This sample presents useful information for developing a nursing process– focused care plan for patients

receiving medications. Brief listings and discussions of what must be contained in each phase of the
nursing process are included. This sample may be used as a template for formatting nursing care plans in
a variety of patient care situations/settings. Assessment Objective Data Objective data include
information available through the senses, such as what is seen, felt, heard, and smelled. Among the
sources of data are the chart, laboratory test results, reports of diagnostic procedures, physical
assessment, and examination findings. Examples of specific data are age, height, weight, allergies,
medication profile, and health history. Subjective Data Subjective data include all spoken information
shared by the patient, such as complaints, problems, or stated needs (e.g., patient complains of
“dizziness, headache, vomiting, and feeling hot for 10 days”). Nursing Diagnoses Once the assessment
phase has been completed, the nurse analyzes objective and subjective data about the patient and the
drug and formulates nursing diagnoses. The following is an example of a nursing diagnosis statement:
“Deficient knowledge related to lack of experience with medication regimen and secondgrade reading
level as an adult as evidenced by inability to perform a return demonstration and inability to state
adverse effects to report to the prescriber.” This statement of the nursing diagnosis can be broken down
into three parts, as follows: • Part 1—“Deficient knowledge.” This is the statement of the human
response of the patient to illness, injury, medications, or significant change. This can be an actual
response, an increased risk, or an opportunity to improve the patient’s health status. The nursing
diagnosis related to knowledge may be identified as either deficient or readiness for enhanced
(knowledge). • Part 2—“Related to lack of experience with medication regimen and secondgrade
reading level as an adult.” This portion of the statement identifies factors related to the response; it
often includes multiple factors with some degree of connection between them. The nursing diagnosis
statement does not necessarily claim that there is a cause-and-effect link between these factors and the
response, only that there is a connection. • Part 3—“As evidenced by inability to perform a return
demonstration and inability to state adverse effects to report to the prescriber.” This statement lists
clues, cues, evidence, and/or data that support the nurse’s claim that the nursing diagnosis is accurate.
Nursing diagnoses are prioritized in order of criticality based on patient needs or problems. The ABCs of
care (airway, breathing, and circulation) are often used as a basis for prioritization. Prioritizing always
begins with the most important, significant, or critical need of the patient. Nursing diagnoses that
involve actual responses are always ranked above nursing diagnoses that involve only risks. Planning:
Goals and Outcome Criteria The planning phase includes the identification of goals and outcome criteria,
provides time frames, and is patient oriented. Goals are objective, realistic, and measurable patient-
centered statements with time frames and are broad, whereas outcome criteria are more specific
descriptions of patient goals. Implementation In the implementation phase, the nurse intervenes on
behalf of the patient to address specific patient problems and needs. This is done through independent
nursing actions; collaborative activities such as physical therapy, occupational therapy, and music
therapy; and implementation of medical orders. Family, significant others, and caregivers assist in
carrying out this phase of the nursing care plan. Specific interventions that relate to particular drugs
(e.g., giving a particular cardiac drug only after monitoring the patient’s pulse and blood pressure),
nonpharmacologic interventions that enhance the therapeutic effects of medications, and patient
education are major components of the implementation phase. See the previous text discussion of the
nursing process for more information on nursing interventions. Evaluation Evaluation is the part of the
nursing process that includes monitoring whether patient goals and outcome criteria related to the
nursing diagnoses are met. Monitoring includes observing for therapeutic effects of drug treatment as
well as for adverse effects and toxicity. Many indicators are used to monitor these aspects of drug
therapy as well as the results of appropriately related nonpharmacologic interventions. If the goals and
outcome criteria are met, the nursing care plan may or may not be revised to include new nursing
diagnoses; such changes are made only if appropriate. If goals and outcome criteria are not met,
revisions are made to the entire nursing care plan with further evaluation.