NURSING PROCESS CARE PLAN FORMAT EVALUATION

PATIENT’S INITIALS: STUDENT’S NAME:

DATES OF CARE:

ASSESSMENT ANALYSIS PLANNING IMPLEMENTATION EVALUATION

PATIENT GOALS/ SCIENTIFIC

SUPPORTIVE NURSING OUTCOME NURSING PRINCIPLES/ OBSERVATIONS/
DATA DIAGNOSIS CRITERIA ACTIONS RATIONALE CONCLUSIONS
---------------------------------- ------------------------------ -------------------------------- -------------------------------- --------------------------------- --------------------------------

S. What the client says Statement of Problem Goal Statement Actions to relieve problem Tells why each action Have goals been partially
about this problem and help client achieve should help achieve the or fully met?
(Nursing diagnosis goal (use textbooks) goal
Outcome criteria define
O. What you observe: [NANDA List] plus
goals. They define what Describe in terms of the
see, hear, feel, smell, etiology) Each must be specific and Must have statement for
will be observed when outcome criteria
and measure complete statements, each action
goal is met
NOT doctor’s diagnosis including who, what,
+ where, when, how, how Should plan be revised or
Only one diagnosis per Provide time frame long, and how often, etc.
Client lab values, test continued?
page
results
Are measurable Label:
I/Independent actions
+ nurses can do without
Both goals and outcome doctor’s order
criteria stated as
Medications behavioral objective D/Dependent – what the
doctor orders for this
+ problem

C/Collaborative – require
Doctor’s diagnosis
knowledge, skill, and
expertise of another health
From this data, the reader care professional
must be able to tell that
he/she really has a problem

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 NURSING PROCESS CARE PLAN FORMAT

PATIENT’S INITIALS: STUDENT’S NAME:

DATES OF CARE:

ASSESSMENT ANALYSIS PLANNING IMPLEMENTATION EVALUATION

CLIENT GOALS/ SCIENTIFIC

SUPPORTIVE NURSING OUTCOME NURSING PRINCIPLES/ OBSERVATIONS/
DATA DIAGNOSIS CRITERIA ACTIONS RATIONALE CONCLUSIONS

Subjective: Urinary retention r/t The patient will void 1. Palpate the bladder q 1. Palpation allows the The patient had no bladder
AI have to keep changing neurologic impairment sufficient amounts AEB 4Ε. Ind. nurse to determine the distention; however, had a
my pajamas because I can=t of the bladder secondary presence of bladder PVR or 100 ml on my
keep them dry.@ to diabetes STG: distention. shift.
≅ No bladder distention
Objective: and no overflow 2. Implement techniques 2. These measures may STG partially met. Con-
≅ Residual urine >100 ml dribbling during my that encourage void- initiate the voiding tinue with goals.
≅ Small frequent voiding shift ing like positioning reflex.
of less than 50 cc and relaxation. Ind. Patient not discharged
≅ Dribbling (soiled ≅ Has post void residual during my shift.
pajamas and bed linen volume of less than 50 3. Catheterize the client 3. Catheterization is used
ml if voiding is repeat- as a last resort because Continue with LTG. Goal
≅ Bladder distention
edly unsuccessful or of the danger of UTI. not met.
LTG: as ordered. Depend.
≅ Demonstrates no s/s of
a UTI by discharge 4. Instruct the client in 4. Early recognition of
reportable s/s of UTI infection facilitates
(chills, fever, flank prompt intervention to
pain, hematuria). alleviate the problem.
Ind.

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