Nursing Care Plan Template (based on ANA Scope and Standards of Practice, 2015 and NANDA-I, 2018-2020)
Clinically Relevant Assessment Data
Cluster of Assessment Data for Nursing Diagnosis #1
Cluster of Assessment Data for Nursing Diagnosis #2
Nursing Care Plan Template by Chippewa Valley Technical College is licensed under CC BY 4.0
Nursing Diagnosis #1
Related Factors
The actual Problem OR Risk for developing a problem:
What is the cause/Etiology of this problem?
Defining Characteristics
What are the patient’s signs and symptoms of this problem? OR why are they at risk for developing this problem?
Overall Goal Short or long-term, broad goal: What do you want to
Expected Outcomes
accomplish? What is the normal condition if the PROBLEM is resolved or
controlled?
SPECIFIC. MEASURABLE. ACHIEVABLE. REALISTIC. TIMEFRAME.
Nursing Interventions SPECIFIC nursing actions to accomplish the
Rationale State WHY the nursing intervention will assist patient to reach the
goal. Cite an evidence-based resource for interventions.
expected outcomes. For actual problems, should be directed at Related
Factors when possible.
Format: “The nurse will …”
1.
How will you know when the goal is achieved? A statement of the resolution of
the defining characteristics. Format: “The patient will…”
1.
2.
2.
3.
3.
Revision
Evaluation
Identify the degree to which the Expected Outcomes have been met.
Met
 Partially Met  Not Met
State re-assessment data to support your analysis.
If the goal was PARTIALLY MET or NOT MET, identify 2 new interventions
based on your analysis.
1.
2.
Nursing Care Plan Template by Chippewa Valley Technical College is licensed under CC BY 4.0
Nursing Diagnosis #1
Related Factors
The actual Problem OR Risk for developing a problem:
What is the cause/Etiology of this problem?
Defining Characteristics
What are the patient’s signs and symptoms of this problem? OR why are they at risk for developing this problem?
Overall Goal Short or long-term, broad goal: What do you want to
Expected Outcomes
accomplish? What is the normal condition if the PROBLEM is resolved or
controlled?
SPECIFIC. MEASURABLE. ACHIEVABLE. REALISTIC. TIMELY.
Nursing Interventions SPECIFIC nursing actions to accomplish the
Rationale State WHY the nursing intervention will assist patient to reach the
goal. Cite an evidence-based resource for interventions.
expected outcomes. For actual problems should be directed at Related
Factors when possible. Format: “The nurse will …”
How will you know when the goal is achieved? A statement of the resolution of
the defining characteristics. Format: “The patient will…”
1.
1.
2.
2.
3.
3.
Evaluation
Identify the degree to which the Expected Outcomes have been met.
Met
 Partially Met  Not Met
Revision If the goal was PARTIALLY MET or NOT MET, identify 2 new
interventions based on your analysis.
1.
State re-assessment data to support your analysis.
2.
Nursing Care Plan Template by Chippewa Valley Technical College is licensed under CC BY 4.0