CARE PLAN TEMPLATE Nursing Diagnosis/Priority Problem: Pain

CARE PLAN TEMPLATE Nursing Diagnosis/Priority Problem: Pain R/T fall on R leg and knee. Goal 1 Form Assessment Data/ Defining Characteristics (Signs and symptoms supporting the chosen nursing diagnosis) Client Outcomes (SMART: specific, measurable, achievable, realistic and time specific) Nursing Interventions (Nursing initiated actions based on the medical plan of care and client outcomes) Rationale/Evidence Based (Reasons why each intervention is expected to work; connect to nursing theory, pathophysiology, APA cited) Evaluation (Expected Outcomes achieved? Not achieved? What is next? Future plan) Goal 2 Form Assessment Data/ Defining Characteristics (Signs and symptoms supporting the chosen nursing diagnosis) Client Outcomes (SMART: specific, measurable, achievable, realistic and time specific) Nursing Interventions (Nursing initiated actions based on the medical plan of care and client outcomes) Rationale/Evidence Based (Reasons why each intervention is expected to work; connect to nursing theory, pathophysiology, APA cited) Evaluation (Expected Outcomes achieved? Not achieved? What is next? Future plan) References SCIENCE HEALTH SCIENCE NURSING NURSING PNH201

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