Nursing Care Plans

Clinical Manifestations/ Assessment

Assess data from admission to current day

• be selective- objective and subjective data

Nursing Diagnosis

1. ND- client's response to a problem

2. Etiology (Related to)- what piece of the pathophysiology of a medical disease is causing this issue

3. As evidence by (Sign and Symptoms that support this diagnosis)- what’s the evidence of the problem

Goals

• relate directly to the Nursing Diagnosis

• patient-focused and time bound

• always SMART

SMART

specific

measurable

attainable

realistic

time bound

Nursing Interventions

Directly related to help the client reach those specific goals

1. Specific Vital Signs

2. Focused Physical Assessment- which body systems

3. Administer Medication

4. Intervention

5. Intervention

6. Pt/ Family education/ Teaching

Implementation

• provide nursing care based on the care plan

• be prepared, be competent

• time management

Evalution

• done with each intervention

• effective interventions = effective plans = patient should be closer to achieving their goals

• just as specific and measurable so you can identify when a goal is achieved