Tips and Tricks: Writing Nursing Care Plans
In general…
o Your nursing diagnosis book is a great guide when formulating diagnoses.
o If you are having difficulty clustering your data, read the definition, etiology, and defining
characteristics of the diagnoses you are leaning toward.
o Look to your diagnosis book to rule out potential diagnosis and focus on the one that fits
best.
o For each diagnosis, the book lists/provides the following:
o Definition, related factors (etiology), defining characteristics (both subjective and
objective)
 Guidelines for developing your nursing diagnosis
o Desired outcomes (goals)/Evaluation criteria
 Suggestions for Outcomes and how to evaluate them
o Actions/Interventions
 Suggestions for formulating interventions/guiding toward what interventions
you should create for your patient
o Documentation Focus
 Suggestions for what you should assess/reassess, plan for, and points for
discharge planning.
***REMEMBER***
These phrases/words in the book are just a guide to assist you in formulating
an individualized care plan for your client!
Diagnosis
 What is the problem you identified?
o This is the nursing diagnosis itself

What is the etiology or related to?
o MUST be within the nursing domain and SECONDARY TO a medical problem
 Ex: Pain, chronic related to poorly managed pain secondary to peripheral
neuropathy
 Ex: Tissue integrity, impaired related to decreased circulation secondary to
peripheral neuropathy
o **Not all etiologies have a secondary to

What are your defining characteristics?
o What makes the diagnosis pertinent?
 Direct statements from the patient, evidence found on assessment
 Take these DIRECTLY from the scenario or situation – do not write it word for
word from book
o
Characteristics CANNOT be shared between diagnoses. Figure out where it fits BEST.
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Tips and Tricks: Writing Nursing Care Plans
Goals/Outcomes
 This is something that the patient does

These are meant to address issues noted in the diagnosis…let the etiology or defining
characteristics drive your goals.
Patient is recovering from a right total knee arthroplasty. They are complaining of 8/10 pain to
their right knee and have been refusing to get out of bed due to the discomfort. The patient has
not had a bowel movement in 3 days and has hypoactive bowel sounds x 4 quadrants.

o
Nursing Diagnosis: Constipation
 Etiology: Refusing to get out of bed
 Goal: Patient will: Ambulate 100 feet with a four wheeled walker two
times by end of shift.
o
Nursing Diagnosis: Acute Pain
 Ex: Defining characteristic: Rates pain as an 8/10 on a scale of 0-10 in right leg
 Goal: Patient will: Rate pain as a 4/10 in right leg by end of shift
Follow the “OUTCOME” guidelines!
Interventions (Rationale)
 These are what the nurse does to help the patient meet their established goal.
o Ex: Goal: Patient will: Rate pain as a 4/10 in right leg by end of shift
 Intervention: Assess and document pain rating every four hours and PRN
 Intervention: Administer Lortab 5/325 mg every four hours PRN moderate pain

BUT don’t forget the rationale for your interventions!
o Intervention: Assess and document pain rating every four hours and PRN (to evaluate
level of pain, monitor for improvement, and communicate findings to the
interdisciplinary team).
o Intervention: Administer Lortab 5/325 mg every four hours PRN moderate pain (to
provide relief from pain and increase level of comfort).

“Communicate findings to the interdisciplinary team” is ONLY used with the Assess and
Document interventions.
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Tips and Tricks: Writing Nursing Care Plans

So what about the “Consult” interventions?
o Intervention: Consult with respiratory therapy once per shift (to collaborate with
respiratory therapist to provide additional respiratory care through the administration of
albuterol inhalers and other respiratory treatments).

Ensure that the interventions are within the nursing scope of practice and follows “HAT”
guidelines
o How, Action/Amount, Timeframe

Example “rule of thumb” for phrasing particular interventions (rationale):
o Assess and document  to evaluate _____, measure improvement, and communicate
findings to the interdisciplinary team
o Administer  to raise ________, to treat ________, to provide ________
o Encourage  to promote _______
o Provide  to promote/encourage _____
o Promote  to encourage _______
o Consult  to collaborate with _______ for ____________
o Educate  to provide knowledge about ___________
Evaluation
 You evaluate the GOAL (not the intervention!)

Involves examining the goal and judging whether or not a change has occurred.

Met, not met, or partially met…and nothing in between!
o Ex: Patient will: Rate pain as a 4/10 in right leg by end of shift
 Evaluation: Goal met: Patient rated pain as a 3/10 on a scale of 0-10 after
administration of pain medication. Will continue to provide medications as
needed and offer methods of comfort such as repositioning and heat. Will
continue to monitor.
o
o
Met: How do you know? What will you continue to (do the interventions you already
have in place) because (list evidence to state why they have met the goal). Will continue
to monitor.
Partially met: How do you know? Why was the goal only partially met? What needs to
change in order to meet the goals?
 Explain why partially met (what evidence to you have?) and what you will
change (with interventions) in order to meet the goal. Will continue to monitor.
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Tips and Tricks: Writing Nursing Care Plans
o

Not met: How do you know? Explain why not met (what evidence do you have?) and
what you will do to help the client meet the goal (what interventions you will
change/what will you do differently). Will continue to monitor.
Use the guidelines provided in lecture notes to effectively evaluate your outcomes.
Final Words of Wisdom…



Do not write word for word from the diagnosis book
INDIVIDUALIZE the care plan to your patient!
Write your care plan in detail
o As the oncoming nurse, I should be able to read your care plan and know exactly what is
wrong with the patient, what goals are set, what interventions are in place, and what to
look for in order to evaluate if the outcomes were met.
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