The Nursing Care Plan

1. Assessment
2. Diagnosis
3. Planning
4. Intervention/Rationale
5. Evaluation
 Subjective Data

 Objective Data
 Data Analysis

 Problem Identification

 Label-NANDA
 P- Problem
 E - Etiology
 S - Signs and Symptoms (Not “Risk For”)
 Set Priorities
 Specific & Timed
Goals
 Specific and Timed
Interventions
 Include Rationales
 Nurse Initiated Treatments
 Physician Initiated Treatments
 Evaluate the GOALS
 Goals Were Met
 Goals Were Not Met
 Be Specific
 S- Subjective
 O-Objective
 A-Assessment/Nursing Diagnosis
 P-Plan/Goals
 I-Intervention/Rationales
 E-Evaluation