An individual nursing care plan for a patient includes nursing diagnoses, patient outcomes, planning, implementation and evaluation, according to allnurses. The care plan is written documentation of the process a nurse uses to solve a patient's nursing problem.
Patient outcomes are the foundation of the care plan, says allnurses. The primary goal is to collect as much data as possible to facilitate this. Assessment is a critical component of the plan and includes the head-to-toe exam as well as the patient's responses. Abnormal data typically becomes the list of symptoms. Patient outcomes include criteria such as vital signs, nutrition and labs.
The planning section of the care plan includes measurable goals, outcomes and necessary interventions. It includes statements that begin with words such as monitor, assess and check. The interventions discussed are always potentially necessary interventions and are phrased in future tense. The implementation section of the nursing care plan details the actual interventions, says allnurses.
The implementation section of the care plan details the patient care provided, how patient data was gathered and measured against normal ranges, and how often patient data was obtained. Nurses base diagnoses, goals and interventions upon the patient's symptoms, says allnurses. The evaluation section of the individual care plan includes goals met or not met.