Care Plan- RN
Instructions for particular sections in the document are found in the Blue highlighted rows below. Students
are expected to develop 3 NANDA Nursing Diagnoses/ Problem-Based Nursing Diagnoses with supporting
documentation. The first Nursing Diagnosis identified should be the priority nursing diagnosis. This will be
the nursing diagnosis used to develop the Care Plan. Before completing the Care Plan below, document the
client’s assessment using the DocuCare Templates attached to the Care Plan assignment in Canvas.
Priority- NANDA Nursing Diagnosis/ Problem-Based Nursing Diagnosis
1. Choose a NANDA or Problem-Based Nursing Diagnosis
2. The statement should list only one diagnosis and be listed using the following format-
problem followed by “Related to (R/T) the disease process/ pathophysiology
3. Including a statement “As evidenced by clinical manifestations, diagnostic test and labs.
4. Each statement should be supported by rationale
Example: Coping, ineffective family: R/T Temporary family disorganization and role changes as
evidenced by significant other's limited personal communication with client.
Write the PRIORITY Nursing Diagnosis/ Problem-Based Diagnosis and include R/T statement
and as evidenced by sentence including rationale below:
Risk for falls r/t impaired mobility secondary to hip fracture, Unfamiliar environment (hospital
setting) as evidenced by impaired balance, muscle weakness and need for assistive devices.
#2- NANDA Nursing Diagnosis/ Problem-Based Nursing Diagnosis
1. Choose a NANDA or Problem-Based Nursing Diagnosis
2. The statement should list only one diagnosis and be listed using the following format-
problem followed by “Related to (R/T) the disease process/ pathophysiology
3. Including a statement “As evidenced by clinical manifestations, diagnostic test and labs.
4. Each statement should be supported by rationale
Example: Coping, ineffective family: R/T Temporary family disorganization and role changes as
evidenced by significant other's limited personal communication with client.
, Write the #2 Nursing Diagnosis/ Problem-Based Diagnosis and include R/T statement and as
evidenced by sentence including rationale below:
Impaired physical mobility r/t musculoskeletal impairment secondary to hip fracture, as evidenced by
limited range motion, unsteady gait, and decreased ability to perform ADLs independently.
#3- NANDA Nursing Diagnosis/ Problem-Based Nursing Diagnosis
1. Choose a NANDA or Problem-Based Nursing Diagnosis
2. The statement should list only one diagnosis and be listed using the following format-
problem followed by “Related to (R/T) the disease process/ pathophysiology
3. Including a statement “As evidenced by clinical manifestations, diagnostic test and labs.
4. Each statement should be supported by rationale
Example: Coping, ineffective family: R/T Temporary family disorganization and role changes as
evidenced by significant other's limited personal communication with client.
Write the #3 Nursing Diagnosis/ Problem-Based Diagnosis and include R/T statement and as
evidenced by sentence including rationale below:
Deficient Knowledge (Fall Prevention) r/t unfamiliarity with safe measures, as evidenced by patient
verbalizes lack of understanding about environmental hazards and proper use of assistive devices.
Care Plan- Using the Priority Nursing Diagnosis, develop the plan of care.
Subjective Summary (Information stated by Objective Summary (Observable)
client)
Objective Data should be clear, concise and
Subjective Data should be clear, concise and specific to the Nursing Diagnosis
specific to the
Nursing Diagnosis Example Objective Data- what is observed or
measured. May include the client’s behavior, vital
Example Subjective Data- what the client/family signs, lung sounds, urine output, laboratory data,
relates, states or reports. Client reports abdominal diagnostic testing (etc.) as related to the specific
pain. nursing diagnosis.
Subjective Data: Objective Data:
Pain 2/10 in left hip Normal vital signs
Patient states that it hurts while turning Inflammation and redness on left side of the hip
Dizzy spells Limited ROM in left hip
Instructions for particular sections in the document are found in the Blue highlighted rows below. Students
are expected to develop 3 NANDA Nursing Diagnoses/ Problem-Based Nursing Diagnoses with supporting
documentation. The first Nursing Diagnosis identified should be the priority nursing diagnosis. This will be
the nursing diagnosis used to develop the Care Plan. Before completing the Care Plan below, document the
client’s assessment using the DocuCare Templates attached to the Care Plan assignment in Canvas.
Priority- NANDA Nursing Diagnosis/ Problem-Based Nursing Diagnosis
1. Choose a NANDA or Problem-Based Nursing Diagnosis
2. The statement should list only one diagnosis and be listed using the following format-
problem followed by “Related to (R/T) the disease process/ pathophysiology
3. Including a statement “As evidenced by clinical manifestations, diagnostic test and labs.
4. Each statement should be supported by rationale
Example: Coping, ineffective family: R/T Temporary family disorganization and role changes as
evidenced by significant other's limited personal communication with client.
Write the PRIORITY Nursing Diagnosis/ Problem-Based Diagnosis and include R/T statement
and as evidenced by sentence including rationale below:
Risk for falls r/t impaired mobility secondary to hip fracture, Unfamiliar environment (hospital
setting) as evidenced by impaired balance, muscle weakness and need for assistive devices.
#2- NANDA Nursing Diagnosis/ Problem-Based Nursing Diagnosis
1. Choose a NANDA or Problem-Based Nursing Diagnosis
2. The statement should list only one diagnosis and be listed using the following format-
problem followed by “Related to (R/T) the disease process/ pathophysiology
3. Including a statement “As evidenced by clinical manifestations, diagnostic test and labs.
4. Each statement should be supported by rationale
Example: Coping, ineffective family: R/T Temporary family disorganization and role changes as
evidenced by significant other's limited personal communication with client.
, Write the #2 Nursing Diagnosis/ Problem-Based Diagnosis and include R/T statement and as
evidenced by sentence including rationale below:
Impaired physical mobility r/t musculoskeletal impairment secondary to hip fracture, as evidenced by
limited range motion, unsteady gait, and decreased ability to perform ADLs independently.
#3- NANDA Nursing Diagnosis/ Problem-Based Nursing Diagnosis
1. Choose a NANDA or Problem-Based Nursing Diagnosis
2. The statement should list only one diagnosis and be listed using the following format-
problem followed by “Related to (R/T) the disease process/ pathophysiology
3. Including a statement “As evidenced by clinical manifestations, diagnostic test and labs.
4. Each statement should be supported by rationale
Example: Coping, ineffective family: R/T Temporary family disorganization and role changes as
evidenced by significant other's limited personal communication with client.
Write the #3 Nursing Diagnosis/ Problem-Based Diagnosis and include R/T statement and as
evidenced by sentence including rationale below:
Deficient Knowledge (Fall Prevention) r/t unfamiliarity with safe measures, as evidenced by patient
verbalizes lack of understanding about environmental hazards and proper use of assistive devices.
Care Plan- Using the Priority Nursing Diagnosis, develop the plan of care.
Subjective Summary (Information stated by Objective Summary (Observable)
client)
Objective Data should be clear, concise and
Subjective Data should be clear, concise and specific to the Nursing Diagnosis
specific to the
Nursing Diagnosis Example Objective Data- what is observed or
measured. May include the client’s behavior, vital
Example Subjective Data- what the client/family signs, lung sounds, urine output, laboratory data,
relates, states or reports. Client reports abdominal diagnostic testing (etc.) as related to the specific
pain. nursing diagnosis.
Subjective Data: Objective Data:
Pain 2/10 in left hip Normal vital signs
Patient states that it hurts while turning Inflammation and redness on left side of the hip
Dizzy spells Limited ROM in left hip
