Nursing care plan

SUBJECTIVE DATA

(Relevant and timely and quoted from patient)

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OBJECTIVE DATA

(Includes vital signs, and physical

assessment findings)

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NURSING DIAGNOSIS

(NANDA, R/T, AEB)

GOAL

(Condition, Time Frame, Parameters, and must be realistic) SMART and MEASURABLE

Short Term:

Long Term:

NTERVENTIONS AND RATIONALES

(Assess, Assist, Administer/Provide, Consult, and Teach)

ASSESS:

ASSIST:

EVALUATION OF CARE PLAN

(Evaluate each nursing action for effectiveness)

MODIFICATION OF CARE PLAN

(Modify patient care plan based on patient’s

response to interventions)