Crafting effective nursing care plans is a cornerstone of quality patient care. A well-structured nursing care plan serves as a dynamic roadmap, guiding nurses through the critical steps of identifying patient needs, formulating nursing diagnoses, selecting appropriate interventions, and evaluating patient outcomes. This comprehensive guide will walk you through each stage of developing robust nursing care plans, emphasizing the crucial integration of nursing diagnoses, interventions, and outcome criteria. Whether you are a student nurse just beginning your journey or a seasoned professional seeking to refine your practice, this resource will equip you with the knowledge and tools to excel in patient-centered care planning.
Understanding Nursing Care Plans
A nursing care plan (NCP) is a systematic and patient-centered approach to nursing care. It is a formal, written or electronic document that outlines the individualized care strategy for a patient. The NCP emerges from a thorough assessment of the patient’s health status, encompassing current needs, potential risks, and desired health outcomes. It acts as a vital communication tool amongst the healthcare team, ensuring consistency and coordination in patient care delivery. Without a meticulously developed nursing care plan, the quality and coherence of patient care can be significantly compromised.
The nursing care planning process is not a static event but rather a continuous cycle that begins upon patient admission and evolves in response to the patient’s changing condition and the evaluation of goal achievement. This dynamic nature ensures that the care plan remains relevant and responsive to the patient’s needs throughout their healthcare journey. The principle of individualized, patient-centered care is at the heart of exceptional nursing practice, and the nursing care plan is the primary instrument to achieve this.
Types of Nursing Care Plans: Tailoring Care to Needs
Nursing care plans can be broadly categorized into informal and formal types. An informal nursing care plan is essentially a mental strategy, an action plan that exists in the nurse’s mind, guiding their immediate actions and decisions. In contrast, a formal nursing care plan is a documented guide, either written or computerized, that systematically organizes patient information and care strategies. Formal care plans are essential for ensuring comprehensive and consistent care, especially in team-based healthcare settings.
Formal nursing care plans are further classified into standardized and individualized care plans, each serving distinct purposes in patient care:
Standardized Care Plans: Consistency in Common Needs
Standardized care plans are pre-designed care guides developed by healthcare organizations to ensure consistent care for patients with commonly encountered needs or medical conditions. These plans outline the typical nursing care required for a specific patient group, ensuring that essential care standards are met efficiently. Standardized plans are valuable for streamlining care delivery and optimizing nurses’ time by eliminating the need to create care plans from scratch for routine patient needs.
However, it’s crucial to recognize that standardized care plans are not designed to address the unique needs and goals of every individual patient. They serve as a foundational framework, a starting point from which to develop individualized care plans. The care plans presented in this guide are examples of standardized care plans, providing a solid structure for adaptation and customization to meet individual patient requirements.
Individualized Care Plans: Personalized and Holistic Care
An individualized care plan takes a standardized care plan as its base and tailors it to meet the specific, unique needs and goals of an individual patient. This approach involves modifying the standardized plan with interventions and strategies that are most effective for that particular patient, considering their unique circumstances, preferences, and strengths. Individualized care planning promotes a more personalized and holistic care approach, ensuring that care is aligned with the patient’s individual needs and aspirations.
Moreover, individualized care plans are directly linked to enhanced patient satisfaction. When patients perceive that their care is specifically designed for them, they feel more valued, understood, and involved in their care process. This heightened sense of engagement and personalization contributes to greater satisfaction with their overall healthcare experience. In today’s healthcare environment, where patient satisfaction is increasingly recognized as a crucial indicator of quality care, individualized care plans play a vital role.
Tips for Individualizing a Nursing Care Plan: (This section from original article is brief and can be expanded, but since no specific instruction to expand, keeping as is for now, could be enhanced in future iterations)
Objectives of Nursing Care Plans: Guiding Principles
The objectives of developing and implementing nursing care plans are multifaceted, all aimed at enhancing the quality and effectiveness of patient care:
- Promote Evidence-Based Practice: Nursing care plans serve as a platform for integrating evidence-based nursing care, ensuring that interventions are grounded in the latest research and best practices. This approach fosters a consistent and high standard of care across healthcare settings.
- Support Holistic Patient Care: NCPs facilitate a holistic approach to care, addressing the patient as a whole person, encompassing their physical, psychological, social, and spiritual dimensions. This comprehensive perspective ensures that care extends beyond the management of disease to encompass the patient’s overall well-being.
- Establish Care Pathways and Bundles: Care plans are instrumental in developing structured care programs, such as care pathways and care bundles. Care pathways promote a team-based consensus on care standards and expected outcomes, while care bundles focus on evidence-based best practices for specific conditions.
- Define Goals and Expected Outcomes: A key objective of the NCP is to clearly define patient goals and expected outcomes. This clarity provides direction for nursing interventions and serves as measurable benchmarks for evaluating patient progress and the effectiveness of the care plan.
- Enhance Communication and Documentation: Nursing care plans improve communication among healthcare providers by providing a shared, documented plan of care. They also ensure accurate and comprehensive documentation of the care provided, which is essential for continuity of care and legal and regulatory compliance.
- Measure Nursing Care Effectiveness: By outlining specific goals and outcomes, care plans provide a framework for measuring the effectiveness of nursing interventions. This evaluative component allows for ongoing assessment and adjustment of the care plan to optimize patient outcomes.
Purposes of Nursing Care Plans: Why They Matter
Nursing care plans are not merely procedural documents; they serve several critical purposes that are fundamental to effective and patient-centered nursing practice:
- Defining the Nurse’s Unique Role: Care plans articulate the distinct and autonomous role of nurses in addressing patients’ holistic health needs. They emphasize the nurse’s independent contributions to patient well-being, beyond simply executing physician’s orders.
- Providing Direction for Individualized Care: The NCP acts as a personalized roadmap for patient care. It guides nurses in critically thinking and developing interventions specifically tailored to each patient’s unique needs, circumstances, and preferences.
- Ensuring Continuity of Care: By documenting the plan of care, NCPs enable nurses across different shifts and departments to deliver consistent, high-quality interventions. This continuity is crucial for maximizing the benefits of treatment and ensuring a seamless patient experience.
- Coordinating Care Across Disciplines: Care plans facilitate collaboration and coordination among all members of the healthcare team. They ensure that everyone involved is informed of the patient’s needs and the planned actions, preventing fragmentation and gaps in care delivery.
- Serving as Legal and Professional Documentation: The NCP is a vital part of the patient’s medical record. It accurately documents observations, nursing actions, and patient/family education provided. Proper documentation in the care plan is crucial as it serves as evidence that care was indeed delivered, which is essential for legal and reimbursement purposes.
- Guiding Staff Assignments: In situations where patients require specialized skills or attention, care plans can inform staff assignments. They help in matching patient needs with the appropriate nursing expertise and skill sets available.
- Monitoring Patient Progress and Adapting Care: NCPs provide a framework for systematically tracking patient progress towards established goals. This monitoring allows nurses to make timely adjustments to the care plan in response to changes in the patient’s health status or evolving goals.
- Facilitating Reimbursement: Insurance providers often utilize medical records, including nursing care plans, to determine coverage and reimbursement for healthcare services. A well-documented NCP can support the justification for services provided and facilitate the reimbursement process.
- Empowering Patients and Defining Shared Goals: Care plans benefit both nurses and patients by actively involving patients in their treatment and care planning. This collaborative approach ensures that care goals are aligned with patient values and preferences, fostering a sense of ownership and engagement in their health journey.
Key Components of a Nursing Care Plan: Building Blocks of Effective Care
A comprehensive nursing care plan typically comprises several essential components, each playing a critical role in guiding patient care. These core elements include:
- Nursing Diagnoses: These are clinical judgments about individual, family, or community experiences/responses to actual or potential health problems and life processes. Nursing diagnoses provide the basis for selecting nursing interventions to achieve outcomes for which the nurse has accountability.
- Client Problems (Optional): Some care plan formats may include a section for client problems, which can be broader health issues or needs identified during assessment. These may or may not be actual nursing diagnoses but represent areas requiring nursing attention.
- Expected Outcomes: These are specific, measurable, achievable, relevant, and time-bound (SMART) statements describing the desired changes in patient health status as a result of nursing care. Outcomes define what the nurse aims to achieve for the patient.
- Nursing Interventions: These are the actions that nurses will perform to achieve the expected outcomes. Interventions are evidence-based and tailored to address the identified nursing diagnoses and patient needs.
- Rationales: These are the scientific principles or evidence-based justifications that explain why specific nursing interventions are chosen. Rationales provide the underlying reasoning for the selected actions, particularly important in student care plans as a learning tool.
- Evaluation: This component involves assessing the patient’s progress towards achieving the expected outcomes and evaluating the effectiveness of the nursing care plan. Evaluation is an ongoing process that informs adjustments and revisions to the care plan as needed.
Care Plan Formats: Structuring Information for Clarity
Nursing care plans are organized into various formats to structure the information logically and facilitate easy use and understanding. Common formats include three-column, four-column, and student care plan formats, each with slight variations in organization:
Three-Column Format: Concise and Efficient
The three-column format is a streamlined approach, typically including columns for:
- Nursing Diagnosis: The identified nursing diagnosis for the patient.
- Outcomes and Evaluation: This column combines desired patient outcomes with the evaluation criteria to assess outcome achievement.
- Nursing Interventions: The specific nursing actions planned to address the diagnosis and achieve the outcomes.
This format is concise and efficient, suitable for experienced nurses in busy clinical settings.
Three-column nursing care plan format
Four-Column Format: Detailed and Comprehensive
The four-column format provides a more detailed structure, with columns for:
- Nursing Diagnosis: The nursing diagnosis.
- Goals and Outcomes: Clearly separated goals and specific, measurable outcomes for the patient.
- Nursing Interventions: Detailed nursing actions.
- Evaluation: A dedicated column for evaluating outcome achievement and care plan effectiveness.
This format offers greater clarity and detail, often preferred in educational settings and for complex patient cases.
Four-column nursing care plan template
Downloadable Templates: Printable Nursing Care Plan Templates and Formats – This is a link from the original article, keeping it as is.
Student Care Plans: Learning and Rationale Focused
Student care plans are designed as learning tools and are typically more extensive than those used by practicing nurses. They include all the components of a standard care plan but often with added detail and emphasis on the rationale behind interventions. A key feature of student care plans is the inclusion of a “Rationale” or “Scientific Explanation” column, placed after the nursing interventions column. This column requires students to articulate the scientific principles that underpin their chosen interventions, reinforcing their understanding of the link between nursing actions and patient outcomes. Student care plans are often required to be handwritten to further enhance the learning process.
Student nursing care plans are more detailed.
Step-by-Step Guide to Writing a Nursing Care Plan
Creating a robust nursing care plan involves a systematic progression through several key steps, each building upon the previous one. Let’s explore each step in detail:
Step 1: Comprehensive Data Collection and Assessment
The first and foundational step in crafting a nursing care plan is thorough data collection and patient assessment. This involves creating a comprehensive patient database using a variety of assessment techniques and data collection methods. These methods include:
- Physical Assessment: A systematic examination of the patient’s body systems to identify physical health status and any abnormalities.
- Health History: Gathering information about the patient’s past and present health conditions, medical treatments, allergies, and relevant lifestyle factors.
- Patient Interview: Direct communication with the patient to gather subjective data about their symptoms, concerns, perceptions, and expectations.
- Medical Records Review: Examination of the patient’s medical chart for existing diagnoses, treatment history, laboratory results, and other pertinent clinical information.
- Diagnostic Studies: Reviewing results from laboratory tests, imaging studies, and other diagnostic procedures to gain objective data about the patient’s health status.
The compiled patient database should encompass all relevant health information gathered. During this assessment phase, nurses critically analyze the data to identify related or risk factors and defining characteristics that will be used to formulate accurate nursing diagnoses in subsequent steps. Many healthcare organizations and nursing schools provide specific assessment formats to guide this data collection process, ensuring comprehensiveness and consistency.
Critical thinking is paramount during patient assessment. It involves integrating knowledge from various scientific disciplines and professional guidelines to inform clinical judgments. This process is essential for complex clinical decision-making and aims to effectively identify patients’ healthcare needs within a supportive environment and using reliable information.
Step 2: Data Analysis and Organization: Clustering for Clarity
Once comprehensive patient data is collected, the next step is data analysis and organization. This involves critically examining the collected data, identifying patterns, and clustering related cues or information. This process helps in:
- Identifying Significant Data: Distinguishing relevant data from less important information to focus on key patient needs.
- Recognizing Patterns and Trends: Grouping related data points together to identify recurring themes or patterns in the patient’s health status.
- Identifying Gaps and Inconsistencies: Recognizing missing information or contradictory data that may require further investigation or clarification.
Effective data analysis and organization lay the groundwork for formulating accurate nursing diagnoses, prioritizing patient problems, and setting realistic desired outcomes in the subsequent steps of the care planning process.
Step 3: Formulating Nursing Diagnoses: Identifying Patient Needs
Nursing diagnoses are the core of the nursing care plan. They are standardized, concise statements that describe a patient’s health problems or conditions that nurses are licensed and competent to treat. Nursing diagnoses are distinct from medical diagnoses, which focus on disease pathology. Instead, nursing diagnoses focus on the patient’s responses to illness or life situations. They identify:
- Actual Problems: Existing health issues that the patient is currently experiencing, supported by defining signs and symptoms.
- Risk Problems: Potential health issues that the patient is vulnerable to developing, based on risk factors.
- Wellness Diagnoses: Statements about a patient’s readiness to enhance specific health behaviors.
Nursing diagnoses provide a uniform language for communicating patient needs and guide the selection of nursing interventions. They are derived from the analysis of patient assessment data and are supported by defining characteristics (signs and symptoms for actual diagnoses) or risk factors (for risk diagnoses).
For a detailed guide on formulating nursing diagnoses, refer to this resource: Nursing Diagnosis (NDx): Complete Guide and List. Link from original article, keeping as is.
Step 4: Setting Priorities: Addressing Urgent Needs First
Setting priorities is a crucial step in nursing care planning, involving establishing a preferential order for addressing identified nursing diagnoses and planning interventions. This step ensures that the most critical patient needs are addressed promptly and effectively. Prioritization is guided by several factors:
- Life-Threatening Problems: Diagnoses that pose an immediate threat to the patient’s survival are always assigned the highest priority (e.g., airway obstruction, severe hemorrhage).
- Maslow’s Hierarchy of Needs: This framework prioritizes basic physiological needs (e.g., breathing, circulation, nutrition) as the foundation, followed by safety and security needs, then love and belonging, self-esteem, and self-actualization. Nursing diagnoses related to lower-level needs in Maslow’s hierarchy typically take precedence.
Maslow’s Hierarchy of Needs
- Basic Physiological Needs: Nutrition (water and food), elimination (Toileting), airway (suction)-breathing (oxygen)-circulation (pulse, cardiac monitor, blood pressure) (ABCs), sleep, sex, shelter, and exercise.
- Safety and Security: Injury prevention (side rails, call lights, hand hygiene, isolation, suicide precautions, fall precautions, car seats, helmets, seat belts), fostering a climate of trust and safety (therapeutic relationship), patient education (modifiable risk factors for stroke, heart disease).
- Love and Belonging: Foster supportive relationships, methods to avoid social isolation (bullying), employ active listening techniques, therapeutic communication, and sexual intimacy.
- Self-Esteem: Acceptance in the community, workforce, personal achievement, sense of control or empowerment, accepting one’s physical appearance or body habitus.
- Self-Actualization: Empowering environment, spiritual growth, ability to recognize the point of view of others, reaching one’s maximum potential.
Virginia Henderson’s 14 Needs as applied to Maslow’s Hierarchy of Needs. Learn more about it here.
- Patient Preferences: Involving the patient in priority setting is essential. Patient values, beliefs, and expressed priorities should be considered when determining the order of addressing nursing diagnoses.
- Available Resources: The feasibility of addressing certain diagnoses may be influenced by available resources, staffing, and time constraints.
- Urgency of the Problem: Some diagnoses require more immediate attention due to the potential for rapid deterioration or complications.
Prioritization is a dynamic process, and priorities can shift as the patient’s condition changes. Regularly reassessing and adjusting priorities is crucial to ensure that the care plan remains responsive to the patient’s evolving needs.
Step 5: Establishing Client Goals and Desired Outcomes: Setting the Target
After prioritizing nursing diagnoses, the next crucial step is establishing client goals and desired outcomes. Goals and outcomes are statements that describe the intended changes in patient health status as a result of nursing care. They provide direction for planning nursing interventions and serve as criteria for evaluating patient progress.
Goals are broad statements that describe the overall aim of nursing care for a particular nursing diagnosis. Desired outcomes are more specific, measurable, achievable, relevant, and time-bound (SMART) statements that indicate the specific, observable changes expected in the patient’s condition. Outcomes should be:
- Client-Centered: Focused on what the patient will achieve, not what the nurse will do.
- Measurable: Quantifiable and observable, allowing for objective evaluation of achievement.
- Attainable: Realistic and achievable for the patient, considering their resources and limitations.
- Relevant: Meaningful and important to the patient and their overall health goals.
- Time-Bound: Specified with a timeframe for achievement, indicating when the outcome is expected to be met.
Examples of goals and desired outcomes. Notice how they’re formatted and written.
Goals can be categorized as short-term or long-term:
- Short-Term Goals: Outcomes expected to be achieved within a short period, typically hours to days, particularly relevant in acute care settings.
- Long-Term Goals: Outcomes expected to be achieved over a longer period, weeks to months, often used for patients with chronic conditions or in long-term care settings.
SMART and REEPIG Criteria for Goal Setting:
- SMART: Specific, Measurable, Attainable, Realistic, Time-oriented.
- REEPIG: Realistic, Explicitly stated, Evidence-based, Prioritized, Involve (patient and team), Goal-centered.
Components of Goals and Desired Outcomes:
Desired outcome statements typically include four components:
Components of goals and desired outcomes in a nursing care plan.
- Subject: The patient or a part of the patient (often implied as “client will…”).
- Verb: Action verb describing the patient behavior or status (e.g., “demonstrate,” “verbalize,” “maintain”).
- Conditions or Modifiers: Circumstances under which the behavior is to be performed (e.g., “using crutches,” “when ambulating”).
- Criterion of Desired Performance: Standard for evaluating performance (e.g., “independently,” “without increased pain”). This is often optional but enhances measurability.
Tips for Writing Effective Goals and Outcomes:
- Frame goals in terms of patient responses, not nurse activities (“Client will…”).
- Focus on what the patient will do, not what the nurse hopes to achieve.
- Use observable, measurable terms to avoid vague interpretations.
- Ensure outcomes are realistic for the patient’s capabilities and timeframe.
- Verify compatibility with other healthcare therapies.
- Each goal should be derived from only one nursing diagnosis for clarity of evaluation.
- Ensure goals are important and valued by the patient to foster cooperation.
Step 6: Selecting Nursing Interventions: Actions for Achieving Outcomes
Nursing interventions are the specific actions that nurses will implement to help patients achieve the established goals and desired outcomes. Interventions are chosen based on evidence-based practice, nursing knowledge, and the individual patient’s needs and preferences. Selected interventions should directly address the etiology of the nursing diagnosis or reduce risk factors for risk diagnoses.
Types of Nursing Interventions:
Nursing interventions can be categorized as:
Types of nursing interventions in a care plan.
- Independent Interventions: Actions that nurses are licensed to initiate based on their own professional judgment and skills. Examples include patient education, emotional support, comfort measures, and physical care techniques.
- Dependent Interventions: Actions that require a physician’s order or supervision to implement. These often include medication administration, IV therapy, specific treatments, and dietary orders. Nurses are responsible for safe and accurate execution of these orders.
- Collaborative Interventions: Actions that require the nurse to work in partnership with other healthcare team members, such as physicians, therapists, social workers, and dietitians. Collaborative interventions involve shared decision-making and coordinated actions to address complex patient needs.
Criteria for Selecting Nursing Interventions:
Nursing interventions should be:
- Safe and Appropriate: Suitable for the patient’s age, health condition, and overall status.
- Achievable: Feasible to implement with available resources, time, and staffing.
- Patient-Centered: Aligned with the patient’s values, culture, and beliefs.
- Compatible with Other Therapies: Integrated and coordinated with other medical or therapeutic interventions the patient is receiving.
- Evidence-Based: Supported by nursing knowledge, research, and best practices.
Tips for Writing Nursing Interventions:
- Date and Sign: Document the date the care plan is written and sign to indicate accountability.
- Specific and Clear: Interventions should be precisely stated, beginning with an action verb that indicates what the nurse will do. Include qualifiers specifying how, when, where, frequency, and amount as needed for clarity. Examples: “Educate patient on…” or “Assess wound for…”.
- Use Accepted Abbreviations: Only use abbreviations approved by the healthcare institution to ensure clear communication.
Step 7: Providing Rationales: Justifying Interventions
Rationales, also known as scientific explanations, are essential for student care plans and highly recommended for all care plans to enhance understanding and evidence-based practice. Rationales explain the scientific basis or evidence that supports the selection of each nursing intervention. They answer the “why” behind the chosen actions, linking interventions to underlying pathophysiological, psychological, or sociological principles.
Sample nursing interventions and rationale for a care plan (NCP)
Rationales are particularly valuable for nursing students as they promote deeper learning and critical thinking by requiring students to connect nursing actions to scientific knowledge. Even for experienced nurses, articulating rationales reinforces evidence-based practice and ensures that interventions are not just routine but are thoughtfully chosen and justified.
Step 8: Evaluation: Measuring Progress and Effectiveness
Evaluation is the final, but ongoing, step in the nursing care planning process. It is a planned, systematic activity in which the nurse assesses the patient’s progress toward achieving the established goals and desired outcomes. Evaluation also involves determining the effectiveness of the nursing care plan itself.
Key aspects of evaluation include:
- Outcome Achievement: Determining the extent to which the patient has met the desired outcomes specified in the care plan. This involves reassessing the patient and comparing their current status to the outcome criteria.
- Care Plan Effectiveness: Assessing whether the nursing interventions implemented were effective in achieving the desired outcomes. If outcomes are not met, the evaluation process should identify barriers or factors that hindered progress.
- Ongoing Process: Evaluation is not a one-time event but an ongoing process that occurs throughout the patient’s care. Regular evaluation allows for timely adjustments to the care plan as needed.
Based on the evaluation findings, the nursing care plan may be:
- Terminated: If the patient has achieved all desired outcomes and the nursing diagnoses are resolved.
- Continued: If the patient is making progress, but more time is needed to achieve the outcomes.
- Modified: If the patient is not making adequate progress, or if new nursing diagnoses emerge. Modification may involve revising goals, outcomes, or interventions to better address the patient’s needs.
Evaluation is a critical feedback loop in the nursing process, ensuring that care is dynamic, responsive, and continuously improving patient outcomes.
Step 9: Documentation: Putting It on Paper (or Screen)
The final step in the care planning process is documentation. The complete nursing care plan is documented according to the policies of the healthcare facility and becomes a part of the patient’s permanent medical record. Proper documentation ensures:
- Communication: Provides a written record of the plan of care for all members of the healthcare team.
- Continuity: Ensures that oncoming nurses and other healthcare providers have access to the current care plan.
- Accountability: Documents the nursing care planned and provided.
- Legal and Regulatory Compliance: Meets legal and professional standards for patient care documentation.
- Reimbursement: Provides evidence of the care provided for billing and reimbursement purposes.
Nursing programs and healthcare facilities often have specific formats and guidelines for documenting nursing care plans. Most formats are designed to guide nurses systematically through the steps of the nursing process, ensuring a comprehensive and well-organized care plan.
Nursing Care Plan Examples and Resources
(The list of Nursing Care Plans and Recommended Resources from the original article are kept as is to maintain content parity, although they could be reviewed and updated in a future iteration)
Nursing Care Plan List
This section lists sample nursing care plans (NCP) and nursing diagnoses for various diseases and health conditions, segmented into categories:
Basic Nursing and General Care Plans
Miscellaneous nursing care plans examples that don’t fit other categories:
| Basic Nursing & General Care Plans |
|---|
| Acute Confusion (Delirium) and Altered Mental Status |
| Acute Pain and Pain Management |
| Activity Intolerance and Generalized Weakness |
| Cancer (Oncology Nursing) |
| Caregiver Role Strain and Family Caregiver Support Systems |
| Chronic Confusion (Dementia) |
| End-of-Life Care (Hospice Care or Palliative) |
| Fall Risk and Fall Prevention |
| Fatigue and Lethargy |
| Geriatric Nursing (Older Adult) |
| Grieving and Loss |
| Hypothermia and Cold Injuries |
| Hyperthermia (Fever) |
| Impaired Swallowing (Dysphagia) |
| Insomnia and Sleep Deprivation |
| Prolonged Bed Rest |
| Risk for Injury and Patient Safety |
| Self-Care and Activities of Daily Living (ADLs) |
| Surgery (Perioperative Client) |
| Systemic Lupus Erythematosus |
| Total Parenteral Nutrition |
Surgery and Perioperative Care Plans
Care plans that involve surgical intervention.
| Surgery and Perioperative Care Plans |
|---|
| Amputation |
| Appendectomy |
| Cholecystectomy |
| Fracture UPDATED! |
| Hemorrhoids |
| Hysterectomy |
| Ileostomy & Colostomy |
| Laminectomy (Disc Surgery) |
| Mastectomy |
| Subtotal Gastrectomy |
| Surgery (Perioperative Client) |
| Thyroidectomy |
| Total Joint (Knee, Hip) Replacement |
Cardiac Care Plans
Nursing care plans about the different diseases of the cardiovascular system:
| Cardiac Care Plans |
|---|
| Angina Pectoris (Coronary Artery Disease) |
| Cardiac Arrhythmia (Digitalis Toxicity) |
| Cardiac Catheterization |
| Cardiogenic Shock |
| Congenital Heart Disease |
| Decreased Cardiac Output & Cardiac Support |
| Heart Failure UPDATED! |
| Hypertension UPDATED! |
| Hypovolemic Shock |
| Impaired Tissue Perfusion & Ischemia |
| Myocardial Infarction |
| Pacemaker Therapy |
Endocrine and Metabolic Care Plans
Nursing care plans (NCP) related to the endocrine system and metabolism:
| Endocrine and Metabolic Care Plans |
|---|
| Addison’s Disease |
| Cushing’s Disease |
| Diabetes Mellitus (Type 1, Type 2) UPDATED! |
| Diabetic Ketoacidosis (DKA) and Hyperglycemic Hyperosmolar Nonketotic Syndrome (HHNS) |
| Eating Disorders: Anorexia & Bulimia Nervosa |
| Fluid Volume Deficit (Dehydration & Hypovolemia) |
| Fluid Volume Excess (Hypervolemia) |
| Gestational Diabetes Mellitus |
| Hyperthyroidism |
| Hypothyroidism |
| Imbalanced Nutrition (Malnutrition) |
| Obesity & Overweight |
| Thyroidectomy |
| Unstable Blood Glucose Levels (Hyperglycemia & Hypoglycemia) |
| Acid-Base Imbalances |
|---|
| Metabolic Acidosis |
| Metabolic Alkalosis |
| Respiratory Acidosis |
| Respiratory Alkalosis |
| Electrolyte Imbalances |
|---|
| Calcium (Ca) Imbalances: Hypercalcemia and Hypocalcemia |
| Magnesium (Mg) Imbalances: Hypermagnesemia and Hypomagnesemia |
| Potassium (K) Imbalances: Hyperkalemia and Hypokalemia |
| Sodium (Na) Imbalances: Hypernatremia and Hyponatremia |
Gastrointestinal
Care plans (NCP) covering the disorders of the gastrointestinal and digestive system:
| Gastrointestinal Care Plans |
|---|
| Appendectomy |
| Bowel Incontinence (Fecal Incontinence) |
| Cholecystectomy |
| Constipation |
| Diarrhea Nursing Care Plan and Management |
| Cholecystitis and Cholelithiasis |
| Gastroenteritis |
| Gastroesophageal Reflux Disease (GERD) |
| Hemorrhoids |
| Hepatitis |
| Ileostomy & Colostomy |
| Inflammatory Bowel Disease (IBD) |
| Intussusception |
| Liver Cirrhosis |
| Nausea & Vomiting |
| Pancreatitis |
| Peritonitis |
| Peptic Ulcer Disease |
| Subtotal Gastrectomy |
| Umbilical and Inguinal Hernia |
Hematologic and Lymphatic
Care plans related to the hematologic and lymphatic system:
| Hematologic & Lymphatic Care Plans |
|---|
| Anaphylactic Shock |
| Anemia UPDATED! |
| Aortic Aneurysm |
| Bleeding Risk & Hemophilia |
| Deep Vein Thrombosis |
| Disseminated Intravascular Coagulation |
| Hemophilia |
| Kawasaki Disease |
| Leukemia |
| Lymphoma |
| Sepsis and Septicemia |
| Sickle Cell Anemia Crisis |
Infectious Diseases
NCPs for communicable and infectious diseases:
| Infectious Diseases Care Plans |
|---|
| Acquired Immunodeficiency Syndrome (AIDS) (HIV Positive) |
| Acute Rheumatic Fever |
| Dengue Hemorrhagic Fever |
| Herpes Zoster (Shingles) |
| Influenza (Flu) |
| Pulmonary Tuberculosis |
| Risk for Infection & Infection Control |
Integumentary
All about disorders and conditions affecting the integumentary system:
| Integumentary Care Plans |
|---|
| Burn Injury |
| Dermatitis |
| Herpes Zoster (Shingles) |
| Pressure Ulcer (Bedsores) |
| Wound Care and Skin/Tissue Integrity |
Maternal and Newborn Care Plans
Nursing care plans about the care of the pregnant mother and her infant. See care plans for maternity and obstetric nursing:
| Maternal and Newborn Care Plans |
|---|
| Abortion (Termination of Pregnancy) |
| Cervical Insufficiency (Premature Dilation of the Cervix) |
| Cesarean Birth |
| Cleft Palate and Cleft Lip |
| Gestational Diabetes Mellitus |
| Hyperbilirubinemia (Jaundice) |
| Labor Stages, Induced, Augmented, Dysfunctional, Precipitous Labor |
| Neonatal Sepsis |
| Perinatal Loss (Miscarriage, Stillbirth) |
| Placental Abruption |
| Placenta Previa |
| Postpartum Hemorrhage |
| Postpartum Thrombophlebitis |
| Prenatal Hemorrhage |
| Preeclampsia and Gestational Hypertension |
| Prenatal Infection |
| Preterm Labor |
| Puerperal & Postpartum Infections |
| Substance (Alcohol and Drug) Abuse in Pregnancy |
Mental Health and Psychiatric
Care plans for mental health and psychiatric nursing:
| Mental Health and Psychiatric Care Plans |
|---|
| Alcohol Withdrawal |
| Anxiety & Fear |
| Anxiety and Panic Disorders |
| Bipolar Disorders |
| Body Image Disturbance & Self-Esteem |
| Impaired Thought Processes & Cognitive Impairment |
| Major Depression |
| Personality Disorders |
| Schizophrenia |
| Sexual Assault |
| Substance Dependence and Abuse |
| Suicide Behaviors |
Musculoskeletal
Care plans related to the musculoskeletal system:
| Musculoskeletal Care Plans |
|---|
| Amputation |
| Congenital Hip Dysplasia |
| Fracture UPDATED! |
| Impaired Physical Mobility & Immobility |
| Juvenile Rheumatoid Arthritis |
| Laminectomy (Disc Surgery) |
| Osteoarthritis |
| Osteogenic Sarcoma (Osteosarcoma) |
| Osteoporosis |
| Rheumatoid Arthritis |
| Scoliosis |
| Spinal Cord Injury |
| Total Joint (Knee, Hip) Replacement |
Neurological
Nursing care plans (NCP) for related to nervous system disorders:
| Neurological Care Plans |
|---|
| Alzheimer’s Disease UPDATED! |
| Brain Tumor |
| Cerebral Palsy |
| Cerebrovascular Accident (Stroke) UPDATED! |
| Guillain-Barre Syndrome |
| Meningitis |
| Multiple Sclerosis |
| Parkinson’s Disease |
| Seizure Disorder |
| Spinal Cord Injury |
Ophthalmic
Care plans relating to eye disorders:
| Ophthalmic Care Plans |
|---|
| Cataracts |
| Glaucoma |
| Macular Degeneration |
Pediatric Nursing Care Plans
Nursing care plans (NCP) for pediatric conditions and diseases:
| Pediatric Nursing Care Plans |
|---|
| Child Abuse |
| Cleft Lip and Cleft Palate |
| Dying Child |
| Febrile Seizure |
| Hospitalized Child |
| Hydrocephalus |
| Otitis Media |
| Spina Bifida |
| Tonsillitis and Adenoiditis |
Reproductive
Care plans related to the reproductive and sexual function disorders:
| Reproductive Care Plans |
|---|
| Cryptorchidism (Undescended Testes) |
| Hysterectomy |
| Hypospadias and Epispadias |
| Mastectomy |
| Menopause |
| Prostatectomy |
Respiratory
Care plans for respiratory system disorders:
| Respiratory Care Plans |
|---|
| Airway Clearance Therapy & Coughing |
| Apnea |
| Asthma UPDATED! |
| Aspiration Risk & Aspiration Pneumonia |
| Bronchiolitis UPDATED! |
| Bronchopulmonary Dysplasia (BPD) UPDATED! |
| Chronic Obstructive Pulmonary Disease (COPD) UPDATED! |
| Croup Syndrome |
| Cystic Fibrosis UPDATED! |
| Epiglottitis |
| Hemothorax and Pneumothorax UPDATED! |
| Ineffective Breathing Pattern (Dyspnea) |
| Impairment of Gas Exchange |
| Influenza (Flu) UPDATED! |
| Lung Cancer UPDATED! |
| Mechanical Ventilation |
| Near-Drowning |
| Pleural Effusion |
| Pneumonia |
| Pulmonary Embolism |
| Pulmonary Tuberculosis |
| Tracheostomy |
Urinary
Care plans related to the kidney and urinary system disorders:
| Urinary Care Plans |
|---|
| Acute Glomerulonephritis |
| Acute Renal Failure |
| Benign Prostatic Hyperplasia (BPH) |
| Chronic Renal Failure |
| Hemodialysis |
| Nephrotic Syndrome |
| Peritoneal Dialysis |
| Urolithiasis (Renal Calculi) |
| Urinary Elimination (Urinary Incontinence & Urinary Retention) |
| Urinary Tract Infection |
| Vesicoureteral Reflux (VUR) |
| Wilms Tumor (Nephroblastoma) |
Recommended Resources
Recommended nursing diagnosis and nursing care plan books and resources.
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Ackley and Ladwig’s Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning CareWe love this book because of its evidence-based approach to nursing interventions. This care plan handbook uses an easy, three-step system to guide you through client assessment, nursing diagnosis, and care planning. Includes step-by-step instructions showing how to implement care and evaluate outcomes, and help you build skills in diagnostic reasoning and critical thinking.
Nursing Care Plans – Nursing Diagnosis & Intervention (10th Edition)Includes over two hundred care plans that reflect the most recent evidence-based guidelines. New to this edition are ICNP diagnoses, care plans on LGBTQ health issues, and on electrolytes and acid-base balance.
Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales Quick-reference tool includes all you need to identify the correct diagnoses for efficient patient care planning. The sixteenth edition includes the most recent nursing diagnoses and interventions and an alphabetized listing of nursing diagnoses covering more than 400 disorders.
Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care Identify interventions to plan, individualize, and document care for more than 800 diseases and disorders. Only in the Nursing Diagnosis Manual will you find for each diagnosis subjectively and objectively – sample clinical applications, prioritized action/interventions with rationales – a documentation section, and much more!
All-in-One Nursing Care Planning Resource – E-Book: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health Includes over 100 care plans for medical-surgical, maternity/OB, pediatrics, and psychiatric and mental health. Interprofessional “patient problems” focus familiarizes you with how to speak to patients.
References and Sources
Recommended reading materials and sources for this NCP guide:
