Care Plan #
Pathophysiology – (to the cellular level)
Signs & Symptoms/Clinical Manifestations (all data subjective and objective: labs, radiology, all diagnostic studies)(What symptoms does your client present with?)
Treatment (Medical, medications, intervention and supportive)
Causes/Risk Factors (chemical, environmental, psychological, physiological and genetic)
REMEMBER THAT THE EXPECTED OUTCOMES MUST BE MEASURABLE.THE INTERVENTIONS ARE WHAT YOU DO TO ASSURE THE OUTCOME AND THE CLIENT’S RESPONSE IS SPECIFICALLY HER RESPONSE.
PLAN OF CARE: Use your top two priorities
NANDA NURSING DIAGNOSIS use NANDA definition
Expected outcomes of care (Goals)
R/T: (What is the cause of the symptom)
Manifested by: (Specific symptoms)
Short term goal
:Create a SMART goal that relates to hospital stay/shift/day.
Long term goal
:Create a SMART goal that is appropriate for discharge.
This is specific to the patient that you are caring for. A list of planned actions that will assist the patient to achieve the desired goal. (i.e. obtain foods that the patient can eat/ likes)
Interventions for short-term goal:
Interventions for long term goal:
Identify what the patients response or “outcome is to the goal or care that you have provided. i.e. patient ate 45% of lunch)
Reassess for short-term goal:
Reassess for long-term goal:
Was it met or not met there is no partially met.
PLEASE GIVE REFERENCES
Summer 2021 JM 9
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