Nursing Diagnoses & Care Planning

Health Problem

Condition needing intervention.

Medical Diagnosis

Identifies disease.

Nursing Diagnosis

Addresses patient response to health issues.

Risk Nursing Diagnosis

Likely future problems.

Health Promotion Nursing Diagnosis

Motivation to improve well-being.

Goal

Desired patient outcome.

Expected Outcome

What is hoped to be achieved.

Outcome Identification

Recognizing results of care.

Nursing Care Plan

Guide for patient care.

Initial Planning

First step in creating care plan.

Ongoing Planning

Adjusting care as needed.

Nurse-Initiated Intervention

Action taken independently.

Physician-Initiated Intervention

Action per doctor’s order.

Collaborative Intervention

Action done with other healthcare team members

Standards

Accepted rules or norms.

Criteria

Measures used to evaluate outcomes.

Discharge Planning

Preparing patient to leave healthcare facility.

Prioritization

Deciding which problems need attention first.

Delegation

Assigning tasks to other staff (e.g., UAPs).

Evidence-Based Practice

Using research to guide care.

Protocols

Step-by-step care instructions.

Implementing

Putting the care plan into action.

Evaluating

Checking if outcomes are met.

Outcome Evaluation

Measuring results of interventions.

Performance Improvement / Quality Improvement (QI)

Continuous care enhancement.