Nursing care plans (NCPs) are the cornerstone of quality patient care, providing a structured, systematic approach to address patient needs and achieve desired health outcomes. At the heart of every effective NCP lies accurate and comprehensive Diagnosis For Nursing Care Plan. This guide delves into the critical role of diagnosis in nursing care planning, offering a step-by-step approach to creating superior care plans that are both patient-centered and outcome-driven.
Understanding Nursing Care Plans
A nursing care plan (NCP) is more than just a document; it’s a dynamic tool that guides nurses in delivering holistic and individualized care. It is a formal process that involves identifying a patient’s existing health needs, potential risks, and desired outcomes. NCPs serve as a vital communication bridge between nurses, patients, and the interdisciplinary healthcare team, ensuring everyone is aligned in the patient’s care journey. Without a well-defined nursing care planning process, the consistency and quality of patient care can be significantly compromised.
The nursing care planning process is not a one-time event but a continuous cycle. It begins upon a patient’s admission and is regularly updated based on the patient’s changing condition and the evaluation of progress towards established goals. This ongoing adaptation ensures that the care plan remains relevant and effective throughout the patient’s healthcare experience. Delivering patient-centered care through meticulous planning is fundamental to excellence in nursing practice.
Types of Nursing Care Plans: Formal and Informal
Nursing care plans can be broadly categorized into informal and formal plans:
- Informal Nursing Care Plans: These are mental strategies or action plans that a nurse develops and keeps in their mind. They are often based on experience and quick assessments, suitable for routine situations but lack the structured documentation and communication benefits of formal plans.
- Formal Nursing Care Plans: These are documented, written or computerized guides that systematically organize patient care information. Formal care plans are essential for complex cases, ensuring continuity of care, and facilitating communication among healthcare providers.
Formal care plans are further divided into standardized and individualized care plans:
Standardized Care Plans: Consistency in Common Needs
Standardized care plans are pre-written guides developed by healthcare agencies and nursing staff to ensure consistent care for patients with common, recurring needs or medical conditions. These plans provide a baseline of care, ensuring that essential criteria are met efficiently. They are particularly useful in streamlining nursing workflows and saving time by eliminating the need to create care plans from scratch for every patient with similar needs.
Standardized care plans, while efficient, are not designed to address the specific nuances of each patient’s unique situation. They serve as a starting point, a template that must be adapted and personalized to create a truly effective individualized care plan.
Individualized Care Plans: Tailoring Care to Unique Needs
An individualized care plan involves customizing a standardized care plan to meet the specific needs, preferences, and goals of an individual patient. This approach recognizes that each patient is unique, with distinct health challenges, strengths, and aspirations. Individualized care plans incorporate approaches proven effective for a particular patient, ensuring a more personalized and holistic care experience.
Individualized care plans are not just about better clinical outcomes; they also significantly enhance patient satisfaction. When patients perceive that their care is tailored to their specific circumstances, they feel more valued, understood, and involved in their care. This heightened satisfaction is increasingly crucial in today’s healthcare landscape, where patient experience is a key metric of quality care.
Tips for Individualizing a Nursing Care Plan:
- Thorough Assessment: Go beyond the standardized assessment to understand the patient’s unique history, lifestyle, cultural background, and personal preferences.
- Patient Involvement: Actively involve the patient and their family in the care planning process. Their input is invaluable in identifying realistic goals and acceptable interventions.
- Flexibility: Be prepared to deviate from the standardized plan as needed. Patient responses and changing conditions may require adjustments to interventions and goals.
- Focus on Strengths: Identify and build upon the patient’s strengths and resources. This positive approach can empower patients and improve adherence to the care plan.
- Regular Review: Individualized care plans are not static. Regularly review and revise the plan based on patient progress, new information, and ongoing evaluation.
Objectives of Nursing Care Plans
The objectives of developing and implementing nursing care plans are multifaceted and aim to enhance the quality and effectiveness of patient care:
- Promote Evidence-Based Care: NCPs encourage the use of current best practices and research findings in patient care, ensuring that interventions are grounded in evidence and likely to be effective.
- Support Holistic Care: NCPs facilitate a holistic approach to care, addressing the patient’s physical, psychological, social, and spiritual needs. This comprehensive perspective recognizes the interconnectedness of these aspects in overall health and well-being.
- Establish Care Pathways and Bundles: NCPs provide a framework for developing structured care pathways, which involve multidisciplinary teams collaborating to define standards of care and expected outcomes for specific patient populations. They also support the implementation of care bundles, sets of evidence-based practices for specific conditions, ensuring consistent and optimal care delivery.
- Clearly Define Goals and Outcomes: NCPs necessitate the clear identification of both short-term and long-term goals and expected outcomes. This clarity provides direction for nursing interventions and allows for measurable evaluation of patient progress.
- Improve Communication and Documentation: NCPs serve as a central point of reference for communicating the patient’s care plan to all members of the healthcare team. They also provide a structured format for documenting care, ensuring accurate and comprehensive records.
- Measure Nursing Care Effectiveness: By outlining specific goals and interventions, NCPs provide a basis for evaluating the effectiveness of nursing care. This evaluation process allows for continuous improvement and refinement of care delivery.
Purposes and Importance of Nursing Care Plans
Nursing care plans are essential tools that serve several critical purposes in healthcare delivery:
- Defines the Nurse’s Role: NCPs clearly delineate the unique and independent role of nurses in patient care. They emphasize the nurse’s responsibility in addressing patients’ overall health and well-being, beyond simply following physician’s orders.
- Provides Direction for Individualized Care: NCPs act as a roadmap for patient care, guiding nurses to think critically and develop interventions tailored to each patient’s specific needs and circumstances.
- Ensures Continuity of Care: With a documented NCP, nurses across different shifts and departments can deliver consistent, high-quality interventions. This continuity maximizes the benefits of treatment for patients, regardless of which nurse is on duty.
- Coordinates Care Among Disciplines: NCPs ensure that all members of the healthcare team are informed of the patient’s needs and the planned actions. This coordinated approach prevents gaps in care and promotes efficient teamwork.
- Serves as Legal Documentation: NCPs are integral components of patient medical records. They document observations, nursing actions, and patient education provided. Accurate documentation in the NCP is legal evidence that care was delivered.
- Guides Staff Assignment: In situations where patients require specialized care, NCPs help in assigning staff with the necessary skills and expertise to meet those specific needs effectively.
- Monitors Patient Progress: NCPs facilitate the tracking of patient progress toward goals. Regular review of the NCP allows for timely adjustments to the plan in response to changes in the patient’s health status or goals.
- Supports Reimbursement: Insurance companies often review medical records, including NCPs, to determine the appropriateness and necessity of care provided, impacting reimbursement for healthcare services.
- Empowers Patients and Defines Goals: NCPs, when developed collaboratively with patients, involve them actively in their treatment and care. This collaborative approach ensures that care goals are aligned with patient values and preferences, increasing patient engagement and adherence.
Key Components of a Nursing Care Plan
A comprehensive nursing care plan typically includes several essential components:
- Nursing Diagnoses: These are clinical judgments about individual, family, or community responses to actual or potential health problems or life processes. Nursing diagnoses provide the foundation for selecting nursing interventions to achieve patient outcomes.
- Client Problems: This component may be used interchangeably with nursing diagnoses in some settings. It broadly describes the health issues or challenges the patient is facing.
- Expected Outcomes (Goals): 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.
- Nursing Interventions: These are the actions that nurses will implement to achieve the expected outcomes. Interventions should be evidence-based, individualized, and specific to the patient’s needs.
- Rationales: In some care plan formats, particularly in student care plans, rationales are included to explain the scientific basis or evidence supporting each nursing intervention.
- Evaluation: This is the process of assessing the patient’s progress towards achieving the expected outcomes. Evaluation helps determine the effectiveness of the care plan and guides necessary revisions.
Care Plan Formats: Structuring the NCP
Nursing care plans can be organized in various formats, often categorized by the number of columns used to present the information. Common formats include three-column, four-column, and sometimes five-column plans.
Three-Column Format
The three-column format is a streamlined approach that typically includes:
- Nursing Diagnosis: Clearly stated nursing diagnosis.
- Outcomes and Evaluation: Combined column for desired patient outcomes and evaluation criteria.
- Nursing Interventions: Specific nursing actions to be implemented.
This format is concise and focuses on the essential elements of the care plan.
Three-column nursing care plan format
Four-Column Format
The four-column format provides a more detailed structure, separating outcomes and evaluation into distinct columns:
- Nursing Diagnosis: Clearly stated nursing diagnosis.
- Goals and Outcomes: Specific, measurable patient goals and expected outcomes.
- Nursing Interventions: Detailed nursing actions.
- Evaluation: Criteria and methods for evaluating goal achievement.
This format offers greater clarity and emphasis on outcome measurement.
Four-column nursing care plan template
Downloadable Templates:
For practical use, various templates are available for different nursing care plan formats. These templates can be downloaded, edited, and shared to facilitate care planning.
Download: Printable Nursing Care Plan Templates and Formats
Student Care Plans: Detailed Learning Tools
Student care plans are typically more extensive and detailed than those used by practicing nurses. They serve as a critical learning tool for nursing students, helping them to develop comprehensive assessment, diagnostic, planning, and evaluation skills.
Student nursing care plans are more detailed.
Key features of student care plans often include:
- Handwritten Format: Often required to be handwritten to reinforce the learning process.
- Rationale Column: A dedicated column for “Rationale” or “Scientific Explanation” following the nursing interventions. This column requires students to justify their chosen interventions with scientific principles, deepening their understanding of the underlying reasons for care actions.
Step-by-Step Guide to Writing a Nursing Care Plan
Creating an effective nursing care plan involves a systematic, step-by-step process that mirrors the nursing process itself. Here’s a detailed guide:
Step 1: Data Collection or Assessment – The Foundation of Diagnosis
The initial step in developing a nursing care plan is thorough data collection or assessment. This involves creating a comprehensive patient database using various assessment techniques and methods. These include:
- Physical Assessment: A systematic examination of the patient’s body to identify physical signs and symptoms.
- Health History: Gathering information about the patient’s past and present health conditions, medications, allergies, and relevant lifestyle factors.
- Patient Interview: Direct communication with the patient to understand their perspective, concerns, and health goals.
- Medical Records Review: Examining the patient’s medical chart for physician’s notes, lab results, diagnostic reports, and previous care plans.
- Diagnostic Studies: Reviewing results from laboratory tests, imaging studies, and other diagnostic procedures.
A complete patient database encompasses all health-related information gathered from these sources. During this phase, nurses utilize critical thinking to identify patterns, inconsistencies, and significant data that will inform the nursing diagnosis. This includes recognizing related or risk factors and defining characteristics that will be used to formulate accurate nursing diagnoses. Many healthcare agencies and nursing schools provide specific assessment formats to guide this data collection process.
Critical thinking is paramount in patient assessment. It involves integrating knowledge from various scientific disciplines and professional guidelines to make informed 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 – Clustering for Clarity
Once comprehensive patient data is collected, the next step is data analysis and organization. This involves:
- Analyzing Data: Examining the collected data to identify significant findings, patterns, and potential health problems.
- Clustering Data: Grouping related data points together to identify themes and potential nursing diagnoses. For example, grouping data related to shortness of breath, fatigue, and edema might lead to a diagnosis related to impaired gas exchange or fluid volume overload.
- Organizing Data: Structuring the data in a logical manner, often using frameworks like body systems or functional health patterns, to facilitate the identification of nursing diagnoses, priorities, and desired outcomes.
This step transforms raw data into meaningful information that can be used to formulate nursing diagnoses and guide subsequent care planning steps.
Step 3: Formulating Nursing Diagnoses – Defining Patient Problems
Nursing diagnoses are standardized, concise statements that identify a patient’s health problems, risks, or vulnerabilities that nurses are qualified and licensed to treat. They provide a uniform language for communicating patient needs and focusing nursing care. Nursing diagnoses differ from medical diagnoses, which identify diseases; instead, nursing diagnoses describe the patient’s response to illness or health conditions. They focus on actual or potential health problems that nurses can independently address through nursing interventions.
For a detailed guide on formulating nursing diagnoses, refer to: Nursing Diagnosis (NDx): Complete Guide and List.
The process of formulating a nursing diagnosis typically involves:
- Identifying Problem: Recognizing a health issue or potential risk based on the assessment data.
- Stating the Diagnosis: Using standardized nursing diagnosis terminology (e.g., from NANDA-I) to clearly and concisely name the problem.
- Identifying Related Factors (Etiology): Determining the factors that are causing or contributing to the problem (“related to” statement).
- Defining Characteristics (Signs and Symptoms): Listing the evidence from the assessment data that supports the diagnosis (“as evidenced by” statement).
A well-formulated nursing diagnosis provides a clear direction for planning patient care.
Step 4: Setting Priorities – Addressing Urgent Needs First
Setting priorities is a crucial step in care planning, involving establishing a preferential order for addressing nursing diagnoses and implementing interventions. This step requires nurses to collaborate with the patient to determine which problems require immediate attention. Diagnoses are typically categorized and ranked by priority level:
- High Priority: Life-threatening problems or those that could cause significant harm if left untreated (e.g., impaired airway, ineffective breathing, acute pain).
- Medium Priority: Problems that are not immediately life-threatening but could cause significant discomfort or delay recovery (e.g., risk for infection, impaired skin integrity, knowledge deficit).
- Low Priority: Problems that are important for long-term well-being but do not require immediate attention (e.g., disturbed body image, readiness for enhanced learning).
Maslow’s Hierarchy of Needs provides a useful framework for prioritizing nursing diagnoses. This theory, developed by Abraham Maslow, organizes human needs into a pyramid, with basic physiological needs at the base and self-actualization at the peak. According to Maslow, lower-level needs must be met before higher-level needs can be effectively addressed.
Maslow’s Hierarchy of Needs in Nursing Priority Setting:
-
Physiological Needs (Highest Priority): These are fundamental needs for survival and physiological homeostasis. Examples include:
- Nutrition (fluids and food)
- Elimination (bowel and bladder function)
- Airway, Breathing, Circulation (ABCs)
- Sleep and Rest
- Comfort and Pain Relief
- Thermoregulation
-
Safety and Security Needs: These needs relate to physical and emotional safety and security. Examples include:
- Risk for Injury Prevention (falls, infection, accidents)
- Security of Environment
- Psychological Safety (trust, emotional stability)
-
Love and Belonging Needs: These needs involve social connection, intimacy, and belonging. Examples include:
- Social Interaction and Support
- Love and Affection
- Group Affiliation
-
Self-Esteem Needs: These needs relate to feelings of self-worth, confidence, and achievement. Examples include:
- Sense of Accomplishment
- Recognition and Respect
- Positive Self-Image
-
Self-Actualization Needs (Lowest Priority): These are the highest-level needs, relating to personal growth, fulfillment, and achieving one’s full potential. Examples include:
- Personal Growth and Development
- Creativity and Problem-Solving
- Spiritual Fulfillment
It’s important to note that patient values, beliefs, available resources, and the urgency of the health problem also influence priority setting. Patient involvement in this process is crucial to ensure cooperation and adherence to the care plan.
Step 5: Establishing Client Goals and Desired Outcomes – Defining Success
After prioritizing nursing diagnoses, the next step is to establish client goals and desired outcomes for each priority diagnosis. Goals and desired outcomes describe what the nurse aims to achieve through nursing interventions. They should be:
- Client-Centered: Focused on what the patient will achieve or experience.
- Measurable: Quantifiable and observable, allowing for evaluation of progress.
- Achievable: Realistic and attainable given the patient’s condition and resources.
- Relevant: Aligned with the patient’s values, needs, and overall health goals.
- Time-Bound: Specifying a timeframe for goal achievement.
Examples of goals and desired outcomes.
Goals can be categorized as short-term or long-term:
- Short-Term Goals: Achievable within a few hours to days, often focusing on immediate needs and stabilization.
- Long-Term Goals: Achievable over weeks or months, focusing on rehabilitation, chronic condition management, or discharge planning.
SMART criteria are widely used to guide the development of effective goals and desired outcomes:
- Specific: Clearly defined and focused.
- Measurable: Quantifiable and observable.
- Attainable: Realistic and achievable.
- Relevant: Patient-centered and meaningful.
- Time-Oriented: With a defined timeframe for achievement.
REEPIG standards further enhance the quality of goals:
- Realistic: Achievable with available resources.
- Explicitly Stated: Clearly and unambiguously written.
- Evidence-Based: Supported by research or best practices.
- Prioritized: Addressing the most urgent needs first.
- Involve Patient and Team: Developed collaboratively with the patient and healthcare team.
- Goal-Centered: Directly related to addressing the nursing diagnosis.
Components of Goal and Desired Outcome Statements:
- Subject: The patient (often implied).
- Verb: Action the patient will perform (e.g., “will verbalize,” “will demonstrate,” “will maintain”).
- Conditions or Modifiers: Circumstances under which the behavior will occur (e.g., “using pain scale,” “with assistance”).
- Criterion of Performance: Standard for evaluating performance (e.g., “pain level less than 3,” “maintain fluid intake of 1500ml/day”).
Components of goals and desired outcomes.
Tips for Writing Effective Goals and Desired Outcomes:
- Focus on patient responses, not nurse activities. Begin with “Client will…”
- Focus on what the patient will do, not what the nurse hopes to achieve.
- Use observable and measurable terms. Avoid vague language.
- Ensure outcomes are realistic for the patient’s capabilities and timeframe.
- Ensure goals are compatible with other therapies.
- Each goal should be derived from only one nursing diagnosis.
- Ensure the patient values and considers the goals important.
Step 6: Selecting Nursing Interventions – Actions for Goal Achievement
Nursing interventions are the specific actions a nurse will perform to help the patient achieve the established goals and desired outcomes. Interventions should be:
- Evidence-Based: Supported by research or best practices.
- Individualized: Tailored to the patient’s specific needs and circumstances.
- Specific and Clear: Describing exactly what the nurse will do, when, and how often.
- Safe and Appropriate: Considering the patient’s age, health condition, and other therapies.
- Achievable: Feasible with available resources and time.
- Aligned with Patient Values: Respecting the patient’s culture, beliefs, and preferences.
Types of nursing interventions.
Nursing interventions can be categorized as:
- Independent Interventions: Actions nurses are licensed to initiate based on their professional judgment and skills (e.g., patient education, emotional support, repositioning, monitoring vital signs).
- Dependent Interventions: Actions carried out under physician orders or supervision (e.g., medication administration, wound care, specific treatments).
- Collaborative Interventions: Actions implemented in collaboration with other healthcare team members (e.g., physical therapy, dietary consults, social work referrals).
Tips for Writing Nursing Interventions:
- Date and sign the care plan to indicate accountability and track revisions.
- Interventions should be specific and start with an action verb (e.g., “Assess,” “Administer,” “Educate,” “Monitor,” “Assist”).
- Include qualifiers to specify how, when, where, frequency, and amount of the intervention.
- Use only approved abbreviations within the institution.
Step 7: Providing Rationales – Scientific Basis for Interventions
Rationales, also known as scientific explanations, explain the underlying reasons why a particular nursing intervention was selected. They connect the intervention to the patient’s nursing diagnosis and desired outcome, often based on pathophysiological or psychological principles. Rationales are particularly emphasized in student care plans as a learning tool to enhance understanding.
Sample nursing interventions and rationale.
While rationales are not always included in routine care plans for practicing nurses, understanding the rationale behind each intervention is crucial for providing informed and effective care.
Step 8: Evaluation – Measuring Effectiveness and Adapting Care
Evaluation is the final, yet ongoing, step in the nursing process and care planning. It involves:
- Assessing Patient Progress: Comparing the patient’s current health status to the desired outcomes established in the care plan.
- Determining Goal Achievement: Evaluating the extent to which the patient has achieved the short-term and long-term goals.
- Evaluating Intervention Effectiveness: Analyzing the effectiveness of the nursing interventions in facilitating goal achievement.
- Modifying the Care Plan: Based on the evaluation, the care plan may be:
- Terminated: If goals have been fully achieved and the problem resolved.
- Continued: If progress is being made, but goals are not yet fully achieved.
- Revised: If progress is inadequate or the patient’s condition has changed, requiring adjustments to diagnoses, goals, or interventions.
Evaluation is a continuous process, not just a final step. Regular evaluation ensures that the care plan remains dynamic and responsive to the patient’s evolving needs.
Step 9: Documentation – Putting it on Paper and in the Record
The completed nursing care plan must be documented according to hospital policy and becomes a permanent part of the patient’s medical record. Documentation serves multiple purposes:
- Communication: Provides a written record of the care plan for all healthcare providers involved in the patient’s care.
- Accountability: Demonstrates the planned and delivered nursing care.
- Legal Record: Serves as legal evidence of the care provided.
- Reimbursement: Supports billing and reimbursement processes.
- Quality Improvement: Provides data for quality assurance and performance improvement initiatives.
Different healthcare facilities and nursing programs may have specific documentation formats. Most formats are designed to systematically guide nurses through the interrelated steps of the nursing process.
Comprehensive Nursing Care Plan List
This section provides a categorized list of sample nursing care plans (NCPs) and nursing diagnoses for a wide range of diseases and health conditions, serving as a valuable resource for nurses in various specialties.
Basic Nursing and General Care Plans
| 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
| 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
| 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
| 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
| 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
| 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
| 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
| Integumentary Care Plans |
|---|
| Burn Injury |
| Dermatitis |
| Herpes Zoster (Shingles) |
| Pressure Ulcer (Bedsores) |
| Wound Care and Skin/Tissue Integrity |
Maternal and Newborn Care Plans
| 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
| 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
| 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
| 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
| Ophthalmic Care Plans |
|---|
| Cataracts |
| Glaucoma |
| Macular Degeneration |
Pediatric Nursing Care Plans
| 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
| Reproductive Care Plans |
|---|
| Cryptorchidism (Undescended Testes) |
| Hysterectomy |
| Hypospadias and Epispadias |
| Mastectomy |
| Menopause |
| Prostatectomy |
Respiratory
| 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
| 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 Diagnosis and Care Planning
To further enhance your understanding and skills in nursing diagnosis and care planning, consider these recommended resources:
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Ackley and Ladwig’s Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care
This handbook is highly regarded for its evidence-based approach to nursing interventions. It uses a three-step system to guide you through assessment, diagnosis, and care planning. It includes step-by-step instructions for implementation and outcome evaluation, helping to build diagnostic reasoning and critical thinking skills.
Nursing Care Plans – Nursing Diagnosis & Intervention (10th Edition)
This comprehensive resource features over 200 care plans reflecting the latest evidence-based guidelines. The 10th edition includes ICNP diagnoses, care plans addressing LGBTQ health issues, and expanded content on electrolytes and acid-base balance.
Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales
This quick-reference guide is an essential tool for identifying correct diagnoses and planning efficient patient care. The 16th edition includes the most recent nursing diagnoses and interventions, with an alphabetized listing covering over 400 disorders.
Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care
This manual is invaluable for planning, individualizing, and documenting care for over 800 diseases and disorders. For each diagnosis, it provides subjective and objective data, sample clinical applications, prioritized actions/interventions with rationales, and documentation guidelines.
This comprehensive e-book 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 skills.
By mastering the principles of diagnosis for nursing care plan and utilizing these resources, nurses can significantly enhance their ability to provide effective, patient-centered care and improve patient outcomes.
