Crafting an effective nursing care plan is a cornerstone of quality patient care. It’s a systematic approach that not only pinpoints current patient needs but also anticipates potential health risks. This guide will walk you through the essential steps of developing a robust nursing care plan, with a particular focus on integrating NANDA-I diagnoses for precise and standardized care. Whether you are a student nurse or a seasoned professional, this comprehensive resource provides a detailed walkthrough, examples, and objectives to help you master the art of writing exceptional nursing care plans. We also include downloadable templates to streamline your workflow.
Understanding the Nursing Care Plan
A nursing care plan (NCP) is more than just a document; it’s a dynamic blueprint for patient care. It serves as a formalized process where nurses accurately identify existing patient needs and proactively address potential risks. Crucially, it acts as a vital communication tool, ensuring seamless coordination among nurses, patients, and the broader healthcare team. This shared understanding is paramount for achieving consistent and positive healthcare outcomes. Without a structured nursing care planning process, the consistency and quality of patient care would be significantly compromised, potentially leading to fragmented and less effective treatments.
The nursing care planning process is not static; it begins at the moment of patient admission and evolves continuously. It’s a living document that is regularly updated to reflect changes in the patient’s condition and the ongoing evaluation of their progress toward set goals. This dedication to individualized, patient-centered care is the bedrock of excellence in nursing practice. It ensures that each patient receives care that is specifically tailored to their unique circumstances and needs.
Types of Nursing Care Plans: Formal vs. Informal, Standardized vs. Individualized
Nursing care plans exist on a spectrum, ranging from informal mental notes to detailed, written documents.
- Informal Nursing Care Plans: These are essentially mental strategies, existing within the nurse‘s mind. They represent quick, on-the-spot adjustments to care based on immediate patient needs.
- Formal Nursing Care Plans: In contrast, formal care plans are documented guides, either written or computerized, that systematically organize all aspects of a patient’s care. These are essential for ensuring consistency and clarity, especially in complex care scenarios.
Formal care plans are further categorized to meet diverse patient needs and clinical settings:
- Standardized Care Plans: These are pre-written guides designed for groups of patients with common, recurring needs. They streamline care for typical conditions, ensuring that all patients with similar diagnoses receive a baseline level of quality care.
- Individualized Care Plans: These are customized plans that adapt standardized care plans to address a specific patient’s unique requirements. They are essential for patients whose needs are not fully met by standard protocols, allowing for personalized interventions and goals.
Delving Deeper: Standardized vs. Individualized Care Plans
Standardized Care Plans are invaluable tools in healthcare settings, acting as pre-approved protocols developed by nursing staff and healthcare agencies. They are designed to guarantee consistent care for patients facing common health challenges. By setting a minimum standard of care, they also optimize nurses’ efficiency, eliminating the need to repeatedly create plans for routine patient needs within a nursing unit.
However, it’s crucial to recognize that standardized care plans are not designed to be a perfect fit for every patient. They serve as an excellent starting point, a foundational framework that must often be adapted to create a truly individualized care plan.
The care plan examples presented in this guide are primarily standardized care plans. They are intended to provide a solid foundation upon which nurses can build individualized plans tailored to their patients’ specific needs.
Individualized Care Plans take patient care to a more personal level. They involve carefully adjusting a standardized care plan to align with the unique needs and goals of each patient. This approach emphasizes using strategies known to be effective for that particular individual, considering their specific circumstances, preferences, and health status. This level of customization is critical for delivering truly holistic care, which addresses the patient as a whole, encompassing their physical, emotional, social, and spiritual well-being.
Moreover, individualized care plans are directly linked to improved patient satisfaction. When patients perceive that their care is specifically designed for them, they feel more valued and understood. This heightened sense of personal attention significantly boosts their satisfaction with the healthcare experience. In today’s healthcare environment, where patient satisfaction is a key indicator of quality, the ability to create and implement individualized care plans is more important than ever.
Tips for Individualizing Nursing Care Plans:
- Thorough Assessment: Begin with a detailed and comprehensive assessment to fully understand the patient’s unique needs, preferences, and goals.
- Patient Involvement: Actively involve the patient in the care planning process. Their input is crucial for creating a plan that is both effective and acceptable to them.
- Flexibility: Be prepared to modify the standardized plan based on the patient’s response to interventions and changes in their condition.
- Focus on Strengths: Identify and build upon the patient’s strengths and resources to promote their active participation in their care.
- Cultural Sensitivity: Consider the patient’s cultural background, beliefs, and values when tailoring the care plan.
- Realistic Goals: Set achievable and realistic goals that are meaningful to the patient and contribute to their overall well-being.
- Regular Review: Continuously review and update the care plan to ensure it remains relevant and effective throughout the patient’s care journey.
By following these tips, nurses can transform standardized plans into highly individualized roadmaps for care, optimizing patient outcomes and satisfaction.
Objectives of Nursing Care Plans
The objectives of creating nursing care plans are multifaceted, all aimed at enhancing the quality and effectiveness of patient care. Key objectives include:
- Promoting Evidence-Based Care: Nursing care plans facilitate the integration of the latest research and best practices into patient care, ensuring that interventions are grounded in solid evidence. They help create consistent and predictable healthcare experiences across different settings.
- Supporting Holistic Care: Care plans are designed to address the patient as a whole person, acknowledging the interconnectedness of physical, psychological, social, and spiritual aspects of health. This holistic approach is essential for effective disease management and prevention.
- Establishing Care Pathways and Bundles: Nursing care plans are instrumental in developing structured programs like care pathways and care bundles. Care pathways foster teamwork to standardize care and outcomes, while care bundles focus on implementing best practices for specific conditions.
- Defining Goals and Expected Outcomes: A crucial objective is to clearly differentiate and articulate both broad goals and specific, measurable expected outcomes for patient care. This clarity is essential for guiding interventions and evaluating progress.
- Improving Communication and Documentation: Care plans serve as a framework for enhancing communication among healthcare providers and for ensuring thorough documentation of the care provided. This is vital for continuity of care and legal accountability.
- Measuring Nursing Care Effectiveness: By outlining specific goals and outcomes, care plans provide a benchmark for measuring the effectiveness of nursing interventions and the overall quality of care delivered.
Purposes and Importance of Nursing Care Plans
Nursing care plans are not merely procedural documents; they serve several critical purposes that significantly enhance patient care and the nursing profession. Their importance can be highlighted in the following key areas:
- Defining the Nurse’s Role: Care plans clarify and emphasize the unique, independent role of nurses in patient care. They highlight the nurse’s responsibility in addressing patients’ overall health and well-being, going beyond simply following physician’s orders.
- Providing Direction for Individualized Patient Care: A care plan acts as a detailed roadmap for patient care, guiding nurses to think critically and develop interventions that are specifically tailored to each patient’s unique needs and circumstances.
- Ensuring Continuity of Care: By documenting care plans, nurses across different shifts and departments can maintain consistent care quality and intervention strategies. This consistency ensures patients receive the maximum benefit from their treatment, regardless of who is on duty.
- Coordinating Care Across Disciplines: Care plans facilitate effective communication and coordination among all members of the healthcare team. By ensuring everyone is aware of the patient’s needs and planned actions, care plans prevent gaps in service and promote a unified approach.
- Serving as a Documentation Tool: Care plans are essential for documentation. They accurately outline necessary observations, nursing actions, and instructions for the patient and family members. Proper documentation in the care plan is critical; if care isn’t documented, it’s legally considered as not having been provided.
- Guiding Staff Assignments: In situations where patients require specialized care, care plans help in assigning staff with the precise skills needed. This ensures that patients receive care from professionals best equipped to meet their specific needs.
- Monitoring Patient Progress: Care plans provide a structured way to track a patient’s progress and make necessary adjustments to the care strategy as their condition evolves or their goals change.
- Supporting Reimbursement Processes: Insurance companies often rely on medical records, including care plans, to determine the extent of reimbursement for hospital care. Well-documented care plans can therefore impact the financial aspects of healthcare delivery.
- Defining Patient Goals and Promoting Engagement: By involving patients in the development of their care plans, nurses empower them to become active participants in their treatment. This collaborative approach benefits both nurses and patients, fostering a sense of shared responsibility and improved outcomes.
Key Components of a Nursing Care Plan
A comprehensive nursing care plan typically includes several core components, each playing a vital role in guiding patient care. These elements are usually organized to provide a clear and structured approach to planning and delivering nursing interventions. The standard components of a nursing care plan (NCP) are:
- Nursing Diagnoses: These are clinical judgments about individual, family, or community responses to actual and potential health problems or life processes. Nursing diagnoses, often based on NANDA (North American Nursing Diagnosis Association) classifications, provide a standardized language for nurses to identify and address patient needs.
- Patient Problems: This section describes the health issues or challenges the patient is currently facing. It may include medical diagnoses as well as other health-related problems identified through nursing assessment.
- Expected Outcomes: These are specific, measurable, achievable, relevant, and time-bound (SMART) goals that define the desired changes in patient health status as a result of nursing care. They are derived from the nursing diagnoses and set the direction for nursing interventions.
- Nursing Interventions: These are the actions that nurses will implement to achieve the expected outcomes. Interventions should be evidence-based, tailored to the individual patient, and designed to address the root causes of the nursing diagnoses.
- Rationales: For each nursing intervention, a rationale provides the scientific basis or evidence explaining why that particular intervention is appropriate and effective for achieving the desired outcome. Rationales are particularly important in student care plans as they reinforce the link between nursing actions and patient outcomes.
Common Nursing Care Plan Formats
Nursing care plans can be structured in various formats, often categorized by the number of columns used to organize the information. The most common formats are three-column and four-column plans. Some agencies may also use a five-column format.
Three-Column Format
The three-column format is a streamlined approach that includes:
- Nursing Diagnosis: Clearly stated, often using NANDA terminology.
- Outcomes and Evaluation: Combines desired patient outcomes with the criteria for evaluating whether these outcomes have been met.
- Interventions: Lists the specific nursing actions to be implemented.
This format is concise and effective for quick reference, especially in settings where nurses are familiar with standard care protocols.
Example of a three-column nursing care plan format.
Four-Column Format
The four-column format provides a more detailed and structured approach:
- Nursing Diagnosis: As in the three-column format, this column states the nursing diagnosis.
- Goals and Outcomes: Separates goals (broad statements of desired change) from specific, measurable outcomes.
- Interventions: Details the nursing actions planned.
- Evaluation: Focuses specifically on how and when the outcomes will be evaluated.
This format is particularly useful for complex cases and in educational settings where a more thorough and explicit plan is beneficial.
Example of a four-column nursing care plan template.
You can download sample templates for various nursing care plan formats using this link:
Download: Printable Nursing Care Plan Templates and Formats
Student Care Plans: A Detailed Learning Tool
Student care plans are intentionally more detailed and comprehensive than those used by practicing nurses. This added depth serves a critical learning purpose, helping student nurses develop a thorough understanding of the care planning process.
Student nursing care plans are designed to be highly detailed for learning purposes.
Typically, student care plans are handwritten and include an additional column for “Rationale” or “Scientific Explanation.” This rationale column requires students to articulate the scientific principles that underpin each nursing intervention, reinforcing their understanding of the why behind nursing actions.
Step-by-Step Guide: Writing a Nursing Care Plan
Creating a nursing care plan is a systematic process that involves several key steps, each building upon the previous one to create a comprehensive and effective plan. Here’s a detailed guide on how to write a nursing care plan (NCP) effectively:
Step 1: Data Collection and Comprehensive Assessment
The initial step in crafting a nursing care plan is thorough data collection and patient assessment. This involves creating a comprehensive client database using various assessment techniques and data collection methods. These methods include:
- Physical Assessment: A hands-on examination to evaluate the patient’s physical health status.
- Health History: Gathering detailed information about the patient’s past and present health conditions, treatments, and related factors.
- Patient Interview: Direct communication with the patient to understand their perspective, symptoms, concerns, and health goals.
- Medical Records Review: Examining the patient’s medical charts for historical data, previous diagnoses, and treatment records.
- Diagnostic Studies: Analyzing results from laboratory tests, imaging, and other diagnostic procedures.
A complete client database encompasses all pertinent health information gathered through these methods. During this phase, nurses identify related or risk factors and defining characteristics that will be crucial for formulating accurate nursing diagnoses. Many healthcare facilities and nursing schools provide specific assessment formats to guide this process, ensuring all necessary data points are covered.
Critical thinking is paramount in patient assessment. It involves integrating knowledge from various scientific disciplines and professional guidelines to inform evaluations. This cognitive process is essential for complex clinical decision-making, aiming to effectively identify patients’ healthcare needs within a supportive environment and using reliable information.
Step 2: Data Analysis and Organization
Once you have compiled a comprehensive dataset about the patient’s health, the next step is to analyze, cluster, and organize this data. This analytical phase is crucial for:
- Identifying Patterns: Look for recurring themes or clusters of symptoms and health issues.
- Prioritizing Problems: Determine which health issues are most pressing and require immediate attention.
- Formulating Nursing Diagnoses: Based on the analyzed data, begin to identify appropriate nursing diagnoses that accurately reflect the patient’s needs and problems.
- Setting Desired Outcomes: Start thinking about what you hope to achieve for the patient in terms of health improvement and problem resolution.
Organizing data might involve grouping related symptoms together, such as all symptoms related to respiratory distress or pain management. This structured approach ensures that no critical information is overlooked and sets the stage for accurate diagnosis and effective planning.
Step 3: Formulating NANDA Nursing Diagnoses
Nursing diagnoses are standardized, professional judgments that describe a patient’s health problems or potential problems that nurses are licensed and competent to treat. They provide a uniform language for nurses to communicate about patient needs and responses to health conditions. These diagnoses focus on actual or potential health problems that can be prevented or resolved through independent nursing interventions.
For standardized terminology, nurses often use the NANDA-I (North American Nursing Diagnosis Association International) system. NANDA-I provides a comprehensive classification of nursing diagnoses, which helps ensure consistency and clarity in care planning and documentation.
We offer a detailed guide on formulating nursing diagnoses, including examples and a comprehensive list, in our dedicated resource: Nursing Diagnosis (NDx): Complete Guide and List. This resource can further assist you in understanding and applying NANDA diagnoses effectively.
Step 4: Setting Priorities for Nursing Diagnoses
Setting priorities involves ranking nursing diagnoses in order of importance. This step is crucial because it determines the sequence in which nursing interventions will be addressed. The nurse, in collaboration with the patient, decides which problems require immediate attention. Diagnoses are typically categorized into high, medium, or low priority.
- High Priority: These are life-threatening problems that require immediate intervention to maintain patient safety and well-being. Examples include compromised airway, breathing, or circulation (ABCs).
- Medium Priority: These are problems that are not immediately life-threatening but could cause significant discomfort or complications if not addressed promptly. Examples include acute pain, risk of infection, or impaired mobility.
- Low Priority: These are problems that are important for the patient’s long-term well-being but do not require immediate intervention. Examples include knowledge deficit, mild anxiety, or long-term rehabilitation needs.
Maslow’s Hierarchy of Needs is a useful framework for prioritizing nursing diagnoses. Developed by Abraham Maslow in 1943, this hierarchy categorizes human needs into five levels, arranged in a pyramid. Basic physiological needs must be met before higher-level needs can be addressed.
Maslow’s Hierarchy of Needs in Nursing:
-
Basic Physiological Needs: These are the most fundamental needs essential for survival. In a nursing context, this includes:
- Nutrition (water and food)
- Elimination (toileting)
- Airway, Breathing, Circulation (ABCs – including suctioning, oxygen administration, cardiac monitoring, and blood pressure management)
- Sleep
- Sex
- Shelter
- Exercise
-
Safety and Security Needs: Once physiological needs are met, safety and security become paramount. This includes:
- Injury prevention (side rails, call lights, hand hygiene, isolation protocols, suicide precautions, fall precautions, car seats, helmets, seat belts)
- Creating a climate of trust and safety (therapeutic relationship)
- Patient education about safety measures and risk factors (e.g., modifiable risk factors for stroke, heart disease)
-
Love and Belonging Needs: These involve social connections and emotional support:
- Fostering supportive relationships
- Strategies to avoid social isolation (addressing issues like bullying)
- Employing active listening techniques
- Therapeutic communication
- Addressing needs related to sexual intimacy
-
Self-Esteem Needs: These pertain to feelings of self-worth and accomplishment:
- Promoting acceptance within the community and workplace
- Recognizing personal achievements
- Fostering a sense of control or empowerment
- Encouraging acceptance of one’s physical appearance and body image
-
Self-Actualization Needs: This is the highest level, focused on personal growth and fulfillment:
- Providing an empowering environment
- Supporting spiritual growth
- Encouraging the ability to consider different viewpoints
- Facilitating the patient in reaching their maximum potential
Virginia Henderson’s 14 Needs as applied to Maslow’s Hierarchy of Needs. Learn more about it here.
When setting priorities, also consider the patient’s health values, beliefs, available resources, and the urgency of the health issue. Patient involvement in this process is crucial to enhance cooperation and ensure the care plan aligns with their personal priorities.
Step 5: Establishing Patient Goals and Desired Outcomes
After prioritizing nursing diagnoses, the next step is to set goals and desired outcomes for each priority diagnosis. Goals or desired outcomes describe what the nurse aims to achieve through nursing interventions. They serve several critical functions:
- Direction for Interventions: Goals guide the planning of specific nursing interventions.
- Evaluation Criteria: They provide measurable criteria for evaluating patient progress.
- Problem Resolution Indicators: They help determine when a problem has been resolved.
- Motivation for Patient and Nurse: They provide a sense of achievement and progress, motivating both the patient and the nursing team.
Examples of well-written goals and desired outcomes for a nursing care plan.
Typically, one overall goal is established for each nursing diagnosis. The terms “goal outcomes” and “expected outcomes” are often used interchangeably.
Effective goals should be SMART, a widely used acronym in healthcare:
- Specific: Goals must be clear, detailed, and unambiguous.
- Measurable: Progress towards goals must be quantifiable and trackable.
- Attainable: Goals should be achievable given the patient’s current condition and resources.
- Realistic: Goals must be relevant to the patient’s needs and circumstances, and practically achievable within the healthcare setting.
- Time-Oriented: Each goal should have a defined timeframe for achievement.
Additionally, goals should adhere to the REEPIG standards, which emphasize high-quality care planning:
- Realistic: Achievable with available resources.
- Explicitly Stated: Clearly articulated to avoid misinterpretation.
- Evidence-Based: Supported by research and best practices.
- Prioritized: Addressing the most urgent needs first.
- Involve: Including the patient and multidisciplinary team members in planning.
- Goal-Centered: Directly contributing to the set goals.
Short-Term and Long-Term Goals
Goals and expected outcomes must be measurable and patient-centered. They should focus on problem prevention, resolution, and rehabilitation. Goals are further classified as short-term or long-term:
- Short-Term Goals: These are achievable within a short period, typically hours to a few days, especially in acute care settings where immediate needs are prioritized.
- Long-Term Goals: These are objectives to be achieved over a longer duration, weeks to months, and are common for patients with chronic conditions or those in long-term care facilities.
- Discharge Planning Goals: These long-term goals are crucial for planning patient care beyond the hospital setting, promoting continued recovery and problem resolution through home health services, physical therapy, or other referrals.
Components of Well-Formed Goals and Desired Outcomes
A well-structured goal or desired outcome statement typically includes four components:
- Subject: Usually the patient, or a specific part or attribute of the patient (e.g., pulse rate, temperature, urinary output). Often implied as “patient” unless referring to family or significant others.
- Verb: Specifies the action the patient is expected to perform, learn, or experience.
- Conditions or Modifiers: Clarify “what, when, where, or how” the behavior should be performed, providing context.
- Criterion of Desired Performance: Defines the standard for evaluating performance or the level at which the patient should perform the behavior. This is often optional but adds precision.
Key components to include when writing effective goals and desired outcomes in a nursing care plan.
Tips for Writing Effective Goals and Desired Outcomes:
- Frame goals in terms of patient responses, not nurse activities. Start with “Patient will […].”
- Focus on what the patient will do, not what the nurse hopes to achieve.
- Use observable and measurable terms, avoiding vague language.
- Ensure outcomes are realistic given the patient’s resources, abilities, and time frame.
- Verify goals are compatible with other healthcare professionals’ therapies.
- Derive each goal from only one nursing diagnosis to facilitate clear evaluation.
- Confirm that the patient values and considers the goals important to ensure cooperation.
Step 6: Selecting and Implementing Nursing Interventions
Nursing interventions are the specific actions a nurse performs to help patients achieve their goals. These interventions should be strategically chosen to address the etiology of the nursing diagnosis. For risk diagnoses, interventions focus on reducing risk factors. While interventions are identified in the planning phase of the nursing process, they are actually carried out during the implementation phase.
Types of Nursing Interventions
Nursing interventions can be categorized into three types:
The three main types of nursing interventions used in patient care plans.
-
Independent Nursing Interventions: These are actions nurses are authorized to initiate based on their professional judgment and skills. They include:
- Ongoing patient assessment
- Emotional support
- Providing comfort measures
- Patient and family teaching
- Physical care
- Referrals to other healthcare professionals
-
Dependent Nursing Interventions: These interventions require a physician’s order or supervision. They include:
- Administering medications
- Intravenous therapy
- Diagnostic tests
- Medical treatments
- Dietary orders
- Activity and rest orders
- Nurses are also responsible for assessment and patient education related to these dependent interventions.
-
Collaborative Interventions: These are actions carried out in coordination with other healthcare team members such as physicians, social workers, dietitians, and therapists. These interventions leverage the expertise of multiple disciplines to provide comprehensive care.
Effective Nursing Interventions should be:
- Safe and appropriate for the patient’s age, health condition, and overall status.
- Achievable given available resources and time constraints.
- Aligned with the patient’s values, cultural background, and beliefs.
- Compatible with other planned therapies.
- Grounded in nursing knowledge, experience, and relevant scientific evidence.
Tips for Writing Nursing Interventions:
- Date and sign the care plan to ensure accountability and track planning progress.
- Write specific and clear interventions, starting with an action verb that indicates what the nurse should do. Add qualifiers detailing how, when, where, how often, and in what amount.
- Example: “Educate parents on how to accurately measure temperature using a digital thermometer and when to seek medical advice for temperature changes.”
- Example: “Assess urine every shift for color, amount, odor, and turbidity, and document findings in the patient’s chart.”
- Use only institution-approved abbreviations to maintain clarity and avoid errors.
Step 7: Providing Rationales for Interventions
Rationales, or scientific explanations, justify why a particular nursing intervention was selected. They explain the scientific principles behind the intervention and how it is expected to achieve the desired outcome.
Example of nursing interventions paired with their scientific rationales.
While rationales are typically included in student care plans to enhance learning and understanding, they are not always a standard component of care plans used by practicing nurses in clinical settings. They are valuable for nursing students as they help connect pathophysiological and psychological principles to nursing practice.
Step 8: Evaluation of the Nursing Care Plan
Evaluation is a crucial, ongoing process to assess the patient’s progress toward achieving the set goals and to determine the effectiveness of the nursing care plan (NCP). It is an integral part of the nursing process that helps decide whether to continue, modify, or terminate specific nursing interventions.
Evaluation involves:
- Assessing Goal Achievement: Determining if the patient has met the desired outcomes outlined in the care plan.
- Analyzing Intervention Effectiveness: Evaluating whether the nursing interventions are producing the intended results.
- Making Necessary Modifications: Based on the evaluation, adjusting the care plan as needed, which may include changing interventions, setting new goals, or addressing new nursing diagnoses.
Step 9: Documenting the Nursing Care Plan
The final step is to document the patient’s care plan according to hospital policy. This documentation becomes part of the patient’s permanent medical record, accessible to all members of the healthcare team, including oncoming nurses. Different nursing programs and healthcare facilities may have varying formats for care plan documentation, but most are designed to systematically follow the steps of the nursing process. Many institutions use a five-column format to ensure all aspects of the care plan are clearly documented.
Comprehensive Nursing Care Plan List
Below is an extensive list of sample nursing care plans (NCPs) and nursing diagnoses categorized by medical specialties and health conditions. This list is designed to provide a broad overview and quick access to care plans relevant to various clinical scenarios.
Basic Nursing and General Care Plans
These care plans cover general nursing needs and conditions that do not fit neatly into 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
These care plans are designed for patients undergoing surgical interventions.
| 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
These plans focus on diseases and conditions 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
These NCPs address disorders of 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
These care plans cover disorders of the 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
These care plans focus on disorders of the blood and lymphatic systems.
| 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 Care Plans
These NCPs are 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 Care Plans
These care plans address conditions affecting the skin and related tissues.
| Integumentary Care Plans |
|---|
| Burn Injury |
| Dermatitis |
| Herpes Zoster (Shingles) |
| Pressure Ulcer (Bedsores) |
| Wound Care and Skin/Tissue Integrity |
Maternal and Newborn Care Plans
These care plans are for pregnant mothers and newborns, covering 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
These care plans are 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
These care plans address disorders of 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 Care Plans
These NCPs are for disorders of the nervous system.
| 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
These care plans relate to eye disorders.
| Ophthalmic Care Plans |
|---|
| Cataracts |
| Glaucoma |
| Macular Degeneration |
Pediatric Nursing Care Plans
These NCPs are 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
These care plans address disorders of the reproductive and sexual functions.
| Reproductive Care Plans |
|---|
| Cryptorchidism (Undescended Testes) |
| Hysterectomy |
| Hypospadias and Epispadias |
| Mastectomy |
| Menopause |
| Prostatectomy |
Respiratory Care Plans
These care plans are for disorders of the respiratory system.
| 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
These care plans are for disorders of the kidneys and urinary system.
| 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 for Nursing Care Plans
To further enhance your understanding and skills in creating nursing care plans, consider these highly recommended resources:
Disclosure: The following are affiliate links from Amazon.com. We may earn a small commission if you purchase through these links, at no extra cost to you. For more details, please see our privacy policy.
Ackley and Ladwig’s Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care
This handbook is invaluable for its evidence-based approach to nursing interventions. It simplifies care planning with a three-step system covering assessment, diagnosis, and planning. It also includes detailed instructions on implementing care and evaluating outcomes, crucial for developing diagnostic reasoning and critical thinking skills.
Nursing Care Plans – Nursing Diagnosis & Intervention (10th Edition)
This comprehensive guide features over 200 care plans based on the latest evidence-based guidelines. The new edition includes ICNP diagnoses and care plans addressing LGBTQ health issues, and electrolyte and acid-base balance.
Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales
A quick and essential reference tool for identifying correct diagnoses and efficient care planning. The 16th edition is updated with the latest nursing diagnoses and interventions, alphabetically listed and covering over 400 disorders.
Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care
This manual aids in planning, individualizing, and documenting care for over 800 diseases and disorders. It uniquely offers subjective and objective data for each diagnosis, sample applications, prioritized interventions with rationales, and detailed documentation guidance.
This resource includes over 100 care plans across medical-surgical, maternity/OB, pediatrics, and psychiatric-mental health nursing. It emphasizes interprofessional “patient problems” to improve patient communication and care coordination.
References and Further Reading
To ensure the accuracy and depth of this nursing care plan guide, we have consulted a range of reputable sources and materials within the nursing and healthcare fields.
