What is a Nursing Care Plan?
A nursing care plan (NCP) is a crucial, formalized roadmap in healthcare that meticulously identifies a patient’s current health needs and anticipates potential future needs or risks. Think of it as a blueprint for patient care, facilitating clear and effective communication among nurses, patients, and the broader healthcare team. This collaborative approach ensures everyone is on the same page, working together to achieve the best possible health outcomes for the patient. 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 treatment.
The nursing care planning process is not a static event; it’s a dynamic and ongoing cycle. It begins the moment a patient is admitted to a healthcare facility and continues to evolve throughout their care journey. The plan is regularly updated to reflect any changes in the patient’s condition and is continuously evaluated against the established goals to measure progress and make necessary adjustments. This commitment to planning and delivering individualized, patient-centered care is the cornerstone of excellence in modern nursing practice. It ensures that each patient receives care that is not only effective but also tailored to their specific circumstances and needs.
Types of Nursing Care Plans
Nursing care plans exist on a spectrum from informal mental notes to detailed written documents. They can be broadly categorized as informal or formal:
An informal nursing care plan is essentially a mental strategy. It’s the plan of action that a nurse carries in their mind, based on their immediate assessment and understanding of the patient’s needs. This type of plan is flexible and allows for quick adjustments in response to real-time changes in a patient’s condition.
A formal nursing care plan, in contrast, is a documented guide. It can be written or computerized and serves as a comprehensive record of the patient’s care information. Formal care plans are essential for ensuring consistency and continuity of care, especially when multiple healthcare providers are involved.
Formal care plans are further divided into two main types: standardized and individualized care plans:
Standardized care plans are pre-written guides that outline the typical nursing care required for patients with common needs or medical conditions. These plans are designed to ensure that every patient with a particular condition receives a baseline level of consistent, high-quality care. They are particularly useful for streamlining care for routine situations and improving efficiency in busy healthcare settings.
Individualized care plans are specifically tailored to meet a particular patient’s unique needs and goals. They are developed by adapting standardized care plans or creating entirely new plans to address aspects of a patient’s condition that are not covered by general guidelines. Individualized care plans are crucial for providing truly patient-centered care, recognizing that each person’s health journey is distinct.
Standardized Care Plans
Standardized care plans are essentially best-practice guidelines developed by experienced nursing staff and healthcare organizations. Their primary purpose is to guarantee that patients with specific, common conditions receive consistent and evidence-based care. By outlining the essential elements of care for typical patient populations, standardized plans help to establish a minimum acceptable level of care and promote efficient use of nursing time. They eliminate the need for nurses to repeatedly develop care strategies for routine situations, allowing them to focus on more complex or unique patient needs.
It’s important to understand that standardized care plans are not designed to be a one-size-fits-all solution. They are not tailored to the nuanced needs and specific goals of each individual patient. Instead, they serve as a valuable starting point, a foundational framework upon which nurses can build. They provide a solid base for developing a more personalized and effective individualized care plan.
The example care plans you will find in this guide are primarily standardized care plans. Think of them as templates or directions, offering a robust framework to guide you in developing a truly individualized care plan that is perfectly suited to your patient’s unique circumstances.
Individualized Care Plans
An individualized care plan takes the concept of patient-centered care to a deeper level. It involves a thoughtful process of adapting a standardized care plan – or creating a completely new one – to precisely match the specific needs, preferences, and goals of an individual patient. This approach goes beyond treating the condition; it focuses on treating the whole person. It incorporates strategies and interventions that have been shown to be most effective for patients with similar profiles, while also considering the unique context of the individual. This level of personalization allows for more holistic care, addressing not only the physical aspects of illness but also the emotional, social, and spiritual dimensions of well-being.
The benefits of individualized care plans extend beyond improved clinical outcomes. They can significantly enhance patient satisfaction. When patients perceive that their care is specifically designed for them, that their voices are heard and their values respected, they are more likely to feel engaged in their treatment and satisfied with their overall healthcare experience. In today’s healthcare landscape, where patient satisfaction is increasingly recognized as a key indicator of quality care, individualized care plans are not just a best practice – they are becoming an essential component of a high-quality healthcare environment.
Tips on how to individualize a nursing care plan:
- Involve the Patient: Actively engage the patient (and their family, when appropriate) in the planning process. Their insights into their own needs, preferences, and goals are invaluable.
- Consider the Patient’s History: Review the patient’s medical history, lifestyle, cultural background, and social situation. These factors significantly influence their health needs and how they respond to care.
- Focus on Unique Needs: Identify the patient’s specific challenges, strengths, and resources. What makes their situation different from the “standard” case?
- Set Personalized Goals: Collaboratively establish goals that are meaningful and achievable for the individual patient, taking into account their personal values and priorities.
- Tailor Interventions: Select nursing interventions that are most likely to be effective and acceptable to the patient, considering their preferences, beliefs, and lifestyle.
- Regularly Review and Adjust: Individualized care plans are living documents. Continuously monitor the patient’s progress and be prepared to modify the plan as their needs evolve.
Objectives
The process of writing a nursing care plan is driven by several key objectives, all aimed at enhancing the quality and effectiveness of patient care:
- Promote Evidence-Based Nursing Care: Care plans serve as a mechanism to integrate the latest research findings and best practices into daily nursing care. By encouraging nurses to base their interventions on solid evidence, care plans help ensure patients receive the most effective treatments available. They also contribute to creating a more predictable and comforting environment for patients within hospitals and health centers, reducing anxiety and promoting healing.
- Support Holistic Care: A core objective of nursing care planning is to address the patient as a whole person, not just a collection of symptoms or a disease. This holistic approach recognizes the interconnectedness of physical, psychological, social, and spiritual well-being. Care plans are designed to manage and prevent disease while simultaneously supporting all these dimensions of the patient’s life.
- Establish Structured Care Programs: Nursing care plans are instrumental in developing more structured and standardized approaches to care, such as care pathways and care bundles. Care pathways are collaborative, team-based efforts to define agreed-upon standards of care and expected outcomes for specific patient groups. Care bundles, on the other hand, focus on implementing best practices for managing particular diseases or conditions, ensuring a consistent and high-quality approach.
- Clearly Define Goals and Outcomes: A well-written care plan precisely identifies and differentiates between overall goals of care and the specific, measurable outcomes expected for the patient. This clarity is essential for guiding nursing interventions and for evaluating the effectiveness of care.
- Enhance Communication and Documentation: Care plans serve as a central communication tool for the healthcare team. They provide a documented record of the patient’s needs, planned interventions, and progress, facilitating seamless communication between nurses and other healthcare providers across different shifts and departments.
- Measure Nursing Care Effectiveness: By outlining specific goals and outcomes, nursing care plans provide a framework for evaluating the impact of nursing care. This allows nurses to track patient progress, identify areas where interventions are successful, and make adjustments when needed to improve patient outcomes.
Purposes of a Nursing Care Plan
Nursing care plans are not merely procedural documents; they serve several vital purposes that significantly enhance the quality, efficiency, and patient-centeredness of healthcare delivery:
- Defines Nurse’s Role: Care plans are essential in articulating the unique and independent role of nurses within the healthcare team. They highlight the nurse’s responsibility in addressing patients’ overall health and well-being, emphasizing that nursing care extends beyond simply following physician’s orders. Care plans empower nurses to utilize their expertise and judgment to proactively manage patient needs.
- Provides Direction for Individualized Care: A care plan acts as a detailed roadmap, guiding the nursing care that will be delivered to each patient. It encourages nurses to think critically and proactively in developing interventions that are specifically tailored to the individual’s unique circumstances, needs, and preferences. This individualized approach ensures that care is not generic but rather responsive to the patient’s specific situation.
- Ensures Continuity of Care: Care plans are crucial for maintaining consistent care across different nursing shifts and departments. By providing a shared source of patient information and planned interventions, they enable nurses to deliver the same high-quality care, regardless of who is on duty. This continuity is essential for maximizing the benefits of treatment and providing a seamless patient experience.
- Coordinates Care Among the Healthcare Team: Care plans facilitate effective communication and coordination among all members of the healthcare team. By making patient care needs and planned actions transparent to everyone involved, care plans prevent gaps in care and ensure that all professionals are working collaboratively towards shared goals.
- Serves as Legal Documentation: A well-documented care plan is a critical part of the patient’s medical record. It accurately outlines observations, nursing actions, and patient/family instructions. This documentation serves as evidence that care was provided and meets professional standards. Conversely, if nursing care is not properly documented in the care plan, there is no formal record of it having been delivered.
- Guides Staff Assignment: In situations where patients have complex or specialized care needs, care plans can inform decisions about staff assignments. They help ensure that patients are cared for by nurses with the appropriate skills and expertise to meet their specific requirements.
- Monitors Patient Progress: Care plans are designed to track a patient’s progress over time. By regularly reviewing and evaluating the plan against the patient’s current health status and goals, nurses can identify whether interventions are effective and make necessary adjustments to the care plan as the patient’s condition evolves.
- Supports Reimbursement Processes: Insurance companies often rely on medical records, including nursing care plans, to determine the medical necessity and appropriateness of hospital care. Comprehensive and well-documented care plans can support the reimbursement process, ensuring that healthcare facilities are appropriately compensated for the care they provide.
- Defines Client’s Goals and Promotes Engagement: Care plans are not just for nurses; they benefit patients as well. By involving patients in the development of their care plans, nurses empower them to actively participate in their treatment and care decisions. This collaborative approach enhances patient understanding, promotes adherence to treatment plans, and fosters a sense of ownership in their health journey.
Components
A comprehensive nursing care plan (NCP) typically includes several key components, each serving a distinct purpose in guiding patient care. These core components are:
- Nursing Diagnoses: These are clinical judgments about individual, family, or community experiences/responses to actual or potential health problems and/or life processes. Nursing diagnoses provide the foundation for the care plan, identifying the specific health issues that nursing interventions will address.
- Client Problems (Optional): Some care plan formats also include a section for client problems, which may be broader than nursing diagnoses and can encompass medical diagnoses or other health-related issues.
- Expected Outcomes: These are specific, measurable, achievable, relevant, and time-bound (SMART) statements that describe the desired changes in the patient’s health status as a result of nursing care. Expected outcomes provide direction for interventions and serve as criteria for evaluating the effectiveness of the care plan.
- Nursing Interventions: These are the specific actions that nurses will take to achieve the expected outcomes and address the nursing diagnoses. Interventions should be evidence-based, tailored to the individual patient, and clearly described.
- Rationales: For each nursing intervention, a rationale explains the scientific basis or evidence supporting the intervention. Rationales are particularly important in student care plans as they promote deeper understanding and critical thinking.
- Evaluation: This component outlines how the effectiveness of the nursing care plan will be evaluated. It includes methods for measuring progress towards expected outcomes and for determining whether the care plan needs to be revised.
These components work together in a logical sequence, ensuring that the nursing care plan is comprehensive, patient-centered, and outcome-oriented.
Care Plan Formats
Nursing care plans can be organized and presented in various formats, often categorized by the number of columns used to structure the information. The most common formats are three-column and four-column plans, although some agencies may use five-column formats or other variations. The choice of format often depends on agency preferences, the complexity of patient needs, and whether the care plan is for student learning or professional practice.
Three-Column Format
The three-column format is a streamlined and efficient way to organize a nursing care plan. It typically includes the following columns:
- Nursing Diagnosis: This column lists the identified nursing diagnoses for the patient.
- Outcomes and Evaluation: This column combines the desired patient outcomes and the evaluation criteria. For each nursing diagnosis, it specifies what is expected of the patient (outcomes) and how progress towards those outcomes will be measured (evaluation).
- Interventions: This column details the specific nursing interventions planned to address each nursing diagnosis and achieve the desired outcomes.
This format is concise and focuses on the essential elements of the care plan, making it practical for busy clinical settings.
Three-column nursing care plan format for efficient documentation.
Four-Column Format
The four-column format provides a more detailed and structured approach to nursing care planning. It separates outcomes and evaluation into distinct columns, offering greater clarity and emphasis on each component. The typical columns in a four-column format are:
- Nursing Diagnosis: As in the three-column format, this column lists the identified nursing diagnoses.
- Goals and Outcomes: This column specifies the overall goals of care related to each nursing diagnosis, as well as the more specific, measurable outcomes expected for the patient.
- Interventions: This column details the nursing interventions, as in the three-column format.
- Evaluation: This column focuses specifically on the evaluation phase, outlining how the achievement of outcomes will be assessed and documented.
The four-column format is often preferred when a more comprehensive and explicit care plan is needed, such as in complex cases or for educational purposes.
Four-column nursing care plan template for detailed care planning.
To help you get started, we’ve prepared sample templates for different nursing care plan formats. Feel free to download, edit, modify, and share these templates to suit your needs.
Download: Printable Nursing Care Plan Templates and Formats
Student Care Plans
Student care plans serve a dual purpose: they are both a tool for patient care and a valuable learning activity for student nurses. As such, they are typically more extensive and detailed than the care plans used by practicing nurses. The increased detail is intended to help students develop a deep understanding of the nursing process and the rationale behind each aspect of care.
Student nursing care plans require more in-depth analysis and rationale.
Often, student nurses are required to handwrite their care plans, further emphasizing the learning process. A common feature of student care plans is an additional column for “Rationale” or “Scientific Explanation.” This column, placed after the nursing interventions column, requires students to articulate the scientific principles that justify the selection of each nursing intervention. This emphasis on rationale helps students connect their actions to underlying physiological, psychological, and pharmacological concepts, fostering critical thinking and evidence-based practice.
Writing a Nursing Care Plan
Creating an effective nursing care plan (NCP) is a systematic process. By following a step-by-step approach, you can ensure that your care plan is comprehensive, patient-centered, and directly addresses the individual needs of your client.
Step 1: Data Collection or Assessment
The foundation of any good nursing care plan is a thorough and accurate patient assessment. The first step in writing an NCP is to build a comprehensive client database. This involves utilizing a variety of assessment techniques and data collection methods, including:
- Physical Assessment: Conducting a hands-on examination to gather objective data about the patient’s physical condition (physical assessment).
- Health History: Obtaining a detailed account of the patient’s past and present health status, including medical conditions, surgeries, medications, allergies, and lifestyle factors (health history).
- Interview: Engaging in conversation with the patient (and family, when appropriate) to gather subjective data about their symptoms, feelings, concerns, and perspectives.
- Medical Records Review: Examining the patient’s existing medical records, including physician’s notes, lab results, and previous care plans, to gain a holistic understanding of their health history and current status.
- Diagnostic Studies: Reviewing the results of relevant diagnostic tests, such as blood work, imaging studies, and other procedures, to obtain objective clinical data.
A comprehensive client database includes all the pertinent health information gathered through these methods. During this assessment phase, the nurse’s critical thinking skills are paramount. It’s in this step that you begin to identify related or risk factors and defining characteristics that will be crucial in formulating accurate and relevant nursing diagnoses. Some healthcare facilities or nursing schools may provide specific assessment formats to guide this data collection process, ensuring consistency and completeness.
Critical thinking is not just beneficial, it’s key during patient assessment. It requires integrating knowledge from various scientific disciplines, understanding professional guidelines, and applying these to inform your evaluations. This cognitive process is absolutely crucial for complex clinical decision-making, allowing nurses to effectively pinpoint patients’ healthcare needs within a supportive environment and using reliable information.
Step 2: Data Analysis and Organization
Once you have collected a substantial amount of data about the patient’s health, the next step is to make sense of it all. Data analysis and organization involve critically examining the collected information, identifying patterns, and grouping related data points together. This process is essential for moving from raw data to meaningful insights that will inform your nursing diagnoses and care plan.
This step involves:
- Analyzing Data: Carefully reviewing all the data collected in Step 1. Look for significant findings, abnormal values, patient statements, and any information that stands out as relevant to the patient’s health status.
- Clustering Data: Grouping related pieces of information together. For example, you might cluster symptoms like shortness of breath, fatigue, and coughing together as they may relate to a respiratory problem. Similarly, anxiety, insomnia, and restlessness could be clustered as potential indicators of psychosocial distress.
- Identifying Patterns: Look for trends and patterns in the clustered data. Are there recurring symptoms? Are certain factors consistently present? Identifying patterns helps you move beyond individual data points and see the bigger picture of the patient’s health issues.
- Synthesizing Information: Combine and synthesize the analyzed and clustered data to form a comprehensive understanding of the patient’s health status. This synthesis will lead you to identify potential nursing diagnoses, prioritize patient needs, and determine desired outcomes.
The outcome of this step is a well-organized and interpreted set of patient data that provides a clear picture of the patient’s health concerns and forms the basis for the next crucial step: formulating nursing diagnoses.
Step 3: Formulating Your Nursing Diagnoses
Nursing diagnoses are the core of the nursing care plan. They represent a standardized and professional way of identifying, focusing on, and addressing specific patient needs and responses to health problems. They are distinct from medical diagnoses, which identify diseases or pathologies. Nursing diagnoses, instead, focus on the patient’s response to illness or health conditions. They describe actual or potential health problems that nurses are qualified and licensed to address independently through nursing interventions.
Nursing diagnoses are:
- Uniform and Standardized: They use a common language that is understood by nurses worldwide, facilitating clear communication and consistent documentation.
- Patient-Centered: They focus on the individual patient’s needs, responses, and experiences, rather than just the disease itself.
- Actionable: They identify problems that nurses can directly impact through nursing interventions.
- Dynamic: They can change as the patient’s condition evolves, requiring ongoing assessment and adjustment.
To guide you through the process of formulating accurate and effective nursing diagnoses, we have a detailed guide available: Nursing Diagnosis (NDx): Complete Guide and List. This comprehensive resource provides step-by-step instructions, examples, and a complete list of nursing diagnoses to help you master this essential skill.
Step 4: Setting Priorities
Once you have identified a list of nursing diagnoses for your patient, the next crucial step is setting priorities. This involves establishing a preferential order for addressing the diagnoses and planning your nursing interventions. Not all nursing diagnoses are equally urgent or important. Prioritization ensures that the most critical needs are addressed first, while less urgent needs are managed subsequently.
In this step, the nurse collaborates with the patient (when possible) to determine which of the identified problems requires immediate attention. Diagnoses are typically ranked into categories of priority:
- High Priority: These are diagnoses that represent life-threatening problems or pose an immediate risk to the patient’s well-being. These needs must be addressed first to ensure patient safety and stability. Examples include diagnoses related to airway, breathing, circulation (ABCs), acute pain, or severe anxiety.
- Medium Priority: These diagnoses are important but not immediately life-threatening. They address needs that can impact the patient’s health and well-being in the near future. Examples might include risk for infection, impaired skin integrity, or knowledge deficit.
- Low Priority: These diagnoses relate to long-term needs or problems that are not directly threatening to the patient’s current health status. They may focus on health promotion, coping, or long-term rehabilitation. Examples could include disturbed body image or readiness for enhanced self-care.
Maslow’s Hierarchy of Needs provides a useful framework for prioritizing nursing diagnoses. This theory, developed by Abraham Maslow in 1943, proposes that human needs are hierarchical, with basic physiological needs at the base and higher-level needs emerging only after the lower needs are met.
Maslow’s Hierarchy of Needs in Nursing Priority:
- Basic Physiological Needs: These are the most fundamental needs for survival and include:
- Nutrition: Maintaining adequate fluid and food intake (water and food).
- Elimination: Managing bodily waste removal (Toileting).
- Oxygenation: Ensuring adequate respiratory function (airway (suction)-breathing (oxygen)-circulation (pulse, cardiac monitor, blood pressure) (ABCs)).
- Rest and Sleep: Promoting sufficient sleep and rest (sleep).
- Other physiological needs: Sex, shelter, and exercise.
- Safety and Security Needs: Once physiological needs are met, safety and security become paramount. These include:
- Physical Safety: Preventing harm and injury (Injury prevention (side rails, call lights, hand hygiene, isolation, suicide precautions, fall precautions, car seats, helmets, seat belts)).
- Emotional Safety: Fostering trust and security (therapeutic relationship), and providing patient education (modifiable risk factors for stroke, heart disease).
- Love and Belonging Needs: These social needs emerge after safety is established and include:
- Social Connection: Fostering supportive relationships, and preventing social isolation (bullying)
- Communication and Intimacy: Employing active listening techniques, therapeutic communication, and addressing needs for sexual intimacy.
- Self-Esteem Needs: These relate to feelings of self-worth, competence, and achievement:
- Confidence and Respect: Acceptance in the community, workforce, personal achievement, sense of control or empowerment, accepting one’s physical appearance or body habitus.
- Self-Actualization Needs: At the pinnacle of the hierarchy, self-actualization represents reaching one’s full potential:
- Personal Growth and Fulfillment: Empowering environment, spiritual growth, ability to recognize the point of view of others, reaching one’s maximum potential.
Virginia Henderson’s 14 Needs are thoughtfully mapped to Maslow’s Hierarchy of Needs, providing a comprehensive framework for prioritizing patient care. Learn more about it here.
In addition to Maslow’s Hierarchy, other factors to consider when setting priorities include the patient’s health values and beliefs, available resources, and the overall urgency of the situation. Actively involving the patient in the prioritization process is crucial for enhancing their cooperation and ensuring that the care plan aligns with their personal values and goals.
Step 5: Establishing Client Goals and Desired Outcomes
Following the prioritization of nursing diagnoses, the next step is to collaboratively set goals and desired outcomes for each priority diagnosis. Goals and desired outcomes are statements that describe what you hope to achieve through your nursing interventions. They represent the intended positive changes in the patient’s health status.
Goals are broad statements that describe the overall aim of nursing care for a particular diagnosis. They are usually long-term and reflect the ultimate desired result.
Desired outcomes, on the other hand, are more specific, measurable, short-term statements that indicate the steps towards achieving the overall goal. They serve as benchmarks for evaluating patient progress and the effectiveness of interventions. The terms “goal outcomes“ and “expected outcomes” are often used interchangeably in practice.
Examples of well-written goals and desired outcomes in a nursing care plan.
Well-defined goals and desired outcomes are essential because they:
- Provide Direction: They guide the planning of nursing interventions, ensuring that actions are focused and purposeful.
- Serve as Evaluation Criteria: They provide measurable benchmarks for assessing patient progress and the effectiveness of the care plan.
- Enable Problem Resolution: They help both the patient and the nurse determine when problems have been resolved or are being effectively managed.
- Enhance Motivation: Achieving goals and desired outcomes provides a sense of accomplishment for both the patient and the nurse, fostering motivation and continued progress.
According to Hamilton and Price (2013), effective goals and desired outcomes should be SMART:
- Specific: Clearly defined and focused, leaving no room for ambiguity.
- Measurable: Quantifiable and able to be tracked and assessed.
- Attainable: Realistic and achievable for the patient given their current condition and resources.
- Realistic: Relevant to the patient’s needs, values, and overall health goals.
- Time-Oriented: Defined with a specific timeframe for achievement.
Hogston (2011) further suggests using the REEPIG standards to ensure high-quality care plans:
- Realistic: Achievable given available resources and patient circumstances.
- Explicitly Stated: Clearly and unambiguously written to avoid misinterpretation.
- Evidence-Based: Supported by research or best practices.
- Prioritized: Addressing the most urgent problems first.
- Involve: Developed collaboratively with the patient and relevant members of the healthcare team.
- Goal-Centered: Focused on achieving the established goals and desired outcomes.
Short-Term and Long-Term Goals
Goals and expected outcomes can be categorized by timeframe: short-term and long-term. Both types are essential for comprehensive care planning, but they serve different purposes and are relevant in different care settings. Crucially, both short-term and long-term goals must be measurable and client-centered, focusing on what the patient will achieve. Goals should be framed around problem prevention, resolution, and rehabilitation.
- Short-term goals are focused on immediate needs and behaviors that can be achieved relatively quickly, typically within hours or days. They describe the immediate steps towards overall improvement and are particularly relevant in acute care settings where patients’ needs may change rapidly.
- Long-term goals describe objectives to be achieved over a longer period, typically weeks or months. They are essential for patients with chronic conditions, those in rehabilitation, or those receiving care in long-term care facilities or at home. Long-term goals guide ongoing care and promote sustained improvement.
- Discharge planning heavily relies on long-term goals. It involves setting goals that extend beyond the immediate hospitalization, promoting continued recovery and problem resolution through home healthcare, physical therapy, referrals, and other community resources.
Components of Goals and Desired Outcomes
Well-written goals and desired outcome statements typically include four key components:
- Subject: The individual who is expected to achieve the outcome. In most cases, the subject is the client (patient). Sometimes, it may be a part of the client (e.g., “patient’s respiratory rate”) or an attribute (e.g., “patient’s pain level”). Often, the subject “client” is implied and omitted for brevity.
- Verb: An action verb that describes the action the client is expected to perform, demonstrate, or achieve. This verb should be observable and measurable. Examples include “will verbalize,” “will demonstrate,” “will ambulate,” “will maintain.”
- Conditions or Modifiers: Words or phrases that describe the circumstances under which the behavior is to be performed. These answer the “what, when, where, or how” of the expected outcome. Conditions add specificity and context to the outcome statement.
- Criterion of Desired Performance: The standard by which the performance is evaluated or the level of performance expected. This component specifies how well or to what extent the client must perform the behavior to be considered successful. Criteria should be measurable and objective. This component is sometimes optional, depending on the specific outcome.
Key components to include when writing effective goals and desired outcomes in a nursing care plan.
Key Tips for Writing Effective Goals and Desired Outcomes:
- Focus on Client Responses: Write goals and outcomes in terms of patient responses and behaviors, not as activities of the nurse. Start each goal with “Client will […]” to ensure the focus remains on the patient.
- Client-Centered, Not Nurse-Centered: Avoid writing goals that describe what the nurse hopes to accomplish. Instead, focus on what the client will do or achieve.
- Use Observable and Measurable Terms: Employ verbs and criteria that are specific, observable, and measurable. Avoid vague terms that are open to interpretation or subjective judgment.
- Realistic and Achievable: Ensure that desired outcomes are realistic and achievable for the patient, considering their resources, capabilities, limitations, and the timeframe of care.
- Compatible with Other Therapies: Make sure goals are consistent with and supportive of other therapies the patient is receiving from other healthcare professionals.
- Single Diagnosis per Goal: Derive each goal from only one nursing diagnosis. This ensures clarity and simplifies evaluation, making it easier to link interventions to specific diagnoses.
- Patient-Valued Goals: Involve the patient in goal setting and ensure that the goals are important and valued by them. This promotes patient cooperation and engagement in the care plan.
Step 6: Selecting Nursing Interventions
Nursing interventions are the actions that nurses perform to help patients achieve their goals and desired outcomes. They are the “what” of the nursing care plan – the specific activities and strategies that will be implemented to address the patient’s nursing diagnoses. The interventions you choose should directly target the root cause (etiology) of the priority nursing problem or diagnosis. For risk diagnoses, interventions should focus on reducing or managing the identified risk factors.
Nursing interventions are identified and written during the planning stage of the nursing process, but they are actually carried out during the implementation step. Selecting appropriate and effective nursing interventions is a critical skill that requires nursing knowledge, clinical judgment, and patient-centered consideration.
Types of Nursing Interventions
Nursing interventions can be broadly classified into three categories: independent, dependent, and collaborative interventions:
Understanding the different types of nursing interventions: independent, dependent, and collaborative.
- Independent nursing interventions are actions that nurses are authorized to initiate based on their professional knowledge, judgment, and skills. These interventions do not require direct orders from a physician or other healthcare provider. Examples of independent interventions include:
- Ongoing Assessment: Regularly monitoring and evaluating the patient’s condition.
- Emotional Support: Providing reassurance, encouragement, and counseling.
- Comfort Measures: Implementing strategies to enhance patient comfort (comfort).
- Patient Education: Teaching patients about their health condition, treatment, and self-care.
- Physical Care: Assisting with activities of daily living, hygiene, and mobility.
- Referrals: Connecting patients with other healthcare professionals or community resources.
- Dependent nursing interventions are actions that require an order or supervision from a physician or other authorized healthcare provider. These interventions are carried out in response to medical diagnoses and treatment plans. Examples of dependent interventions include:
- Medication Administration: Giving prescribed medications.
- Intravenous Therapy: Managing IV fluids and medications (intravenous therapy).
- Diagnostic Tests: Preparing patients for and assisting with diagnostic procedures.
- Medical Treatments: Implementing specific medical treatments as ordered.
- Dietary Orders: Ensuring patients receive prescribed diets.
- Activity Orders: Following orders related to patient activity and rest.
- Assessment and Explanation: Even when implementing dependent interventions, nurses play a vital role in assessing the patient’s response and providing explanations about the ordered treatments.
- Collaborative interventions are actions that nurses carry out in partnership with other members of the healthcare team. These interventions require interdisciplinary communication and shared decision-making. Examples of collaborative interventions involve working with:
- Physicians: Coordinating medical and nursing care.
- Social Workers: Addressing psychosocial and discharge planning needs.
- Dietitians: Developing nutritional plans.
- Therapists (Physical, Occupational, Speech): Integrating therapy services into the overall care plan.
- Other Specialists: Consulting with pharmacists, respiratory therapists, and other specialists as needed.
Effective nursing interventions should be:
- Safe and Appropriate: Suitable for the patient’s age, health condition, and overall status.
- Achievable: Feasible to implement given available resources, time, and staffing.
- Patient-Centered: Aligned with the patient’s values, culture, and beliefs.
- Consistent with Other Therapies: Integrated and compatible with other medical and therapeutic interventions the patient is receiving.
- Evidence-Based: Grounded in nursing knowledge, clinical experience, and relevant scientific evidence.
Key Tips for Writing Effective Nursing Interventions:
- Date and Sign: Always date and sign the care plan when you write it. The date is crucial for tracking the plan’s currency and for future review and planning. Your signature demonstrates accountability for the plan.
- Be Specific and Clear: Nursing interventions should be specific, clearly stated, and begin with an action verb that precisely indicates what the nurse is to do. The action verb initiates the intervention and must be precise. Qualifiers (how, when, where, time, frequency, amount) provide essential context and detail for the planned activity. For example: “Educate parents on how to take temperature and notify of any changes,” or “Assess urine for color, amount, odor, and turbidity.”
- Use Accepted Abbreviations Only: Use only abbreviations that are officially accepted and understood within your healthcare institution. Avoid using unapproved or ambiguous abbreviations that could lead to misunderstandings or errors.
Step 7: Providing Rationale
Rationales, also known as scientific explanations or justifications, are a critical component of student nursing care plans and highly recommended for all care plans to enhance understanding and critical thinking. A rationale explains why a particular nursing intervention was chosen for the NCP. It provides the scientific basis, evidence, or clinical reasoning behind the intervention.
Example of nursing interventions paired with clear and concise rationales in a care plan.
Rationales are not typically included in routine, professional care plans used in everyday clinical practice due to time constraints and the assumption of professional knowledge. However, they are invaluable in student care plans because they:
- Promote Learning: Rationales force students to delve deeper into the underlying principles of nursing care, strengthening their understanding of pathophysiology, pharmacology, and other relevant sciences.
- Enhance Critical Thinking: By requiring students to articulate the “why” behind their interventions, rationales foster critical thinking and clinical reasoning skills.
- Bridge Theory and Practice: Rationales help students connect theoretical knowledge to practical application, making learning more meaningful and relevant.
- Improve Evidence-Based Practice: The process of finding and writing rationales encourages students to seek out evidence and best practices to support their interventions, laying the foundation for evidence-based nursing practice.
To write effective rationales, you should:
- Focus on the “Why”: Explain the scientific or clinical reason why the intervention is expected to be effective in addressing the nursing diagnosis and achieving the desired outcome.
- Use Scientific Principles: Draw upon knowledge from anatomy, physiology, pathophysiology, pharmacology, psychology, sociology, and other relevant disciplines.
- Cite Evidence (If Possible): Whenever possible, cite research studies, evidence-based guidelines, or authoritative sources to support your rationales.
- Be Concise and Clear: Write rationales that are brief, to the point, and easy to understand. Avoid overly technical jargon unless necessary.
- Link to Intervention and Outcome: Ensure the rationale clearly explains how the chosen intervention is linked to the desired patient outcome and the nursing diagnosis.
Step 8: Evaluation
Evaluation is the final, but ongoing, step in the nursing process and in the use of a nursing care plan. It is a planned, systematic, and purposeful activity in which you:
- Assess Patient Progress: Determine the patient’s progress towards achieving the established goals and desired outcomes.
- Evaluate Care Plan Effectiveness: Judge the effectiveness of the nursing care plan in resolving or managing the patient’s nursing diagnoses.
- Make Decisions About Future Care: Based on the evaluation, decide whether to continue, modify, or terminate specific nursing interventions or the entire care plan.
Evaluation is not a one-time event that occurs at the end of care; it is an essential and continuous aspect of the nursing process. Regular evaluation allows nurses to:
- Track Patient Progress: Monitor whether the patient is moving towards the desired outcomes and identify any deviations from the expected trajectory.
- Identify What Works and What Doesn’t: Determine which interventions are effective in helping the patient and which may need to be adjusted or replaced.
- Ensure Patient Needs are Met: Confirm that the care plan is continuing to address the patient’s evolving needs and priorities.
- Promote Accountability: Evaluation holds nurses accountable for the outcomes of their care and encourages continuous improvement in practice.
- Adapt to Change: Healthcare is dynamic. Evaluation ensures that the care plan remains responsive to changes in the patient’s condition, new medical information, and evolving patient goals.
The conclusions drawn from the evaluation step are critical because they directly inform decisions about the future course of nursing care. Evaluation determines whether:
- Interventions should be terminated: If goals and outcomes have been fully achieved and the problem is resolved.
- Interventions should be continued: If progress is being made, but goals have not yet been fully met.
- Interventions should be changed: If there is little or no progress, or if the patient’s condition or needs have changed, requiring a revision of the care plan.
Step 9: Putting it on Paper
The culmination of the nursing care planning process is documentation. The client’s care plan is formally documented according to the policies and procedures of the healthcare facility. This documented care plan becomes an integral part of the patient’s permanent medical record, serving as a vital communication tool for all members of the healthcare team, especially for nurses during shift changes and handovers. The oncoming nurse relies on the documented care plan to understand the patient’s current needs, planned interventions, and progress to date.
Different nursing programs and healthcare institutions may utilize various care plan formats. However, most formats are designed to guide the nurse (or student nurse) systematically through the interrelated steps of the nursing process. Many educational settings and some clinical agencies favor a five-column format for student care plans, which typically includes columns for:
- Assessment Data
- Nursing Diagnosis
- Goals and Desired Outcomes
- Nursing Interventions
- Evaluation
This structured format helps students learn and apply each step of the nursing process in a logical and comprehensive manner.
Nursing Care Plan List
To further assist you in understanding and creating nursing care plans, we have compiled an extensive list of example nursing care plans (NCPs) and nursing diagnoses for a wide range of diseases and health conditions. These examples are categorized by clinical specialty to help you quickly find relevant care plans for your area of practice or study.
Basic Nursing and General Care Plans
This section includes miscellaneous nursing care plan examples that are broadly applicable and don’t fit neatly into other specialty categories. These are fundamental care plans addressing common patient needs across various healthcare settings.
| 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
This category includes care plans specifically designed for patients undergoing surgical interventions. These plans address the unique needs of patients before, during, and after surgery (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
This section focuses on nursing care plans related to various diseases and conditions of the cardiovascular system. These plans address issues such as heart failure, hypertension, and decreased cardiac output.
| 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
This category provides nursing care plans (NCPs) specifically for conditions related to the endocrine system and metabolic disorders. These plans cover diabetes, thyroid disorders, and fluid and electrolyte imbalances.
| 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
This section contains care plans (NCPs) addressing disorders of the gastrointestinal and digestive system. These include conditions like bowel incontinence, constipation, and inflammatory bowel disease.
| 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
This section provides care plans related to the hematologic and lymphatic system, including conditions like anemia, deep vein thrombosis, and leukemia.
| 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
This category includes NCPs for communicable and infectious diseases, such as AIDS, influenza, and tuberculosis.
| 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
This section is all about disorders and conditions affecting the integumentary system, which includes the skin, hair, and nails. Care plans here address burn injuries, dermatitis, and pressure ulcers.
| Integumentary Care Plans |
|---|
| Burn Injury |
| Dermatitis |
| Herpes Zoster (Shingles) |
| Pressure Ulcer (Bedsores) |
| Wound Care and Skin/Tissue Integrity |
Maternal and Newborn Care Plans
This category includes nursing care plans focused on the care of pregnant mothers and their infants. See care plans for maternity and obstetric nursing, covering topics from abortion to preterm labor.
| 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
This section offers care plans for mental health and psychiatric nursing, covering conditions such as anxiety, bipolar disorders, and schizophrenia.
| 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 in this section relate to the musculoskeletal system, addressing conditions like fractures, osteoarthritis, and spinal cord injuries.
| 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
This section provides nursing care plans (NCPs) for disorders related to the nervous system. These include Alzheimer’s disease, stroke, and multiple sclerosis.
| 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 in this section relate to eye disorders. This includes conditions like cataracts, glaucoma, and macular degeneration.
| Ophthalmic Care Plans |
|---|
| Cataracts |
| Glaucoma |
| Macular Degeneration |
Pediatric Nursing Care Plans
This category includes nursing care plans (NCPs) specifically for pediatric conditions and diseases, covering topics like child abuse, hydrocephalus, and tonsillitis.
| 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
This section features care plans related to reproductive and sexual function disorders, including conditions like hysterectomy, menopause, and prostatectomy.
| Reproductive Care Plans |
|---|
| Cryptorchidism (Undescended Testes) |
| Hysterectomy |
| Hypospadias and Epispadias |
| Mastectomy |
| Menopause |
| Prostatectomy |
Respiratory
Care plans for respiratory system disorders are included here. These cover conditions like asthma, COPD, pneumonia, and pulmonary embolism.
| 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
This final section includes care plans related to the kidney and urinary system disorders, covering conditions such as urinary tract infections, renal failure, and urolithiasis.
| 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
To deepen your understanding and skills in nursing diagnosis and care planning, we recommend these excellent books and resources.
Disclosure: Please note that the links below are affiliate links from Amazon. Purchasing through these links does not increase your cost, and we may earn a small commission which helps support our website. For more details, please see our privacy policy.
Ackley and Ladwig’s Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care
We highly recommend this handbook for its strong evidence-based approach to nursing interventions. This comprehensive guide uses a clear, three-step system to lead you through client assessment, nursing diagnosis formulation, and effective care planning. It provides step-by-step instructions on how to implement care and evaluate outcomes, helping you build robust skills in diagnostic reasoning and critical thinking essential for nursing practice.
Nursing Care Plans – Nursing Diagnosis & Intervention (10th Edition)
This essential resource includes over two hundred detailed care plans, reflecting the most current evidence-based guidelines in nursing. The latest edition features ICNP diagnoses, new care plans addressing LGBTQ health issues, and expanded content on electrolytes and acid-base balance, making it a thoroughly updated and highly relevant guide for contemporary nursing practice.
Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales
This quick and practical reference tool provides all you need to accurately identify nursing diagnoses and plan efficient patient care. The 16th edition includes the most recent NANDA-I approved nursing diagnoses and interventions, presented in an easy-to-use alphabetized listing that covers over 400 medical disorders. It’s an invaluable resource for nurses needing fast, reliable information at the point of care.
Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care
This manual is specifically designed to help you identify appropriate interventions to plan, personalize, and effectively document care for over 800 different diseases and disorders. Unique to this Nursing Diagnosis Manual are comprehensive entries for each diagnosis, including subjective and objective data, sample clinical applications, prioritized actions/interventions with detailed rationales, and a dedicated section on documentation, among other valuable features.
This comprehensive e-book provides over 100 ready-to-use care plans covering medical-surgical, maternity/OB, pediatrics, and psychiatric and mental health nursing. Its interprofessional “patient problems” focus helps familiarize you with how to effectively communicate with patients and other healthcare team members, enhancing your collaborative care approach.
References and Sources
Recommended reading materials and sources used to compile this NCP guide:
