Careplan Guidelines Developed by: Norma Gail Yearick, MSN, RN Nursing Diagnosis: Format of Nursing Diagnoses ~ Problem related

to Cause as evidenced by Symptoms and Signs of the Problem. Components of Nursing Diagnoses ~ Problem = the NANDA Diagnostic Label. You should have a reference book with NANDA Diagnostic Labels. Carry it with you to clinical! Cause = factors that are contributing to or causing the problem. Note that causes for a particular diagnostic label may be found among the risk factors that are provided for the NANDA diagnostic labels. Symptoms and Signs of the Problem = data and information that you have gathered about the patient that tell you that the problem exists. Note that the NANDA Diagnostic Labels have accompanying defining characteristics that support the selection of the label. These items can be plugged into this part of the nursing diagnosis.

Nursing Diagnosis Example: Acute pain related to tissue injury from surgical incision, as evidenced by patients complaints of pain with rating of 8 out of 10, facial grimacing, and guarding of abdomen. Outcomes/Goals (NOC): Establish the goals that you want the patient to meet to indicate that the problem has been effectively addressed. You may be required to use Nursing Outcomes Classifications (NOC). If required to use NOC, you should have a text book for this purpose. Template: Patient will (specify behavior) by (specify time). Example: Patient will rate pain at 4 out of 10 or less every 2 hours with the administration of pain Examples: 1. Assess patients level of pain every 2 hours and PRN. Example: 2/5/13 1500 Outcome met. Patient has reported through this shift (0700 1500) that Interventions (NIC): Evaluation: Identify nursing interventions that will Evaluate and specify whether the be used to address the problem and Outcome was met. to assist the patient to meet the If the outcome is met, specify whether established Outcome. the care plan should be continued so You may be required to use Nursing that this problem will continue to be Intervention Classifications (NIC). If addressed. required to use NIC, you should have a If the outcome was not met, identify text book for this purpose. whether the outcome and/or interventions need to be revised.

medication.

2. Administer pain medication, as ordered by physician. 3. Position patient for comfort, using pillows to support positions.

pain has remained at a level of 3 out of 10. Continue plan of care.