Nursing Care Plan

PLAN OF CARE

PATIENT or NURSING ORIENTED PROBLEM OR PATIENT NEED

PATIENT ASSESSMENT DATA

OPTIMAL PATIENT OUTCOME or GOAL

Patient problem/issues/need - which is related to <insert>

Patient problems/issues/needs can be actual present and occurring now

Or potential when the patient is considered to be ‘at risk of’.

As evidenced by (or how do we know this problem exists)

Objective patient data

Subjective patient data

Lab and other test results

What do we (patient and nurse) want to achieve:

Specific, measurable, attainable, realistic and time orientated (SMART goals)

1.

2.

3.

4.

5.

6.

One row per problem

Up to 6 prioritised problems (minimum 4)