NURSING CARE PLAN

Complete this form for comprehensive patient care planning

Patient Information

Assessment Findings

Instructions: Document comprehensive assessment including vital signs, physical examination findings, mental status, and relevant laboratory/diagnostic results.

Nursing Diagnoses (Priority Ranked)

Instructions: List 3-5 priority nursing diagnoses using NANDA format with related factors and defining characteristics.
Priority Nursing Diagnosis Related Factors Defining Characteristics
1
2
3
4
5

Patient Goals & Expected Outcomes

Instructions: For each nursing diagnosis, establish SMART goals (Specific, Measurable, Achievable, Relevant, Time-bound) with expected outcomes.

Nursing Diagnosis #1:

Nursing Diagnosis #2:

Nursing Diagnosis #3:

Nursing Interventions & Rationale

Instructions: List specific, evidence-based interventions for each diagnosis with scientific rationale for each action.
Nursing Diagnosis Nursing Interventions Rationale (Scientific Basis)

Implementation & Evaluation

Instructions: Document interventions performed, patient response, effectiveness, and goal achievement. Update daily or per facility protocol.
Date/Time Interventions Performed Patient Response Goal Progress / Outcome Evaluation

Discharge Planning & Patient Education

Documentation

RN Signature / Date / Time
Instructor/Preceptor Signature / Date / Time