Care Plan

Student Name:

Clinical Location/Ward:                                                                                 Date

Identify a patient you cared for in clinical. Use the information about selected patient to complete the care plan.


Care Plan for:

Medical Diagnosis







Patient EMR























Part 1: Nursing Process Model

Nursing Assessment


Nursing Diagnosis (Priority Nursing Diagnosis and 1 Potential Diagnosis) NANDA
Priority DX  


Planning (SMART Goals)


Re: Priority  
Re: Potential  



Implementation – A. Independent Nursing Actions (Teaching)
Diet and Nutrition  
Prevention and Rehabilitation  


Implementation – B. Dependent Nursing Actions: Also state your Nursing Responsibilities
Medications and Treatments


Include: Drug Classification, How is the drug taken, What are the side effects and adverse effects, what to do with the side effects or prevent them from happening

Diagnostic Procedures


Include: What are your responsibilities as a Nurse, before, during and after the procedure


LAB Exams


Include: Why should be done, Normal Levels, What does an abnormal result indicate?




Evaluation (Outcome of Activities):


Nursing Actions

Must include assessment, interventions, and patient teaching, accompanied by rationale for doing each.

Action Rationale

Part 2: Clinical Judgement Model- Ref: Caputi (2019).

Recognize Cues- NOTICING
Signs and Symptoms

·         Appearance

·         Behavior

·         Cognition

·         Thought processes

·         Clustering of information

·         Recognizing inconsistencies

·         Determining the importance of information

·         Distinguishing the relevant from irrelevant information

·         Judging how much ambiguity is acceptable

·         Comparing and contrasting


Prioritize Hypotheses
·         Setting Priorities  
Generate Solutions  
·         PLAN nursing interventions

Ø  Per disease process

Ø  Patient activities

Ø  Diet and Nutrition

Ø  Medication

Ø  Therapeutic procedures

Take Action-RESPONDING  
·         Delegating

·         Communicating

·         Teaching

·         Implementation

Evaluate Outcomes- REFLECTION  
·         Effectiveness of:

Ø  Accuracy of diagnosis

Ø  Interventions conducted

Ø  Medication

Ø  Procedures done



Reference page

On the following page, provide the APA style reference list used in preparing this care plan.

The instructor will check the sources and the APA style  when grading your work.




Instructor’s Feedback










Reviewed with Student:      ________________________________ (Student Signature)


Faculty:      ________________________________ (Faculty Signature)


Date:   ________________________________                                     



Patient Information      
Medical Diagnosis 1    
Patient EMR 4    
Part 1: Nursing Process Model      
Subjective Data (Minimum of 3) 5    
Objective Data (Minimum of 3) 10    
Nursing Diagnosis: NANDA, Related To, AEB (Minimum of 2) 10    
Goal: Condition, Time Frame, Parameters (Minimum of 3) 10    
Assessment, Interventions, Patient Teaching, and Rationales for each (Minimum of 6) 10    
Part 2: Clinical Judgement Model      
Identify Client’s Needs (Minimum of 3) 5    
Make Clinical Judgement (Minimum of 2) 5    
Clinical Decisions (Minimum of 5) 5    
Form a Hypothesis (Minimum of 1) 5    
Generate Solutions (Minimum of 5) 10    
Take Actions (Minimum of 5) 10    
Evaluate Outcomes (Minimum of 2) 5    
Reference Page      
Cited all content used in the care plan 2    
Citation followed the APA7th style formatting 3    
Total 100%    


The final grade reflects the percentage earned.