NURSING CARE PLAN

Pt Initials

Age:

Gender:

Occupation:

Admit Date:

Physician:

Medical Diagnoses:

FAMILY STATUS:

HOME ENVIRONMENT:

ALLERGIES:

CODE STATUS - DNR/LIVING WILL:

IDENTIFY 3 NURSING ISSUES IN ORDER OF PRIORITY

1.

2.

3.

IDENTIFY 1 NANDA LABEL FOR EACH OF THE 3 NURSING ISSUES

1.

2.

3.

NURSING DIAGNOSTIC LABEL: NANDA

(Use Priority 1 issue)

NURSING DIAGNOSIS (Complete Diagnosis)

(Use Priority 1 issue)

GOAL (1)

OUTCOME STATEMENT

(Write 1 Outcome Statement, use “SMART”

NURSING INTERVENTIONS