1. Proposed Common Guidelines in the
Preparation and Evaluation of
Student Nursing Care Plan
A PROPOSAL TO: Nursing Education Teaching-Learning Groups
By. Katherine P. Barnachea, RN
March 2012

2. Proposed Common Guidelines in the Preparation and Evaluation of Student Nursing Care Plans
TABLE OF CONTENTS
Contents Page
Introduction 2
Purpose 3
Common Guidelines in the Preparation and 3
Evaluation of Student Nursing Care Plan
A. Common Guidelines in the Preparation of 4
Student Nursing Care Plan (Student Guide)
B. Common Guidelines in the Evaluation of 9
Student Nursing Care Plan (Faculty Guide)
Suggested Student Nursing Care Plan Format 13
Summary 14
Reference 14
Appendix 15
A. Suggested Student Nursing Care Plan Working Guide
B. Suggested Nursing Care Plan Output Format
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3. Proposed Common Guidelines in the Preparation and Evaluation of Student Nursing Care Plans
Introduction
Student oriented nursing care plan as a writing assignment of the
student nurses in their experiential practice, has been used by the nurse
educators as a teaching device to facilitate the student’s understanding in
patient’s situation and on solving identified nursing problems. This writing
assignment contains reflection on the application of nursing process as
critical thinking method to solve problems in the nursing practice.
With the long years that this traditional care plans have been used by
the student nurses there are several problems found in evaluating these care
plans, as used by the students. The results presented in the study about
“Critical Analysis of Student Nursing Care Plans in the Nursing Schools of
Dagupan City” clearly detailed the deficiencies on the level of accomplishment
of the analyzed student nursing care plan entries along the literature
requirements of nursing process. With this, the attempt to align the sought
deficiencies was summed up to creating proposed common guidelines on the
preparation and evaluation on writing nursing care plan of student nurses.
This guideline will be used by both the students and their clinical instructors.
The proposal of these common guidelines will serve as an anchor to establish
the critical thinking and decision making skills of student nurses as they
learn the application of nursing process into practice. In the same way, the
clinical instructors can easily evaluate their progress and therefore can
determine their performance in the nursing practice. Through these
guidelines, students will learn the very objective of writing a good nursing care
plans, and its future implications on their identity as professionals.
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4. Proposed Common Guidelines in the Preparation and Evaluation of Student Nursing Care Plans
Purpose
1. The common guideline on preparation of nursing care plan will serve as
the foundation instructions for the student nurses on how they will
apply nursing process in their nursing care plan writing. The guideline
will lead them to proper assessment, conclusion and statement of
diagnosis, creating a reasonable plan of care, implementation of plan
into practice and proper evaluation of their nursing care. As the
students continue to enhance this practice, the development of their
professional identity as a nurse, distinct from other health professions
will be developed.
2. The common guidelines on the evaluation of student nursing care plan
will serve as a grading tool for the nursing faculty to determine the
progress of the students in writing their nursing care plans.
Common Guidelines on the Preparation and Evaluation of Student
Nursing Care Plan
The proposed common guidelines on the preparation and evaluation of
student nursing care plans were anchored from Kozier, et al., (2004)
literatures of nursing process. The guidelines follow the steps of nursing
process: assessment, diagnosis, planning, implementation and evaluation.
Each area of nursing process contains guide indicator that was modified to
specifically lead the students in the preparation of the entries to be written on
the nursing care plan. In the same way grading tool to determine if the
guidelines were met was drafted as an evaluation instrument to be used by
the nursing faculty.
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5. Proposed Common Guidelines in the Preparation and Evaluation of Student Nursing Care Plans
A. Common Guidelines on the Preparation of Student Nursing Care
Plan
(Student’s Guide)
The following guidelines will help the students on the preparation of
their nursing care plans.
ASSESSMENT
Assessment is the first phase of Nursing Process. In this phase,
collection, validation and organization of data are done. Significant data that
will lead to the realization of an actual or potential problem is gathered, and
will then be a basis of establishing a nursing care plan. Guidelines to consider
assessment writing in student nursing care plans are as follows:
1. Collection and documentation of subjective and objective data using
appropriate terminology.
2. Gathering of the primary source of data from the Client: Physical,
Psychological, social-cultural, developmental, spiritual and
environmental conditions.
3. Gathering of the secondary source of data from the client’s support
people, cephalo-caudal assessment and observation of the nurse.
4. Gathering of Client’s Records (medical history, therapeutics and
laboratory results) as a supporting data to the assessment.
5. Review of related literature (e.g. Reference text regarding specific health
problems, professional journals, information about the medical
diagnosis, related readings etc.) as a supporting data to the Assessment
entries.
6. Organization of data according to the Policies and Standards of the
Bachelor of Science and Nursing Program Nursing Care Management
Subjects.
7. Clarification of vague or ambiguous statement of the client.
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6. Proposed Common Guidelines in the Preparation and Evaluation of Student Nursing Care Plans
8. Double checking of Data with extremely abnormal results.
9. Use of reference (textbooks, journals, research reports) to explain the
patient’s situation.
DIAGNOSIS
Diagnosis contains a concluding statement for an actual or potential
problem. To have an accurate conclusion of a nursing diagnosis, guidelines
were presented as follows:
1. Comparison of significant cues against the standards, such as growth
and development patterns, normal vital signs and laboratory values.
2. Generation of tentative hypotheses after determining the relatedness of
facts and determining whether any pattern are present or whether the
data is significant.
3. Identification of the gaps and inconsistencies in the data to ensure that
data are complete and correct.
4. Selection of the nursing diagnoses/collaborative problems that will
reflect the accurate interpretation of the subjective and objective data
analyzed.
5. Listing of appropriate Subjective and objective data as supporting data
for the nursing diagnosis.
6. Proper usage of NANDA terminology as nursing diagnosis. 3 part
statements for an actual problem- Problem, Etiology, Signs/ Symptoms
(PES format). Risk nursing diagnosis use 2 part statements and
syndrome diagnoses use 1 part statements.
7. Writing of accurate, concise, descriptive and specific Diagnostic
statements.
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7. Proposed Common Guidelines in the Preparation and Evaluation of Student Nursing Care Plans
PLANNING
Planning includes the goals of care and guide selections on the specific
nursing interventions to solve the nursing problems defined in the Nursing
Diagnosis. Guidelines in creating a plan of care were as follows:
1. Prioritizing plan considering the client’s health values and beliefs,
resources available to the nurse and client, urgency of health problem
and medical treatment plan.
2. Describing client’s goals / desired outcome in terms of client responses
and what the nurse hopes to achieve by implementing the nursing
interventions.
3. Deriving of goals from the client’s nursing diagnosis primarily from the
first clause (problem).
4. Consideration that goals and outcomes are realistic for the client’s
capabilities, limitations and designated time span if it is indicated.
5. Ensuring that goals and desired outcome were compatible with the
therapies of other professionals.
6. Consideration that each goal is derived from only one nursing
diagnosis.
7. Used of observable, measurable terms on the desired outcomes.
8. Inclusion of the subject, verb, conditions or modifiers and criterion of
desired performance in Goal / Desired Outcome Statement.
9. Consideration of safe and appropriate intervention for the individual’s
age, health and condition.
10. Clearly stating achievable intervention with the resources
available.
11. Consideration that interventions were congruent with the client’s
values, beliefs and culture.
12. Linking specific interventions to specific outcomes.
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8. Proposed Common Guidelines in the Preparation and Evaluation of Student Nursing Care Plans
13. Realistic and appropriate statement of the patient's current
status.
14. Comprehensive and scientific reasoning and identification why
the intervention was selected as rationale for each intervention.
15. Discussion of possible side effects or complication on the specific
interventions.
IMPLEMENTATION
Implementation is the safe carrying out of the planned intervention, a
nurse completes this phase by documentation of the intervention done and
the patient’s response on the intervention implemented. Guidelines to safely
carry out this process are presented by the following:
1. Reassessing the client before implementing an intervention, making
sure if the intervention is still needed.
2. Determining the need for assistance and awareness of the nursing
interventions that student nurse are capable and allowed to do in
accordance with the affiliating institutions policy.
3. Implementation of safe care.
4. Encouraging active participation of the client in implementing the
nursing intervention
EVALUATION
Evaluation is done to determine the progress of the patient in relation to
the goals and stated outcome criteria in the plan of care and to determine
whether the problem was resolved or not.
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9. Proposed Common Guidelines in the Preparation and Evaluation of Student Nursing Care Plans
1. Collection of data using the clearly stated, precise and measurable
outcome as a guide, so that conclusions can be drawn about whether
goals have been met.
2. Comparison of the gathered data as an evaluation of client’s response
was compared with the outcome. Stated goal was met if the client’s
response is the same with the desired outcome. Goal was partially met
if the desired outcome was only partially attained. Goal was not met if
any of the desired outcomes wasn’t met.
3. Determining whether the nursing activities have relation to the
outcome.
4. Explaining why goals were met or unmet. Including specific data on the
effectiveness of interventions.
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10. Proposed Common Guidelines in the Preparation and Evaluation of Student Nursing Care Plans
A. CommonGuidelines on the Evaluation of Student Nursing Care Plans
(Faculty Guide)
This guideline will serve as an evaluative tool to determine the application of
nursing process in the written student nursing care plans. The nurse educator will
assess the extent of accomplishment of the student nursing care plan entries in
accordance to the specified guidelines in each areas of nursing process. The faculty
evaluator will put check marks on the spaces available to determine if each indicator
guideline were: Fully Accomplished (F.A.) = 4points, Moderately Accomplished (M.A.)
= 3points, Least Accomplished (L.A.) =2 points, and Not Accomplished (N.A.) = 1
point.
I. ASSESSMENT- minimum acceptable score is 25
ASSESSMENT F.A. M.A. L.A. N.A
(4) (3) (2) (1)
1. Collection and documentation of subjective and
objective data using appropriate terminology.
2. Gathering of the primary source of data from the
Client: Physical, Psychological, social-cultural,
developmental, spiritual and environmental
conditions.
3. Gathering of the secondary source of data from
the client’s support people, cephalo-caudal
assessment and observation of the nurse.
4. Gathering of Client’s Records (medical history,
therapeutics and laboratory results) as a
supporting data to the assessment.
5. Review of related literature (e.g. Reference text
regarding specific health problems, professional
journals, information about the medical
diagnosis, related readings etc.) as a supporting
data to the Assessment entries.
6. Organization of data according to the Policies and
Standards of the Bachelor of Science and Nursing
Program Nursing Care Management Subjects.
7. Clarification of vague or ambiguous statement of
the client
8. Double checking of Data with extremely abnormal
results
9. Use of reference (textbooks, journals, research
reports) to explain the patient’s situation.
SCORE =
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11. Proposed Common Guidelines in the Preparation and Evaluation of Student Nursing Care Plans
II. DIAGNOSIS- minimum acceptable score is 20
DIAGNOSIS F.A. M.A. L.A. N.A
(4) (3) (2) (1)
1. Comparison of significant cues against the
standards, such as growth and development
patterns, normal vital signs and laboratory
values.
2. Generation of tentative hypotheses after
determining the relatedness of facts and
determining whether any pattern are present
or whether the data is significant.
3. Identification of the gaps and inconsistencies
in the data to ensure that data are complete
and correct.
4. Selection of the nursing diagnoses or
collaborative problems that will reflect the
accurate interpretation of the subjective and
objective data analyzed.
5. Listing of appropriate Subjective and
objective data as supporting data for the
nursing diagnosis.
6. Proper usage of NANDA terminology as
nursing diagnosis. 3 part statements for an
actual problem- Problem, Etiology, Signs/
Symptoms (PES format). Risk nursing
diagnosis use 2 part statements and
syndrome diagnoses use 1 part statements.
7. Writing of accurate, concise, descriptive and
specific Diagnostic statements.
SCORE =
10

12. Proposed Common Guidelines in the Preparation and Evaluation of Student Nursing Care Plans
III. PLANNING- minimum acceptable score is 42
PLANNING F.A. M.A. L.A. N.A
(4) (3) (2) (1)
1. Prioritizing plan considering the client’s health
values and beliefs, resources available to the nurse
and client, urgency of health problem and medical
treatment plan.
2. Describing client’s goals / desired outcome in
terms of client responses and what the nurse
hopes to achieve by implementing the nursing
interventions.
3. Deriving of goals from the client’s nursing
diagnosis primarily from the first clause (problem).
4. Consideration that goals and outcomes are
realistic for the client’s capabilities, limitations and
designated time span if it is indicated.
5. Ensuring that goals and desired outcome were
compatible with the therapies of other
professionals.
6. Consideration that each goal is derived from only
one nursing diagnosis.
7. Used of observable, measurable terms on the
desired outcomes.
8. Inclusion of the subject, verb, conditions or
modifiers and criterion of desired performance in
Goal / Desired Outcome Statement.
9. Consideration of safe and appropriate intervention
for the individual’s age, health and condition.
10.Clearly stating achievable intervention with the
resources available.
11.Consideration that interventions were congruent
with the client’s values, beliefs and culture.
12.Linking specific interventions to specific outcomes.
13.Realistic and appropriate statement of the
patient's current status.
14.Comprehensive and scientific reasoning and
identification why the intervention was selected as
rationale for each intervention.
15.Discussion of possible side effects or complication
on the specific interventions.
SCORE =
11

13. Proposed Common Guidelines in the Preparation and Evaluation of Student Nursing Care Plans
IV. IMPLEMENTATION- minimum acceptable score is 11
IMPLEMENTATION F.A. M.A. L.A. N.A
(4) (3) (2) (1)
1. Reassessing the client before implementing an
intervention, making sure if the intervention is still
needed.
2. Determining the need for assistance and
awareness of the nursing interventions that
student nurse are capable and allowed to do in
accordance with the affiliating institutions policy.
3. Implementation of safe care.
4. Encouraging active participation of the client in
implementing the nursing intervention.
SCORE =
V. EVALUATION- minimum acceptable score is 11
EVALUATION F.A. M.A. L.A. N.A
(4) (3) (2) (1)
1. Collection of data using the clearly stated, precise
and measurable outcome as a guide, so that
conclusions can be drawn about whether goals
have been met.
2. Comparison of the gathered data as an evaluation
of client’s response was compared with the
outcome. Stated goal was met if the client’s
response is the same with the desired outcome.
Goal was partially met if the desired outcome was
only partially attained. Goal was not met if any of
the desired outcomes wasn’t met.
3. Determining whether the nursing activities have
relation to the outcome.
4. Explaining why goals were met or unmet.
Including specific data on effectiveness of
interventions.
SCORE =
*Resubmission of written nursing care plans is recommended if the
student NCP did not met the minimum acceptable score in any of the
areas of nursing process.
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14. Proposed Common Guidelines in the Preparation and Evaluation of Student Nursing Care Plans
Suggested Nursing Care Plan Format
Traditional student nursing care plan format involves six columns
which include: assessment, diagnosis, planning, intervention, rationale and
evaluation. This format has been used for long years in the nursing education
since nursing process was defined as the critical thinking method in the
nursing profession. From the past years, student resort to putting necessary
entries needed in the component format of traditional care plans, without
realizing if the entries are applicable or not.Several problems foundspecifically
on the detailed implementation of students in the planned care.
In this regard, a working guide format was suggested (see Appendix A)
anchored from the proposed preparation on student nursing care plans was
made to be used by the students in leading them to proper analysis and
necessary writing of entries on their care plans. After following each
stepswritten summary of care will be transferred on the suggested format to
have a more detailed documentation in the application of nursing process.
This suggested format has followed the specific steps of nursing process:
assessment, diagnosis, planning, implementation and evaluation. This format
was anchored to the suggested guidelines on the preparation and evaluation
of student nursing care plan.
The assessment column contains the subjective and objective data for
an actual or potential problem. Supporting data that contains explanation as
to how the proposed guidelines on the preparation of nursing care plan in the
area of assessment will be discussed in separate page of paper. The diagnosis
column contains the conclusion of the problem using NANDA (North American
Nursing Diagnosis Association) approved nursing diagnosis. Planning
includes the determination of desired outcome, and planned specific
interventions. Rationale of interventions will be discussed on separate page of
paper. The implementation column includes the detailed documentation on
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15. Proposed Common Guidelines in the Preparation and Evaluation of Student Nursing Care Plans
how the student nurses were able to execute the plan care. Lastly, the
evaluation column will detail the progress of planned care. See the suggested
format in Appendix B.
Summary
The common guideline on the preparation and evaluation of student
nursing care plan was proposed to settle the different problems arising on the
preparation and evaluation of nursing care plans done by the students. A try
out on this guideline assumes to benefit both the student and faculty.
Anchored from the proposed guidelines is the suggested nursing care plan
format that was modified from traditional nursing care plan format was made
to relay written information on the application of nursing process in the
student nursing care plan writing (see Appendix).
Reference:
Kozier, B., Erb, G., Berman, A., Fundamentals of Nursing Practice,
Synder, S. Concepts, Process and Practice
2004 Seventh Edition, Person Education
Inc., New Jersey
C.M.O. 14. Series of 2009 Policies and Standards for Bachelor of
Science in Nursing (BSN) Program
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16. Proposed Common Guidelines in the Preparation and Evaluation of Student Nursing Care Plans
APPENDIX -A
Suggested Student Nursing Care Plan Working Guide
Name of Patient: ___________________ Medical Diagnosis: _____________________
Age: ________ Room Number/ Hospital Department: _________________________
ASSESSMENT-
Primary Source of Data (statement from the Client’s complaints)- organized if
the statement talks about physical, developmental, psychological, spiritual,
sociocultural or environmental conditions
Physical: ____________________ Developmental: ________________________
Psychological: _________________Spiritual: ____________________________
Sociocultural: ______________ Environmental Conditions: ____________
Secondary Source of Data
Support People: ______________________
Cephalo-caudal Assessment- documentation of findings should be
written clearly on the spaces provided below
Integument: _________________________________
Head: _______________________________________
Neck: _______________________________________
Back: _______________________________________
Anterior Trunk: ______________________________________________
Abdomen: ___________________________________________________
Musculoskeletal System: _____________________________________
Neurologic System: ___________________________________________
Genitourinary System: ________________________________________
Other Observations: ___________________________
Vital Signs: RR-_____ T- _______ PR- _______ BP- _________
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17. Proposed Common Guidelines in the Preparation and Evaluation of Student Nursing Care Plans
Client’s Records:
Medical History: * (brief summary)
____________________________________________________________________________
____________________________________________________________________________
Therapeutics: *(must have possible relation to the significant cues)
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Laboratory Results:* (pertinent data that may relate to the significant cues)
____________________________________________________________________________
____________________________________________________________________________
Review of Related Literature about the Medical Diagnosis
____________________________________________________________________________
____________________________________________________________________________
________________________________________________________________________ *
(write the reference material used.)
Summary of Significant Cues
Subjective Data: __________________________
Objective Data: __________________________
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18. Proposed Common Guidelines in the Preparation and Evaluation of Student Nursing Care Plans
Organization of Data:
Put check marks on the space provided to organize the data gathered from
your assessments.
___ Care for Mother, Child and Family
___ Care for Mother, Child, Family and Population Group At risk or with Problems
___ Care of Clients with Problems in Oxygenation
___ Care of Clients with Problems in Fluid and Electrolytes Balance
___ Care of Clients with Problems in Metabolism and Endocrine
___ Care of Clients with Problems in Inflammatory and Immunologic Response
___ Care of the Clients with Problems in Perception and Coordination
___ Care of the Clients with Problems in Cellular Aberrations
___ Care of Clients with Problems in Acute Biologic Crisis
___ Emergency and Disaster Nursing
___ Nutrition and Diet Therapy
___ Pharmacology / Therapeutics
Thought Provoking Questions:
Had you clarified any vague or ambiguous statement of the client?
___YES ___NO
Had you double checked data with extremely abnormal results?
___YES ___NO
Explain the present patient’s situation briefly: *(write your reference)
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
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19. Proposed Common Guidelines in the Preparation and Evaluation of Student Nursing Care Plans
DIAGNOSIS
Does the significant cues compared against the standards:
o Growth and Development?
o Normal Vital Signs?
o Normal Laboratory Results?
___YES ___NO
Tentative hypothesis of the problem: __________________________
Thought Provoking Questions:
Are there any gaps or inconsistencies in the data collected? ___YES ___NO
Does the Nursing Diagnosis reflect accurate interpretation of the subjective
and objective data analyzed?
____YES ____NO
Final Nursing Diagnosis: Problem: _______________________________
Etiology: _______________________________
As evidenced by Signs and Symptoms: _____________________
PLANNING
Goals / Desired Outcome:
_________________________________________________________________________
Thought Provoking Questions:
Does the desired goals primarily address the problem? ___YES ___NO
Is the desired goals realistic for the client’s capabilitites? ___YES ____NO
Is it compatible with the therapies of other professionals? ___YES ____NO
Is your goal derived from only one Nursing Diagnosis? ___YES ___NO
Did you used obeservable, measurable terms on the desired outcome
statement? ___YES ___NO
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20. Proposed Common Guidelines in the Preparation and Evaluation of Student Nursing Care Plans
Did you included the subject, verb, conditions or modifiers and criterion
performance in the Goal/ desired outcome statement? ___YES ___NO
Specific Interventions:
Independent Interventions Dependent Interventions Collaborative Interventions
1. 1.
1.
2. 2.
2.
3. 3.
3.
4. 4.
4.
5. 5.
5.
*(number each interventions according to priority)
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21. Proposed Common Guidelines in the Preparation and Evaluation of Student Nursing Care Plans
Thought Provoking Questions
Were the interventions safe and appropriate for the individual’s age, health
and conditions? ___YES___NO
Were the interventions stated clearly achievable with the resources available?
___YES ___NO
Were the interventions congruent with the client’s values, beliefs and culture?
___YES ___NO
Cite the Rationale of Each Intervention- must contain scientific reasoning and
discussion of possible side effects or complication of the specific interventions.
Independent Dependent Intervention Collaborative
Intervention (Rationale) (Rationale ) Intervention
(Rationale )
1. 1. 1.
2. 2. 2.
3. 3. 3.
4. 4. 4.
5. 5. 5.
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22. Proposed Common Guidelines in the Preparation and Evaluation of Student Nursing Care Plans
IMPLEMENTATION
Must Know!
Reassess the client before implementing the intervention, making sure if
it is still needed. ____Done _____Not done
Determine the need for assistance: ____Done ___Not done
Implement Safe Care: ____Done _____Not done
Encourage active participation of the client in the implementation of
interventions:
___Done ___Not done
Write the Documentation of Care in Narrative Form- Implementation of
care must be reflected according to the plans you’ve constructed above.
______________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
EVALUATION:
Activity: Collection of data using the desired outcome as a guide.
Restate the desired outcome: __________________________________________
Evaluation Data Collected :
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
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23. Proposed Common Guidelines in the Preparation and Evaluation of Student Nursing Care Plans
Thought Provoking Question:
Do the nursing activities/ interventions implemented have relation to
the present outcome of patient?
_____ YES ___NO
State if the goal was met, partially met or not met and explain why:
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Good Job!!! You can now summarize your written care plan on the suggested
student nursing care plan format.
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24. Proposed Common Guidelines in the Preparation and Evaluation of Student Nursing Care Plans
APPENDIX –B
Suggested Nursing Care Plan Output Format
Name of Patient: ____________ Age: ____Medical Diagnosis: _________________
Hospital Department: __________________ Room: ___________Date: _______
ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION EVALUATION
Desired THIS COLUMN WILL Contents on
Subjective Outcome: BE THE ACTUAL this column
Data: NARRATIVE will include
DOCUMENTATION discussion on
Problem OF THE STUDENTS the progress of
_____________ ON THE patient in
Etiology IMPLEMENTATION relation to the
_____________ OF PLANNED CARE. goals and
Objective Data: Signs and Interventions: stated outcome
symptoms / criteria.
Defining
Objectives
______________
Name of the Student: ___________________________
Clinical Instructor: _____________________________
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25. Proposed Common Guidelines in the Preparation and Evaluation of Student Nursing Care Plans
24