursing Care Plan


The nursing care plan is designed to demonstrate the student’s ability to use pertinent data to plan care for the assigned client. The nursing care plan includes:

1.   the database summarizing pertinent health history, history of present concern, review of systems and physical assessment as indicated; the database should be organized using Gordon’s Functional Health Patterns and differentiate between subjective and objective data; a summary of health and illness patterns should be included as pertinent;

2.   focused assessment(s) related to identified areas of concern; specific assessment tools and/or more detailed information should be included as determined  by the student based on nursing assessment of the client;

3.   a summary of developmental stage according to Erikson with a discussion providing examples of how the client is meeting the expected tasks for this stage, effects of health status on client/family’s ability to achieve tasks for the stage and implications for nursing care;

4.   diagnostic findings related to identified areas of concern incorporated into #1 and #2 and the significance of these in terms of planning care should be discussed; pertinent negative findings should be noted; if the student has identified pertinent diagnostic data but it is not available because it is not ordered or not completed, this should be noted;

5.   a summary of pathophysiology as it pertains to assigned client’s primary medical diagnosis; a concise comparison the client’s signs and symptoms to those usually seen with this diagnosis, including pertinent diagnostic findings should be included;

6.   a prioritized list of nursing diagnoses using NANDA format and based on the data collected; collaborative problems/potential complications should be clearly labeled as such; include a brief discussion with the rationale for selecting the diagnoses identified and establishing the priorities; at least one of the diagnoses should focus on psychosocial concerns for the client;

7.   an overall goal and specific outcomes listed beneath each nursing diagnosis;

8.   a five-column plan for the priority (#1) problem.


The database (#1-5) should be written in narrative format and is limited to 6-8 printed pages, double-spaced using #12 font. Data may be listed and/or bulleted if desired. The nursing diagnoses should be listed on a separate page with outcomes for each diagnosis included immediately after the diagnostic statement and the rationale summarized at the end of the list. The 5-column plan must be printed (not handwritten) using the format introduced in NSGL 330.



Assessment: Database                                                                                                              25%

provides detail/depth needed to clearly describe the client’s health status, organized

using Gordon’s Functional Health Patterns                       

discusses developmental stage and implications for care                                                         

describes pertinent subjective and objective data as it relates to disease process

and/or health status, noting pertinent negatives                                                      

incorporates focused assessment(s) as relevant to identified concerns                                     

discusses relevant diagnostic findings in relation to planning                           

identifies preferences and usual patterns of daily living necessary to individualize plan   

Diagnosing/Planning:     (Problem list and expected outcomes)                                       25%

states nursing diagnoses in accepted format

lists diagnoses in order of priority

identifies rationale for selected nursing diagnoses and ranking

includes appropriate diagnoses based on data collected

states problems that are appropriate for the nurse’s scope of practice and for which the nurse can prescribe the primary treatment

demonstrates correlation between data clusters and defining characteristics for each diagnosis

differentiates between actual, potential and collaborative problems and potential complications states outcomes that are measurable, realistic and mutual

specifies performance criteria for stated outcomes with appropriate modifiers           

uses client-centered action verbs in goal statements

defines outcomes for actual problems that will resolve the problem if achieved

identifies both short-term and long-term goals

Interventions: 5-column Plan                                                                                                     25%

identifies nursing interventions that are realistic for client and correlate with stated outcomes

uses etiology in diagnostic statement to identify appropriate interventions

describes nursing actions with descriptive qualifiers

includes a variety of approaches to achieve stated outcomes

modifies standard measures to individualize for client

provides specific parameters for implementation

includes independent nursing measures focused on correcting the stated problem

demonstrates depth beyond the “standard” plan

states rationale for actions that demonstrate theoretical/scientific principles and integrates research

Evaluation of plan                                                                                                                     15%

identifies if outcomes met, not met or partially met with rationale to support

summarizes pertinent observations to support conclusions

states modifications of the plan based on client response

Presentation                                                                                                                              10%

uses correct spelling, grammar and terminology

uses standard abbreviations correctly

presents information clearly and in a logical sequence

cites references using APA format