CARE PLAN TIPS
Except for "risk for" which have 2
parts, nursing diagnosis have 3 parts:
- The NANDA diagnosis label,
- The "related to" (r/t) portion, and
- tThe "as evidenced by" (AEB)
- Look at the
- Look for the
defining characteristics or symptoms
from your assessment
- Look for the
related factors - things that cause
- Make the sentence
read: NANDA Diagnosis…RT…AEB…
- Develop SMART
patient goals or the "patient will" statements
- Specific &
that match the intent of the interventions and goals
outcome or result of goal interventions.
- Timed, and a date
More specifically...as you begin to write the care
plan, refer to your assessment findings. What is the priority problem?
Are there clues to the need for patient teaching? What symptoms is the
Often it helps to look at the NANDA list
first, and see if there is one particular diagnosis that seems to
fit the situation. Then look up that diagnosis in the Nursing
Diagnosis book. Look at their definition, to see if it fits your
Then look for the defining characteristics or evidence: These
are the signs and symptoms you have seen in the patient. They will
be the "as evidenced by" or AEB of the diagnosis statement.
Next, look for the related factors:
These are the "related to" or R/T part of the statement. Remember,
avoid using the medical diagnosis as a "related to" part. However,
it may be used as a "secondary to" statement.
Then change it around to make the sentence read:
For example, if my patient has sores on his legs, and he also has
Diabetes Mellitus, you might use the statement:
Decreased blood flow and nutrients to tissues of the lower
extremities, secondary to Diabetes Mellitus AEB a 2 cm
skin lesion on the left great toe, and a 4 cm lesion on the inner
aspect of the right ankle."
Nursing diagnoses that are in the "risk for"
categories do not need the AEB portion of the statement, since there
is no actual evidence. However, you should avoid using too many
"risk for" diagnosis. One or two, out of eight to ten, is
Assessment abnormalities should always be
reflected in the nursing diagnosis, and subjective and objective
data. If the assessment data is not there, you have no evidence.
Gradually, with practice, you will find that
nursing diagnoses are easier and easier to develop.
GOALS or OUTCOMES:
Next you'll want to develop patient goals or
the "patient will" statements. These must be specific, measurable,
attainable, realistic, timed, and dated. Collaborate with the
patient, to gain cooperation with the planned goals. They should
also be measurable, and include a time frame, and a date. Goals
should conform to the nursing diagnosis. Make them specific to your
- They should be individualized to your
patient, not just "canned" from the book.
- They should be attainable for your patient.
- Then look in the Nursing Diagnosis book for
nursing interventions that could be used to assist the patient
to attain the goal(s), you have established.
- Next, find the rationale that match the
intent of the interventions and goals.
- And finally, evaluate the outcome of the
interventions. These statements should match the wording used in
the goal column, and be followed by the statement as to whether
the goal was "met, partially met, or not met.
- You may use other nursing books, to
supplement the information found in the Nursing Diagnosis book.
Generally, the "computerized care plan programs" are not
acceptable for nursing school.
Copyright © 7/1999 - /2007 Tess Pape, PhD, MSN, BSN, RN, CNOR
9/3/07 Meditella home office in Abilene, TX.
Copyright © 2007 Meditella. All