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Writing a Nursing Care Plan

Writing a Nursing Care Plan - Aquickreview NursingDiagnosis...

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Writing a Nursing Care Plan A quick review Nursing Diagnosis 0.  A clinical judgment about individual, family, or community  responses to actual or potential health problems/ life processes.  (NANDA) 1. Not a medical diagnosis 2. NANDA defines the “label” for the identified problem Must come from NANDA book. Sometimes must specify type (ie. Ineffective Tissue Perfusion or Risk for Infection) 3.  3 components for actual problems (PES) 0. Problem (per NANDA) 1. Etiology (“related factors”) 2. Signs and symptoms (“defining characteristics”) 4. Only 2 components for potential problems 3. Problem (per NANDA) 4. Etiology (“risk factors”) 5. Written as 5. Problem  6. R/T (etiology) 7. AEB (S+S) 0. For actual  problem 1. Written as 0. Problem  1. R/T (etiology) 2. AEB (S+S) 2. For potential  problem 3. Written as 3. “Risk for” problem 4. R/T or Risk Factors Expected Outcomes 6.  A goal established by both nurse and patient which addresses a  specific Nursing Diagnosis and is
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8. Measurable 9. Realistic 10.Achievable within a specified time frame 7. One goal per Nursing Diagnosis 8.
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