Nursing Care Plan Master

Diagnosis: Pt. Age:

Student Name: Sherlina (Shane) Hillman

Assessment

Objective/Subjective Diagnosis (7 Basic Needs) Pt. Problem & Etiology NS-PT Action Pt Outcome Name a Need You must have two needs

See NANDA for your for each need; must have Nursing Dx. approved diagnosis Not the 2-Objective Medical Diagnosis and See Rosdahl or Care 2 Subjective symptoms Plan Book For subjective symptoms document Pt states, “______” with Pts words in quotations

1st part is to be tied into the 2nd part by “R/T” related to

Planning

Goals (Projected Pt Outcome/Objectives)

Need one goal per need - 1st part to be connected to the last part by: “As Evidenced By”’ or AEB

At least 2 planned nursing actions for each need

Implementation Evaluation Planned NS-PT Action

Rational for each need

Rationale

Actual

What you actually Always refer back to do. your goal - Must state Include: date & time if : Goal met, Goal not met, or Goal ongoing. Must have goal for each need