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