Nursing Care Plans

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:

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;
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;
a summary of developmental stage according to Erikson with a discussion supporting how the client is meeting the expected tasks for this stage and implications for nursing care;
diagnostic findings related to identified areas of concern which should be incorporated into #1 and #2; 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;
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;
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;
an overall goal and specific outcomes listed beneath each nursing diagnosis;
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.

CRITERIA FOR EVALUATION

Criteria	Grade
Assessment: Database provides detail/depth needed to clearly describe the client's health status discusses developmental stage and implications for care organizes data using Gordon's Functional Health Patterns 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 includes relevant diagnostic findings identifies preferences and usual patterns of daily living necessary to individualize plan	25%
Diagnosing/Planning: Problem list and expected outcomes 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	25%
Interventions: 5-column Plan 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	25%
Evaluation of plan 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	15%
Presentation uses correct spelling, grammar and terminology uses standard abbreviations correctly presents information clearly and in a logical sequence cites references using APA format	10%
TOTAL	100%

last updated: 27 July 2001