– Readiness for enhanced urinary elimination The process of secretion, reabsorption, and excretion of urine

Secretion and excretion of waste product from the body The taking in and absorption of fluids and electrolytes The chemical and physical processes occurring in living organisms and cells for the development and use of protoplasm, the production of waste and energy, with the release of energy for all vital processes – The act of taking up nutrients through body tissues The physical and chemical activities that convert foodstuffs into Substances suitable for absorption and assimilation – Imbalanced nutrition: less than body requirements The activities of taking in, assimilating, and using nutrients for the purposes of tissue maintenance, tissue repair, and the production of energy. To aid nursing diagnosis, below is the list of current NANDA list according to established domains. Remember that even the best care plan is useless unless the client also believes in the same goals. Let them know what you want to see them accomplish for the day and how together you can accomplish it. This will be a much abbreviated version of your care plan. One important thing to do in the mornings (or afternoons) when you are first talking to your client is to let them know what the plan of care for the day is going to be. Again, this is a learning experience for you.ħ. Sometimes, the same interventions won’t work on the same kinds of clients. You are building something like a “database” in your head regarding nursing care. If you didn’t, why not? Was the goal unrealistic for this client? Was the client out of the room most of the day? Did he just refuse your interventions? The lesson here is to learn what works best with different types of clients so that you can better take care of the next client down the line with the same problems. The question here is, “was my goal accomplished? Why or why not?” You may not always achieve your goals. The evaluation column will not be filled out until after you have completed your interventions. Be sure to number and line up your interventions to match your scientific rationale when you are writing them, so the nursing care plan is easy to understand.Ħ. Rationales answer how and why you are doing the intervention with science and research. You’ll need to include scientific rationale for each and every intervention. As long as they will help your client to achieve his or her goals, they are worth doing!ĥ. Remember that nursing care plan must be individualized and the sample care plan below is to serve as a guide.

Your interventions must be appropriate to help solve the etiology (cause of the NANDA). Remember, measurable, measurable, and measurable!Ĥ. How many times? Three! This is a very measurable goal that another person could verify. Or, client will walk around nurses’ station 3 times by the end of the shift. For example, if your client is in pain and rates his pain as an 8 on a scale of 1-10 and you want him, by the end of the day, to rate it as a 3. They should also be verifiable by someone else, so the nurses that read your nursing care plan know exactly what has been achieved in the plan of care. Stay away from words like “a decrease in, an increase in, to look somewhat better, normal, etc.” Your evaluation should include exactly what the changes were. The most important thing about your goals is that you must make them MEASURABLE. Goals should read “Client will…(turn around NANDA)… (time and measureable factors) AEB (outcome). Here is where you put what you would like to see from the client by the end of your shift, clinical week or whatever your timeframe is. The planning column is really a goal column. The nursing diagnosis needs to be in Problem-Etiology-Supportive Data (PES) format.ģ. The “related to” is the etiology or cause of the NANDA (and may be secondary to part of the medical diagnosis). The “as evidenced by” (AEB) should include your assessment data of how you decided on that particular diagnosis. Your diagnosis should read: nursing diagnosis… related to… as evidenced by…. Ask yourself, “Why did I choose this particular diagnosis?” The answer should lie in the assessment data. The diagnosis column will include some assessment data. Do not choose a potential nursing diagnosis first. Choose a priority nursing diagnosis approved by the North American Nursing Diagnosis Association (NANDA). All five of these steps must be complete in order to have a true care plan.Ģ. This is done in five steps: assessment, diagnosis, planning, intervention, and evaluation. The purpose of a nursing care plan is to identify problems of a client and find solutions to the problems.

Feeding intolerance nursing care plan