NURSING CARE PLAN GUIDE
DEFINITION: Organized and systematic process of collecting data from a variety of sources to evaluate the health status of a patient.
ASSESSMENT
Cues
The nurse carry out a complete &
holistic nursing assessment of every
patient's needs
Subjective Data
 
also referred to as symptoms or
covert data

are apparent only to the person
affected and can be described or
verified only by that person.
Itching, pain, and feelings of
worry are examples of
subjective data. It all includes
the client’s sensations, feelings,
values, beliefs, attitudes, and
perception of personal health
status and life situation
Objective Data

Also referred to as signs or
overt data, are detectable by an
observer or can be measured or
tested against an accepted
standard.

They can be seen, heard, felt,
or smelled, and they are
obtained by observation or
physical examination.
Nursing Diagnosis
Problem: statement of the patient's
risk for or actual health problem that
the nurse is licensed and accountable
to treat.
Etiology: factors "related to" or
"associated with" the patient's
problem.
Symptoms: manifestation of
problem identified.
Expected Outcomes
Desired or expected outcomes of
nursing diagnosis:
"Patient will" __________________
_____________________________
_____________________________
or
to____________________________
_____________________________
_____________________________
PLANNING EVALUATION
Nursing Interventions Rationale Outcome Assessment
Independent interventions Scientific principles, theories or Responses to or results of nursing

Are those activities that nurses concepts underlying nursing interventions. An assessment of
are licensed to initiate on the interventions: relative data is made. These
basis of their knowledge and outcome assessments describe how
skills. Document the source with author, the patient looks, feels or behaves
They include physical care, title, edition, and page. after nursing action has been
ongoing assessment, emotional implemented.
support and comfort, teaching,
counseling, environmental May include proposed modifications
management, and making or present plan for improvement of
referrals to other health care nursing care.
professionals.
Dependent interventions

Are activities carried out under
the physician’s orders or
supervision, or according to
specified routines.
Collaborative interventions

Are actions the nurse carries out
in collaboration with other
health team members, such as
physical therapist, social worker