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Nursing Care Plan
– Data analysis and interpretation: Review data collection; group data that support the identified nursing diagnosis;
– Nursing Diagnosis [client’s problem]: Identify 4 nursing diagnoses; (2 diagnoses should be actual problems, and 2 should be potential issues – Develop only 1 priority nursing diagnosis)
– Objectives: Formulate 2 objectives; (1 short term and 1 long term)
– Nursing interventions and justification: Each intervention is pertinent to the nursing diagnosis and the objectives; a justification and reference are provided for each nursing intervention & Each intervention is detailed, specific and pertinent to the client (explains what is being done, when and at which frequency the action is to be executed, how it is done. All 4 types of nursing interventions must be addressed (assessment, independent, collaborative and teaching)
– Evaluation: Indicate the date when the evaluation occurred as well as what to do about nursing interventions.
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