Guideline of Writing Clinical Nursing Diagnosis and Nursing Care Plan

Abstract

Developing guideline of writing clinical nursing diagnosis and nursing care plan is significant to be a guide or tool in writing clinical nursing diagnosis and nursing care plan for nurses and nursing students. When nurses and nursing students use this guideline, it can help them in improving optimal decision making, planning, and implementation. Moreover, writing clinical nursing diagnosis and nursing care plan based on accuracy will increase the standard of care for the nursing profession. As a result, patients are safe and have no complications, as well as patients and families are satisfied with the quality of care that is more standard. Writing clinical nursing diagnosis and nursing care plan being high quality should comprise 6 domains, including 1) setting topics of nursing diagnosis that have 3 parts including problems, causes, and pathologies; 2) supportive data come from a variety of resources such as history, physical examination, vital signs, and laboratory results; 3) purpose of nursing diagnosis is what expects will occur after providing nursing activities; 4) evaluation criteria that should be related with supportive data; 5) nursing activities that should be holistic care including physical, psychological, emotional, social, and spiritual care; and 6) evaluation that should be related with evaluation criteria.