Nursing care plans (NCPs) are vital tools in healthcare, serving as formalized, step-by-step guides for nurses to identify patient needs and deliver consistent, high-quality care. For both student and professional nurses, understanding and utilizing a comprehensive list of nursing care plan diagnoses is fundamental to effective patient management. This guide provides an in-depth look at nursing care plans, their components, and, most importantly, an extensive list of nursing care plan diagnoses to enhance your practice and improve patient outcomes.
Understanding Nursing Care Plans
A Nursing Care Plan (NCP) is more than just documentation; it’s a dynamic process that begins upon a patient’s admission and evolves throughout their care journey. It facilitates clear communication among nurses, patients, and the broader healthcare team, ensuring everyone is aligned on healthcare goals. Without meticulous nursing care planning, the consistency and quality of patient care would be significantly compromised. The process is continuously updated, reflecting changes in the patient’s condition and the evaluation of progress towards established goals. This individualized approach is the cornerstone of excellent nursing practice, ensuring patient-centered care delivery.
Types of Nursing Care Plans: Formal vs. Informal, Standardized vs. Individualized
Nursing care plans can be broadly classified into informal and formal types. An informal nursing care plan is essentially a mental strategy, existing within the nurse’s mind, guiding immediate actions. In contrast, a formal nursing care plan is a documented, structured guide, either written or digital, that systematically organizes patient care information.
Formal care plans are further categorized into standardized and individualized approaches. Standardized care plans are pre-written guidelines designed for groups of patients with common needs. They ensure consistent care for routine conditions and improve efficiency by eliminating the need to recreate plans for frequently encountered situations. However, standardized plans serve as a starting point and may not fully address the unique needs of each patient.
Individualized care plans are developed by tailoring standardized plans to meet a specific patient’s unique requirements and goals. This personalized approach ensures holistic care that is more responsive to individual patient strengths, needs, and preferences. Individualized care plans not only enhance the quality of care but also contribute to improved patient satisfaction, as patients feel more valued and understood when their care is specifically tailored to them.
Key takeaway: While standardized care plans provide a foundational framework, individualizing these plans is crucial to delivering truly patient-centered care. The list of nursing care plan diagnoses provided in this guide are primarily designed to be adaptable and form the basis for individualized care plans.
Objectives of Nursing Care Plans
The objectives of developing and implementing nursing care plans are multifaceted and crucial for optimal patient care:
- Promote Evidence-Based Care: NCPs ensure that nursing interventions are grounded in the latest research and best practices, fostering a familiar and comfortable care environment.
- Support Holistic Care: By addressing the physical, psychological, social, and spiritual dimensions of patient health, NCPs facilitate comprehensive management and disease prevention.
- Establish Care Pathways and Bundles: NCPs contribute to the development of structured care pathways for consistent standards and care bundles focusing on best practices for specific conditions.
- Clarify Goals and Expected Outcomes: NCPs clearly define healthcare objectives, ensuring all stakeholders understand the intended results of the care plan.
- Enhance Communication and Documentation: NCPs serve as a central platform for documenting and communicating all aspects of patient care among the healthcare team.
- Measure Nursing Care Effectiveness: NCPs provide a framework for evaluating the impact of nursing interventions and making necessary adjustments to improve patient outcomes.
Purposes and Importance of Nursing Care Plans
The significance of nursing care plans extends across various aspects of healthcare delivery:
- Defines the Nurse’s Role: NCPs highlight the autonomous role of nurses in addressing patient health and well-being, beyond simply executing physician’s orders.
- Provides Direction for Individualized Care: NCPs act as a roadmap, guiding nurses to think critically and tailor interventions to each patient’s specific needs.
- Ensures Continuity of Care: By providing a consistent reference point, NCPs enable nurses across different shifts and departments to deliver uniform, high-quality care.
- Coordinates Care: NCPs ensure all members of the healthcare team are informed of patient needs and planned actions, preventing gaps and overlaps in care delivery.
- Facilitates Documentation: NCPs provide a structured format to document observations, nursing actions, and patient/family instructions, serving as evidence of care provided.
- Guides Staff Assignment: NCPs help in assigning staff based on patient needs and staff skill sets, optimizing resource utilization.
- Monitors Patient Progress: NCPs allow for systematic tracking of patient progress and facilitate necessary adjustments to the care plan in response to evolving health status.
- Supports Reimbursement: Insurance providers often rely on documented care plans to determine coverage and reimbursement for healthcare services.
- Defines Patient Goals: NCPs involve patients in their treatment, promoting collaboration and shared decision-making in their care.
Key Components of a Nursing Care Plan
A typical nursing care plan includes several essential components, all revolving around the list of nursing care plan diagnoses:
- Nursing Diagnoses: These are clinical judgments about individual, family, or community experiences/responses to actual or potential health problems/life processes. The list of nursing care plan diagnoses forms the foundation of the NCP.
- Client Problems: A broader description of the patient’s health issues, often used interchangeably with nursing diagnoses.
- Expected Outcomes: Measurable, patient-centered goals that define the desired changes in patient health status.
- Nursing Interventions: Specific actions nurses will take to achieve the expected outcomes.
- Rationales: Scientific principles or evidence that justify the selection of particular nursing interventions.
Common Nursing Care Plan Formats
Nursing care plans are often organized using columnar formats for clarity and ease of use. Common formats include three-column, four-column, and student-specific formats.
- Three-Column Format: Typically includes columns for (1) Nursing Diagnoses, (2) Outcomes and Evaluation Criteria, and (3) Nursing Interventions.
- Four-Column Format: Expands on the three-column format by separating outcomes and evaluation into distinct columns: (1) Nursing Diagnoses, (2) Goals and Outcomes, (3) Nursing Interventions, and (4) Evaluation.
- Student Care Plan Format: Student care plans are often more detailed for learning purposes, commonly including a “Rationale” or “Scientific Explanation” column after interventions. These are usually handwritten and emphasize the reasoning behind each intervention.
Step-by-Step Guide to Writing a Nursing Care Plan
Developing an effective nursing care plan involves a systematic approach, starting with comprehensive data collection and culminating in ongoing evaluation.
Step 1: Data Collection or Assessment: Begin by creating a comprehensive patient database using various assessment techniques including physical exams, health history interviews, medical records review, and diagnostic studies. This step is crucial for identifying related or risk factors and defining characteristics necessary for formulating accurate nursing diagnoses from the list of nursing care plan diagnoses.
Step 2: Data Analysis and Organization: Analyze the collected data, clustering related information to identify patterns and formulate nursing diagnoses, prioritize patient problems, and define desired outcomes.
Step 3: Formulating Nursing Diagnoses: This step involves selecting appropriate diagnoses from a list of nursing care plan diagnoses that accurately reflect the patient’s health status and needs. Nursing diagnoses are standardized terms for health problems that nurses can independently address.
Step 4: Setting Priorities: Prioritize nursing diagnoses based on their urgency and potential impact on the patient’s health. Utilize frameworks like Maslow’s Hierarchy of Needs to guide prioritization, focusing first on life-threatening issues and basic physiological needs.
Maslow’s Hierarchy of Needs in Nursing Care Planning:
- Physiological Needs: Address basic survival needs first, such as airway, breathing, circulation, nutrition, elimination, sleep, and pain.
- Safety and Security Needs: Focus on ensuring patient safety and security, including preventing injury, infection control, and fostering a trusting environment.
- Love and Belonging Needs: Address social and emotional needs, promoting supportive relationships and preventing social isolation.
- Self-Esteem Needs: Support patient’s sense of self-worth, achievement, and independence.
- Self-Actualization Needs: Facilitate patient’s personal growth and help them reach their full potential.
Step 5: Establishing Client Goals and Desired Outcomes: Define patient-centered, measurable goals for each nursing diagnosis. Goals should be SMART (Specific, Measurable, Attainable, Realistic, Time-bound) and focus on what the patient will achieve.
Example of Goals and Desired Outcomes:
Goals can be short-term (achievable within hours or days) or long-term (achievable over weeks or months), depending on the care setting and patient needs.
Step 6: Selecting Nursing Interventions: Choose specific nursing interventions designed to achieve the established goals. Interventions can be independent (nurse-initiated), dependent (physician-ordered), or collaborative (interdisciplinary team-based). Interventions should be evidence-based, safe, and aligned with patient values and resources.
Types of Nursing Interventions:
Step 7: Providing Rationale: For student care plans, include rationales explaining the scientific basis for each nursing intervention, linking interventions to the underlying pathophysiology or psychological principles.
Example of Nursing Interventions and Rationale:
Step 8: Evaluation: Continuously evaluate the patient’s progress toward achieving goals and the effectiveness of the nursing care plan. Evaluation informs whether interventions should be continued, modified, or discontinued.
Step 9: Documentation: Document the complete nursing care plan in the patient’s medical record according to institutional policies. Clear and accurate documentation ensures continuity of care and serves as a legal record of care provided.
List of Nursing Care Plan Diagnoses
This section presents a comprehensive list of nursing care plan diagnoses, categorized for easy navigation and use in various clinical settings. This list of nursing care plan diagnoses is designed to be a starting point, encouraging nurses to individualize care plans based on specific patient needs.
Basic Nursing and General Care Plan Diagnoses
This category includes common diagnoses applicable across various patient populations and healthcare settings.
| Basic Nursing & General Care Plan Diagnoses |
|---|
| 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 Plan Diagnoses
This category focuses on diagnoses relevant to patients undergoing surgical procedures and perioperative care.
| Surgery and Perioperative Care Plan Diagnoses |
|---|
| 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 Plan Diagnoses
This section lists diagnoses related to cardiovascular health and cardiac conditions.
| Cardiac Care Plan Diagnoses |
|---|
| 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 Plan Diagnoses
This category includes diagnoses related to endocrine system disorders and metabolic imbalances.
| Endocrine and Metabolic Care Plan Diagnoses |
|---|
| 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
| Acid-Base Imbalances |
|---|
| Metabolic Acidosis |
| Metabolic Alkalosis |
| Respiratory Acidosis |
| Respiratory Alkalosis |
Electrolyte Imbalances
| Electrolyte Imbalances |
|---|
| Calcium (Ca) Imbalances: Hypercalcemia and Hypocalcemia |
| Magnesium (Mg) Imbalances: Hypermagnesemia and Hypomagnesemia |
| Potassium (K) Imbalances: Hyperkalemia and Hypokalemia |
| Sodium (Na) Imbalances: Hypernatremia and Hyponatremia |
Gastrointestinal Care Plan Diagnoses
Diagnoses related to disorders of the gastrointestinal system.
| Gastrointestinal Care Plan Diagnoses |
|---|
| Appendectomy |
| Bowel Incontinence (Fecal Incontinence) |
| Cholecystectomy |
| Constipation |
| Diarrhea Nursing Care Plan and Management |
| Cholecystitis and Cholelithiasis |
| Gastroenteritis |
| Gastroesophageal Reflux Disease (GERD) |
| Hemorrhoids |
| Hepatitis |
| Ileostomy & Colostomy |
| Inflammatory Bowel Disease (IBD) |
| Intussusception |
| Liver Cirrhosis |
| Nausea & Vomiting |
| Pancreatitis |
| Peritonitis |
| Peptic Ulcer Disease |
| Subtotal Gastrectomy |
| Umbilical and Inguinal Hernia |
Hematologic and Lymphatic Care Plan Diagnoses
Diagnoses related to blood and lymphatic system disorders.
| Hematologic & Lymphatic Care Plan Diagnoses |
|---|
| Anaphylactic Shock |
| Anemia UPDATED! |
| Aortic Aneurysm |
| Bleeding Risk & Hemophilia |
| Deep Vein Thrombosis |
| Disseminated Intravascular Coagulation |
| Hemophilia |
| Kawasaki Disease |
| Leukemia |
| Lymphoma |
| Sepsis and Septicemia |
| Sickle Cell Anemia Crisis |
Infectious Diseases Care Plan Diagnoses
Diagnoses for communicable and infectious diseases.
| Infectious Diseases Care Plan Diagnoses |
|---|
| Acquired Immunodeficiency Syndrome (AIDS) (HIV Positive) |
| Acute Rheumatic Fever |
| Dengue Hemorrhagic Fever |
| Herpes Zoster (Shingles) |
| Influenza (Flu) |
| Pulmonary Tuberculosis |
| Risk for Infection & Infection Control |
Integumentary Care Plan Diagnoses
Diagnoses related to skin and tissue integrity disorders.
| Integumentary Care Plan Diagnoses |
|---|
| Burn Injury |
| Dermatitis |
| Herpes Zoster (Shingles) |
| Pressure Ulcer (Bedsores) |
| Wound Care and Skin/Tissue Integrity |
Maternal and Newborn Care Plan Diagnoses
Diagnoses for care of pregnant mothers and newborns.
| Maternal and Newborn Care Plans |
|---|
| Abortion (Termination of Pregnancy) |
| Cervical Insufficiency (Premature Dilation of the Cervix) |
| Cesarean Birth |
| Cleft Palate and Cleft Lip |
| Gestational Diabetes Mellitus |
| Hyperbilirubinemia (Jaundice) |
| Labor Stages, Induced, Augmented, Dysfunctional, Precipitous Labor |
| Neonatal Sepsis |
| Perinatal Loss (Miscarriage, Stillbirth) |
| Placental Abruption |
| Placenta Previa |
| Postpartum Hemorrhage |
| Postpartum Thrombophlebitis |
| Prenatal Hemorrhage |
| Preeclampsia and Gestational Hypertension |
| Prenatal Infection |
| Preterm Labor |
| Puerperal & Postpartum Infections |
| Substance (Alcohol and Drug) Abuse in Pregnancy |
Mental Health and Psychiatric Care Plan Diagnoses
Diagnoses related to mental health and psychiatric conditions.
| Mental Health and Psychiatric Care Plan Diagnoses |
|---|
| 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 Plan Diagnoses
Diagnoses related to disorders of the musculoskeletal system.
| Musculoskeletal Care Plan Diagnoses |
|---|
| Amputation |
| Congenital Hip Dysplasia |
| Fracture UPDATED! |
| Impaired Physical Mobility & Immobility |
| Juvenile Rheumatoid Arthritis |
| Laminectomy (Disc Surgery) |
| Osteoarthritis |
| Osteogenic Sarcoma (Osteosarcoma) |
| Osteoporosis |
| Rheumatoid Arthritis |
| Scoliosis |
| Spinal Cord Injury |
| Total Joint (Knee, Hip) Replacement |
Neurological Care Plan Diagnoses
Diagnoses for disorders of the nervous system.
| Neurological Care Plan Diagnoses |
|---|
| 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 Plan Diagnoses
Diagnoses related to eye disorders.
| Ophthalmic Care Plan Diagnoses |
|---|
| Cataracts |
| Glaucoma |
| Macular Degeneration |
Pediatric Nursing Care Plan Diagnoses
Diagnoses specific to pediatric patient care.
| Pediatric Nursing Care Plan Diagnoses |
|---|
| Child Abuse |
| Cleft Lip and Cleft Palate |
| Dying Child |
| Febrile Seizure |
| Hospitalized Child |
| Hydrocephalus |
| Otitis Media |
| Spina Bifida |
| Tonsillitis and Adenoiditis |
Reproductive Care Plan Diagnoses
Diagnoses related to reproductive and sexual function disorders.
| Reproductive Care Plan Diagnoses |
|---|
| Cryptorchidism (Undescended Testes) |
| Hysterectomy |
| Hypospadias and Epispadias |
| Mastectomy |
| Menopause |
| Prostatectomy |
Respiratory Care Plan Diagnoses
Diagnoses for disorders of the respiratory system.
| Respiratory Care Plan Diagnoses |
|---|
| Airway Clearance Therapy & Coughing |
| Apnea |
| Asthma UPDATED! |
| Aspiration Risk & Aspiration Pneumonia |
| Bronchiolitis UPDATED! |
| Bronchopulmonary Dysplasia (BPD) UPDATED! |
| Chronic Obstructive Pulmonary Disease (COPD) UPDATED! |
| Croup Syndrome |
| Cystic Fibrosis UPDATED! |
| Epiglottitis |
| Hemothorax and Pneumothorax UPDATED! |
| Ineffective Breathing Pattern (Dyspnea) |
| Impairment of Gas Exchange |
| Influenza (Flu) UPDATED! |
| Lung Cancer UPDATED! |
| Mechanical Ventilation |
| Near-Drowning |
| Pleural Effusion |
| Pneumonia |
| Pulmonary Embolism |
| Pulmonary Tuberculosis |
| Tracheostomy |
Urinary Care Plan Diagnoses
Diagnoses related to kidney and urinary system disorders.
| Urinary Care Plan Diagnoses |
|---|
| Acute Glomerulonephritis |
| Acute Renal Failure |
| Benign Prostatic Hyperplasia (BPH) |
| Chronic Renal Failure |
| Hemodialysis |
| Nephrotic Syndrome |
| Peritoneal Dialysis |
| Urolithiasis (Renal Calculi) |
| Urinary Elimination (Urinary Incontinence & Urinary Retention) |
| Urinary Tract Infection |
| Vesicoureteral Reflux (VUR) |
| Wilms Tumor (Nephroblastoma) |
Recommended Resources for Nursing Care Planning
To further enhance your nursing care planning skills, consider these recommended resources:
Ackley and Ladwig’s Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care: Valued for its evidence-based approach, this handbook provides a three-step system for client assessment, nursing diagnosis, and care planning, enhancing diagnostic reasoning and critical thinking skills.
Nursing Care Plans – Nursing Diagnosis & Intervention (10th Edition): Featuring over two hundred care plans with the latest evidence-based guidelines, this edition includes ICNP diagnoses and addresses contemporary health issues.
Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales: A quick-reference tool for accurate diagnoses and efficient care planning, updated with the latest nursing diagnoses and interventions for over 400 disorders.
Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care: This manual offers interventions for planning, individualizing, and documenting care for over 800 conditions, providing clinical applications, rationales, and documentation sections for each diagnosis.
All-in-One Nursing Care Planning Resource – E-Book: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health: Comprehensive resource with over 100 care plans across medical-surgical, maternity, pediatric, and psychiatric-mental health nursing, emphasizing interprofessional patient problem focus.
By utilizing this comprehensive list of nursing care plan diagnoses and following the outlined steps for care planning, nurses can significantly improve patient care quality, ensure consistent and individualized treatment, and contribute to better healthcare outcomes.
