What is a Nursing Care Plan in the Context of Medical Diagnosis?
A nursing care plan (NCP), especially when integrated with a medical diagnosis, is a meticulously structured process that not only pinpoints existing patient needs but also anticipates potential health issues and risks. It serves as a vital communication bridge between nurses, patients, and the broader healthcare team, all working synergistically to achieve optimal healthcare outcomes. In essence, the nursing care plan, deeply rooted in the medical diagnosis, ensures that patient care is not only consistent but also of the highest quality. Without this structured approach to care planning, particularly in relation to the medical diagnosis, the very foundation of effective and coordinated patient care would be significantly weakened.
The process of developing a nursing care plan, informed by a medical diagnosis, is initiated right at the patient’s admission and remains a dynamic document. It’s continuously refined and updated, adapting to the patient’s evolving health status and in response to ongoing evaluations of goal achievement. This dedication to personalized, patient-centered care, grounded in accurate medical diagnoses, is the cornerstone of excellence in modern nursing practice. It’s about treating the individual within the context of their diagnosed condition, ensuring that care is both effective and compassionate.
Types of Nursing Care Plans Based on Medical Diagnoses
Nursing care plans, especially when considering the medical diagnosis, can be broadly categorized as informal or formal. An informal nursing care plan is more of a mental strategy, a nurse’s internal roadmap for patient care. In contrast, a formal nursing care plan is a documented, tangible guide, whether written or digital, that systematically organizes all aspects of a patient’s care information, directly relating to their medical diagnosis.
Formal care plans, which are crucial for complex cases often arising from specific medical diagnoses, are further divided into standardized and individualized plans. Standardized care plans are pre-designed frameworks outlining care for patient groups with common, recurring needs based on typical medical diagnoses. Individualized care plans, on the other hand, are meticulously customized to address the unique needs of a specific patient, needs that are either not covered by a standardized plan or are particularly nuanced due to their specific medical diagnosis and personal circumstances.
Standardized Care Plans in Relation to Common Medical Diagnoses
Standardized care plans are invaluable pre-prepared resources, developed by experienced nursing staff and healthcare institutions. They are designed to guarantee consistent care for patients who share similar medical diagnoses or health conditions. These plans are instrumental in establishing baseline standards of care and optimizing the efficiency of nursing staff. By providing a ready-made structure for routine tasks associated with common medical diagnoses, they free up nurses’ time to focus on more complex and individualized aspects of patient care.
It’s important to note that standardized care plans, while incredibly useful for common medical diagnoses, are not designed to be a perfect fit for every patient’s unique situation and goals. However, they serve as an excellent starting point, a solid foundation upon which to build a more personalized approach. They provide a structured framework that can be adapted and refined to create an individualized care plan that truly meets the holistic needs of each patient, considering their specific medical diagnosis as a core element.
The care plans presented in this guide are primarily standardized care plans. They should be viewed as a flexible framework or direction, intended to be adapted and individualized to meet the specific needs of each patient and their unique medical diagnosis.
Individualized Care Plans for Complex Medical Diagnoses
An individualized care plan is essential when dealing with the complexities of diverse medical diagnoses. It involves carefully tailoring a standardized care plan to align with the specific needs, preferences, and goals of an individual patient. This customization process uses evidence-based approaches known to be effective for patients with similar medical diagnoses but acknowledges the nuances of each case. This patient-centered approach ensures more personalized and holistic care, finely tuned to the patient’s unique circumstances, strengths, and objectives, all within the context of their medical diagnosis.
Moreover, individualized care plans, especially when thoughtfully developed in response to a medical diagnosis, can significantly enhance patient satisfaction. When patients perceive that their care is specifically designed for them, taking into account their medical diagnosis and personal needs, they are more likely to feel understood and valued. This sense of personalized attention directly translates to increased satisfaction with their overall healthcare experience. In today’s healthcare landscape, where patient satisfaction is increasingly recognized as a key indicator of quality care, the individualized nursing care plan, driven by a thorough medical diagnosis, is more important than ever.
Tips on how to individualize a nursing care plan based on medical diagnoses:
- Thoroughly assess the patient’s specific condition and needs related to their medical diagnosis: Go beyond the general guidelines for the diagnosis and delve into the patient’s unique presentation, symptoms, and responses.
- Incorporate patient preferences and values: Understand the patient’s perspective on their illness and treatment, aligning the care plan with their personal beliefs and cultural background.
- Collaborate with the patient and family: Involve them actively in the planning process to ensure the care plan resonates with their needs and goals.
- Regularly review and adjust the plan: Patient conditions and responses to treatment can change. Continuous evaluation and adaptation are crucial for maintaining the plan’s effectiveness.
- Utilize interdisciplinary input: Seek insights from physicians, therapists, and other specialists involved in the patient’s care to create a truly comprehensive and individualized plan.
Objectives of a Nursing Care Plan in Relation to Medical Diagnosis
The overarching goals and objectives of developing a nursing care plan, particularly when considering the medical diagnosis, are multifaceted and patient-centric:
- Promote evidence-based nursing care aligned with medical diagnoses: Ensure that all nursing interventions are grounded in the latest research and best practices relevant to the patient’s specific medical diagnosis, creating a safe and predictable care environment.
- Support holistic care, integrating medical diagnosis with patient well-being: Address the patient as a whole person – physically, psychologically, socially, and spiritually – while managing and preventing disease progression in alignment with their medical diagnosis.
- Establish standardized care pathways and care bundles based on medical diagnoses: Develop structured approaches that streamline care delivery for specific medical diagnoses, ensuring consistent and effective treatment protocols across the healthcare team. Care pathways facilitate team consensus on care standards and expected outcomes, while care bundles focus on best practices for specific disease management.
- Clearly define and differentiate between goals and expected outcomes in the context of medical diagnosis: Establish measurable benchmarks for patient progress that are directly linked to the medical diagnosis, allowing for objective evaluation of the care plan’s effectiveness.
- Enhance communication and documentation of care plans, especially concerning medical diagnoses: Improve clarity and accuracy in recording all aspects of the care plan, ensuring that the medical diagnosis is central to all communication among healthcare providers.
- Provide a framework for measuring and evaluating nursing care effectiveness in relation to medical diagnoses: Create a system for ongoing assessment of nursing interventions, ensuring they are effectively addressing patient needs and improving outcomes as defined by their medical diagnosis.
Purposes and Importance of a Nursing Care Plan in Patient Care and Medical Diagnosis
The purposes and significance of creating a nursing care plan, especially one that is meticulously linked to a medical diagnosis, are profound and far-reaching:
- Defines the nurse’s independent role within the context of a medical diagnosis: Care plans underscore the unique and autonomous role of nurses in addressing patients’ overall health and well-being, going beyond simply following physician’s orders to provide comprehensive care informed by the medical diagnosis.
- Provides a roadmap for individualized patient care based on their medical diagnosis: It acts as a detailed guide for the care provided, enabling nurses to apply critical thinking in developing interventions that are precisely tailored to the individual patient’s needs arising from their specific medical diagnosis.
- Ensures continuity of care across healthcare settings and shifts, informed by the medical diagnosis: By providing a consistent reference point, care plans enable nurses across different shifts and departments to deliver the same high-quality, diagnosis-driven interventions, maximizing the benefits of treatment for patients.
- Facilitates coordinated care among the interdisciplinary healthcare team, centered around the medical diagnosis: Care plans ensure that all team members are fully aware of the patient’s care needs and the necessary actions, preventing gaps in care and promoting a unified approach to managing the medical diagnosis.
- Serves as essential documentation of care provided, linked to the medical diagnosis: It accurately outlines necessary observations, nursing actions, and patient/family instructions. Proper documentation in the care plan provides evidence of care delivery and its alignment with the medical diagnosis. Undocumented care is essentially care not provided in the eyes of legal and regulatory bodies.
- Guides staff assignments based on patient needs and medical diagnosis: In situations where patient care requires specific skills or expertise related to their medical diagnosis, the care plan assists in assigning the most appropriately qualified staff.
- Enables progress monitoring and care plan adjustments in response to the medical diagnosis: Care plans facilitate tracking patient progress and allow for necessary modifications as the patient’s health status and goals evolve in relation to their medical diagnosis.
- Provides a basis for reimbursement and healthcare resource allocation related to medical diagnosis: Insurance companies and healthcare administrators use medical records, including care plans, to determine appropriate reimbursement for hospital care and to justify resource allocation based on the complexity and needs associated with different medical diagnoses.
- Clarifies patient goals and promotes patient involvement in their care and medical diagnosis: Care plans benefit both nurses and patients by actively involving patients in their treatment decisions and care planning, fostering a sense of ownership and collaboration in managing their medical diagnosis.
Key Components of a Nursing Care Plan in Relation to Medical Diagnosis
A comprehensive nursing care plan (NCP), particularly one that is effectively integrated with a medical diagnosis, typically includes several essential components: nursing diagnoses, client problems, expected outcomes, nursing interventions, and rationales. Each of these components plays a crucial role in ensuring that the care plan is both effective and patient-centered, grounded in the medical diagnosis.
Care Plan Formats for Documenting Medical Diagnosis and Nursing Interventions
Nursing care plan formats are generally structured using columns to organize information logically. Common formats include three-column and four-column plans, each designed to efficiently present the key elements of a care plan in relation to the medical diagnosis. Some healthcare facilities may also use a five-column format for even more detailed planning.
Three-Column Format: Integrating Medical Diagnosis, Outcomes, and Interventions
The three-column format is a streamlined approach, featuring columns for: (1) nursing diagnosis (often derived from or directly related to the medical diagnosis), (2) outcomes and evaluation, and (3) nursing interventions. This format efficiently links the identified health issues, desired results, and planned actions in a concise manner.
Three-column nursing care plan format
Four-Column Format: Detailed Planning for Medical Diagnosis and Care
The four-column format offers a more detailed structure, with columns for: (1) nursing diagnosis (reflecting the patient’s response to their medical diagnosis), (2) goals and outcomes, (3) interventions, and (4) evaluation. This format provides a clearer separation of goals and evaluation, allowing for more specific and measurable outcome criteria and a more thorough evaluation process.
Four-column nursing care plan template
Below is a downloadable document containing sample templates for various nursing care plan formats. These templates can be adapted and modified for use in clinical practice or educational settings.
Download: Printable Nursing Care Plan Templates and Formats
Student Care Plans: Emphasizing Rationale and Medical Diagnosis Understanding
Student care plans are intentionally more comprehensive and detailed than those used by practicing nurses. They serve as a crucial learning tool for nursing students, helping them to deeply understand the rationale behind each intervention and the relationship between medical diagnoses and nursing care.
Student nursing care plans are more detailed.
Typically, student nursing care plans are handwritten and include an additional column for “Rationale” or “Scientific Explanation” following the nursing interventions column. These rationales require students to articulate the scientific principles that justify the selection of each nursing intervention, reinforcing their understanding of the underlying pathophysiology and evidence-based practice related to the medical diagnosis.
Writing a Nursing Care Plan: Step-by-Step Guide Integrating Medical Diagnosis
Creating an effective nursing care plan (NCP) that is truly integrated with the medical diagnosis requires a systematic approach. Follow these steps to develop a comprehensive and patient-centered care plan.
Step 1: Comprehensive Data Collection and Assessment, Guided by Medical Diagnosis
The initial step in crafting a nursing care plan is to establish a thorough client database. This involves utilizing various assessment techniques and data collection methods, including physical assessments, health history interviews, medical record reviews, and relevant diagnostic studies. The medical diagnosis serves as a critical guide during this phase, directing the nurse to focus on specific data points and assessments relevant to the patient’s condition. A comprehensive client database encompasses all pertinent health information gathered. This step is crucial for identifying related or risk factors and defining characteristics that will be used to formulate accurate nursing diagnoses that complement the medical diagnosis. Many healthcare agencies and nursing schools provide specific assessment formats to ensure consistency and completeness in data collection.
Critical thinking is paramount during patient assessment. It involves synthesizing knowledge from various scientific disciplines and professional guidelines to inform clinical judgments. This process is essential for complex clinical decision-making and aims to effectively identify patients’ healthcare needs, leveraging a supportive environment and reliable information, all within the context of their medical diagnosis.
Step 2: Data Analysis and Organization in Relation to Medical Diagnosis
Once comprehensive patient data is collected, the next step is to analyze, cluster, and organize this information. This process is heavily influenced by the medical diagnosis, as it provides a framework for understanding the patient’s health issues. The goal is to formulate relevant nursing diagnoses, prioritize identified problems, and define desired outcomes that are all directly linked to the medical diagnosis.
Step 3: Formulating Nursing Diagnoses Based on Medical Assessment
Nursing diagnoses provide a standardized language for identifying and addressing specific patient needs and responses to health problems, both actual and potential. They focus on issues that can be prevented or resolved through independent nursing interventions, working in concert with the overall medical treatment plan. These diagnoses are carefully formulated based on the collected patient data and are directly related to the medical diagnosis.
Detailed guidance on formulating nursing diagnoses is available in this resource: Nursing Diagnosis (NDx): Complete Guide and List.
Step 4: Setting Priorities Based on Patient Needs and Medical Diagnosis
Prioritizing nursing diagnoses and interventions involves establishing a logical sequence for addressing patient problems. This step requires collaboration between the nurse and the patient to determine which issues require immediate attention. Prioritization is often guided by the severity and urgency of the problems, as well as the patient’s overall condition and medical diagnosis. Diagnoses are typically categorized as high, medium, or low priority. Life-threatening problems, especially those directly related to the medical diagnosis, are always given the highest priority.
Maslow’s Hierarchy of Needs provides a valuable framework for prioritizing care and aligning it with patient-centered outcomes. This hierarchy, developed by Abraham Maslow, emphasizes that basic physiological needs must be met before higher-level needs can be addressed. Physiological and safety needs form the foundation of nursing care and interventions, particularly in the context of a medical diagnosis.
Maslow’s Hierarchy of Needs in Nursing Care Planning:
- Basic Physiological Needs: These are the most fundamental needs, including nutrition (water and food), elimination, airway management (suctioning), breathing support (oxygen therapy), circulation monitoring (pulse, cardiac monitor, blood pressure), sleep, sex, shelter, and exercise. Addressing these needs is paramount, especially when a patient’s physiological stability is compromised by their medical diagnosis.
- Safety and Security: Once physiological needs are met, safety and security become priorities. This includes injury prevention (using side rails, call lights, hand hygiene, isolation protocols, suicide precautions, fall precautions, car seats, helmets, seat belts), fostering a climate of trust and safety (therapeutic relationships), and patient education on managing modifiable risk factors related to their medical diagnosis (e.g., risk factors for stroke or heart disease).
- Love and Belonging: Addressing social and emotional needs is crucial for holistic care. This involves fostering supportive relationships, implementing strategies to prevent social isolation (bullying prevention), employing active listening techniques, therapeutic communication, and addressing needs related to sexual intimacy.
- Self-Esteem: Supporting the patient’s sense of self-worth and accomplishment is important for their overall well-being. This includes promoting acceptance within the community, recognizing workforce contributions, celebrating personal achievements, fostering a sense of control or empowerment, and supporting acceptance of one’s physical appearance.
- Self-Actualization: At the highest level of the hierarchy, self-actualization involves creating an empowering environment that supports spiritual growth, the ability to understand diverse perspectives, and the patient’s journey towards reaching their full potential.
Virginia Henderson’s 14 Needs as applied to Maslow’s Hierarchy of Needs. Learn more about it here.
When setting priorities, nurses must consider various factors, including the patient’s health values, beliefs, available resources, and the urgency of the situation, all within the context of their medical diagnosis. Actively involving the patient in this process enhances their cooperation and commitment to the care plan.
Step 5: Defining Client Goals and Desired Outcomes Aligned with Medical Diagnosis
After prioritizing nursing diagnoses, the nurse and the patient collaboratively establish goals for each priority. Goals or desired outcomes articulate what the nurse aims to achieve through implementing nursing interventions derived from the patient’s nursing diagnoses, which are in turn informed by the medical diagnosis. Goals provide direction for planning interventions, serve as benchmarks for evaluating patient progress, and enable both the patient and nurse to track problem resolution and experience a sense of accomplishment.
Examples of goals and desired outcomes. Notice how they’re formatted and written.
For each nursing diagnosis, one overarching goal is typically defined. The terms “goal outcomes“ and “expected outcomes” are often used interchangeably.
Effective goals should adhere to the SMART criteria, as outlined by Hamilton and Price (2013). SMART goals are:
- Specific: Clearly defined, significant, and sensible.
- Measurable or Meaningful: Quantifiable and allows for tracking progress towards the desired result.
- Attainable or Action-Oriented: Feasible and achievable, yet may require effort.
- Realistic or Results-Oriented: Achievable given available resources and patient circumstances.
- Timely or Time-Oriented: Has a defined timeframe or deadline for achievement.
Hogston (2011) proposes the REEPIG standards to ensure high-quality care plans:
- Realistic: Achievable with available resources.
- Explicitly stated: Clear and unambiguous, leaving no room for misinterpretation.
- Evidence-based: Supported by research and best practices.
- Prioritized: Addresses the most urgent problems first.
- Involve: Includes the patient and relevant members of the multidisciplinary team.
- Goal-centered: Designed to meet and achieve the established goals.
Short-Term and Long-Term Goals in Relation to Medical Diagnosis and Recovery
Goals and expected outcomes must be measurable and client-centered. They should focus on problem prevention, resolution, and rehabilitation, all within the context of the patient’s medical diagnosis. Goals can be categorized as short-term or long-term. In acute care settings, short-term goals are often prioritized due to the immediate needs of patients. Long-term goals are more relevant for patients with chronic health conditions or those receiving care in home, nursing home, or extended-care facilities, focusing on sustained management of their medical diagnosis.
- Short-term goal: Describes an achievable change in behavior or status expected within a short timeframe, typically hours or days.
- Long-term goal: Defines an objective to be achieved over a more extended period, usually weeks or months, often related to managing the long-term implications of a medical diagnosis.
- Discharge planning: Focuses on long-term goals that promote continued restorative care and problem resolution through home health services, physical therapy, or other referral sources, ensuring ongoing support after hospital discharge related to their medical diagnosis.
Components of Well-Defined Goals and Desired Outcomes in Nursing Care Plans
Goal and desired outcome statements typically include four key components: a subject, a verb, conditions or modifiers, and a criterion of desired performance.
Components of goals and desired outcomes in a nursing care plan.
- Subject: The client, a part of the client, or an attribute of the client (e.g., pulse rate, temperature, urinary output). Often omitted as it is assumed to be the client unless otherwise specified (e.g., family, significant other).
- Verb: Specifies the action the client is expected to perform, learn, or experience.
- Conditions or modifiers: Clarify the circumstances under which the behavior is to be performed (what, when, where, how).
- Criterion of desired performance: Indicates the standard for evaluating performance or the level at which the client will perform the specified behavior. This component is optional but enhances measurability.
Key tips for writing effective goals and desired outcomes:
- Frame goals and outcomes in terms of client responses, not nurse activities. Start each goal with “Client will […]” to maintain client-centered focus.
- Avoid stating goals as what the nurse hopes to achieve; instead, focus on what the client will do.
- Use observable, measurable terms for outcomes. Avoid vague language that requires subjective interpretation.
- Ensure desired outcomes are realistic considering the client’s resources, capabilities, limitations, and the timeframe of care.
- Verify that goals are consistent with therapies prescribed by other healthcare professionals.
- Ensure each goal is derived from only one nursing diagnosis to facilitate clear evaluation of care effectiveness.
- Finally, confirm that the client considers the goals important and values them to foster cooperation and engagement in the care plan.
Step 6: Selecting Nursing Interventions Based on Medical Diagnosis and Goals
Nursing interventions are the specific actions or activities that nurses implement to help patients achieve their goals. Interventions should be chosen to address the root cause or contributing factors of the priority nursing problem or diagnosis, always considering the medical diagnosis. For risk nursing problems, interventions should focus on mitigating the identified risk factors. Nursing interventions are identified and documented during the planning phase of the nursing process but are actually carried out during the implementation phase.
Types of Nursing Interventions: Independent, Dependent, and Collaborative
Nursing interventions can be categorized as independent, dependent, or collaborative:
Types of nursing interventions in a care plan.
- Independent nursing interventions are actions that nurses are authorized to initiate based on their professional judgment and skills. These include ongoing assessment, emotional support, providing comfort, teaching, physical care, and making referrals to other healthcare professionals.
- Dependent nursing interventions are actions carried out under the orders or supervision of a physician or other authorized healthcare provider. These typically include administering medications, intravenous therapy, ordering diagnostic tests, and implementing specific treatments, diets, or activity/rest regimens. Nurses also play a crucial role in assessing patients and providing explanations when implementing medical orders.
- Collaborative interventions involve actions that nurses carry out in conjunction with other members of the healthcare team, such as physicians, social workers, dietitians, and therapists. These interventions are developed through consultation to leverage the expertise of various professionals and ensure comprehensive patient care.
Effective nursing interventions should be:
- Safe and appropriate for the client’s age, health status, and condition, and aligned with their medical diagnosis.
- Achievable given available resources and time constraints.
- Consistent with the client’s values, culture, and beliefs.
- Compatible with other planned therapies.
- Grounded in nursing knowledge, experience, and relevant scientific principles.
Key tips for writing clear and effective nursing interventions:
- Date and sign the care plan to ensure accountability and facilitate future review and planning.
- Interventions should be specific and clearly stated, beginning with an action verb that precisely describes the nurse’s expected action. Include qualifiers specifying how, when, where, timing, frequency, and amount to provide complete details of the planned activity. Examples: “Educate parents on how to take temperature and report any changes,” or “Assess urine for color, amount, odor, and turbidity every shift.”
- Use only abbreviations that are approved and accepted by the healthcare institution to maintain clarity and avoid errors.
Step 7: Providing Rationale for Nursing Interventions in Relation to Medical Diagnosis
Rationales, also known as scientific explanations, are crucial for justifying the selection of specific nursing interventions within the NCP. They explain why a particular intervention is chosen and how it is expected to address the patient’s needs, especially in relation to their medical diagnosis.
Sample nursing interventions and rationale for a care plan (NCP)
Rationales are typically included in student care plans to enhance learning and help students connect pathophysiological and psychological principles with their chosen nursing interventions. They are less commonly included in routine care plans used by practicing nurses but remain an essential element of evidence-based practice.
Step 8: Evaluation of Care Plan Effectiveness and Patient Progress Based on Medical Diagnosis
Evaluation is a systematic, ongoing, and purposeful process to assess the patient’s progress toward achieving the established goals and desired outcomes. It also involves evaluating the effectiveness of the nursing care plan (NCP) in addressing the patient’s needs related to their medical diagnosis. Evaluation is a critical phase of the nursing process as it determines whether nursing interventions should be continued, modified, or discontinued. The findings from the evaluation inform adjustments to the care plan to optimize patient outcomes.
Step 9: Documenting the Nursing Care Plan for Communication and Continuity
The patient’s care plan is meticulously documented according to hospital policy and becomes an integral part of the patient’s permanent medical record. This documentation is essential for communication among healthcare providers, especially during shift changes and interdepartmental transfers. Different nursing programs and healthcare institutions may utilize various care plan formats, but most are designed to systematically follow the interrelated steps of the nursing process. A common format is the five-column plan, which provides a comprehensive structure for documenting all aspects of patient care.
Comprehensive Nursing Care Plan List: Organized by Medical Diagnosis and Specialty
This section provides an extensive list of sample nursing care plans (NCPs) and nursing diagnoses categorized by medical specialties and health conditions. These resources are designed to assist nurses in developing effective care plans tailored to diverse patient needs and medical diagnoses.
Basic Nursing and General Care Plans: Foundational Resources
These miscellaneous nursing care plan examples cover a broad range of general patient needs and conditions that may not fit into specific medical specialties.
| 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: Pre- and Post-Operative Guidance
These care plans focus on patients undergoing surgical intervention, covering pre-operative and post-operative nursing care needs.
| 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: Cardiovascular Health Management
Nursing care plans addressing various diseases of the cardiovascular system.
| Cardiac Care Plans |
|---|
| Angina Pectoris (Coronary Artery Disease) |
| Cardiac Arrhythmia (Digitalis Toxicity) |
| Cardiac Catheterization |
| Cardiogenic Shock |
| Congenital Heart Disease |
| Decreased Cardiac Output & Cardiac Support |
| Heart Failure UPDATED! |
| Hypertension UPDATED! |
| Hypovolemic Shock |
| Impaired Tissue Perfusion & Ischemia |
| Myocardial Infarction |
| Pacemaker Therapy |
Endocrine and Metabolic Care Plans: Hormonal and Metabolic Balance
Nursing care plans (NCP) related to the endocrine system and metabolic disorders.
| Endocrine and Metabolic Care Plans |
|---|
| Addison’s Disease |
| Cushing’s Disease |
| Diabetes Mellitus (Type 1, Type 2) UPDATED! |
| Diabetic Ketoacidosis (DKA) and Hyperglycemic Hyperosmolar Nonketotic Syndrome (HHNS) |
| Eating Disorders: Anorexia & Bulimia Nervosa |
| Fluid Volume Deficit (Dehydration & Hypovolemia) |
| Fluid Volume Excess (Hypervolemia) |
| Gestational Diabetes Mellitus |
| Hyperthyroidism |
| Hypothyroidism |
| Imbalanced Nutrition (Malnutrition) |
| Obesity & Overweight |
| Thyroidectomy |
| Unstable Blood Glucose Levels (Hyperglycemia & Hypoglycemia) |
| Acid-Base Imbalances |
|---|
| Metabolic Acidosis |
| Metabolic Alkalosis |
| Respiratory Acidosis |
| Respiratory Alkalosis |
| Electrolyte Imbalances |
|---|
| Calcium (Ca) Imbalances: Hypercalcemia and Hypocalcemia |
| Magnesium (Mg) Imbalances: Hypermagnesemia and Hypomagnesemia |
| Potassium (K) Imbalances: Hyperkalemia and Hypokalemia |
| Sodium (Na) Imbalances: Hypernatremia and Hyponatremia |
Gastrointestinal Care Plans: Digestive Health and Disorders
Care plans (NCP) addressing disorders of the gastrointestinal and digestive system.
| Gastrointestinal Care Plans |
|---|
| Appendectomy |
| Bowel Incontinence (Fecal Incontinence) |
| Cholecystectomy |
| Constipation |
| Diarrhea Nursing Care Plan and Management |
| Cholecystitis and Cholelithiasis |
| Gastroenteritis |
| Gastroesophageal Reflux Disease (GERD) |
| Hemorrhoids |
| Hepatitis |
| Ileostomy & Colostomy |
| Inflammatory Bowel Disease (IBD) |
| Intussusception |
| Liver Cirrhosis |
| Nausea & Vomiting |
| Pancreatitis |
| Peritonitis |
| Peptic Ulcer Disease |
| Subtotal Gastrectomy |
| Umbilical and Inguinal Hernia |
Hematologic and Lymphatic Care Plans: Blood and Lymph System Support
Care plans related to the hematologic and lymphatic system.
| Hematologic & Lymphatic Care Plans |
|---|
| Anaphylactic Shock |
| Anemia UPDATED! |
| Aortic Aneurysm |
| Bleeding Risk & Hemophilia |
| Deep Vein Thrombosis |
| Disseminated Intravascular Coagulation |
| Hemophilia |
| Kawasaki Disease |
| Leukemia |
| Lymphoma |
| Sepsis and Septicemia |
| Sickle Cell Anemia Crisis |
Infectious Diseases Care Plans: Managing and Preventing Infections
NCPs for communicable and infectious diseases.
| Infectious Diseases Care Plans |
|---|
| Acquired Immunodeficiency Syndrome (AIDS) (HIV Positive) |
| Acute Rheumatic Fever |
| Dengue Hemorrhagic Fever |
| Herpes Zoster (Shingles) |
| Influenza (Flu) |
| Pulmonary Tuberculosis |
| Risk for Infection & Infection Control |
Integumentary Care Plans: Skin and Tissue Integrity
Focus on disorders and conditions affecting the integumentary system.
| Integumentary Care Plans |
|---|
| Burn Injury |
| Dermatitis |
| Herpes Zoster (Shingles) |
| Pressure Ulcer (Bedsores) |
| Wound Care and Skin/Tissue Integrity |
Maternal and Newborn Care Plans: Pregnancy and Infancy
Nursing care plans for the care of pregnant mothers and their newborns, covering maternity and obstetric nursing.
| Maternal and Newborn Care Plans |
|---|
| Abortion (Termination of Pregnancy) |
| Cervical Insufficiency (Premature Dilation of the Cervix) |
| Cesarean Birth |
| Cleft Palate and Cleft Lip |
| Gestational Diabetes Mellitus |
| Hyperbilirubinemia (Jaundice) |
| Labor Stages, Induced, Augmented, Dysfunctional, Precipitous Labor |
| Neonatal Sepsis |
| Perinatal Loss (Miscarriage, Stillbirth) |
| Placental Abruption |
| Placenta Previa |
| Postpartum Hemorrhage |
| Postpartum Thrombophlebitis |
| Prenatal Hemorrhage |
| Preeclampsia and Gestational Hypertension |
| Prenatal Infection |
| Preterm Labor |
| Puerperal & Postpartum Infections |
| Substance (Alcohol and Drug) Abuse in Pregnancy |
Mental Health and Psychiatric Care Plans: Emotional and Behavioral Well-being
Care plans for mental health and psychiatric nursing.
| Mental Health and Psychiatric Care Plans |
|---|
| Alcohol Withdrawal |
| Anxiety & Fear |
| Anxiety and Panic Disorders |
| Bipolar Disorders |
| Body Image Disturbance & Self-Esteem |
| Impaired Thought Processes & Cognitive Impairment |
| Major Depression |
| Personality Disorders |
| Schizophrenia |
| Sexual Assault |
| Substance Dependence and Abuse |
| Suicide Behaviors |
Musculoskeletal Care Plans: Mobility and Physical Function
Care plans related to the musculoskeletal system.
| Musculoskeletal Care Plans |
|---|
| Amputation |
| Congenital Hip Dysplasia |
| Fracture UPDATED! |
| Impaired Physical Mobility & Immobility |
| Juvenile Rheumatoid Arthritis |
| Laminectomy (Disc Surgery) |
| Osteoarthritis |
| Osteogenic Sarcoma (Osteosarcoma) |
| Osteoporosis |
| Rheumatoid Arthritis |
| Scoliosis |
| Spinal Cord Injury |
| Total Joint (Knee, Hip) Replacement |
Neurological Care Plans: Brain and Nervous System Health
Nursing care plans (NCP) for disorders related to the nervous system.
| Neurological Care Plans |
|---|
| Alzheimer’s Disease UPDATED! |
| Brain Tumor |
| Cerebral Palsy |
| Cerebrovascular Accident (Stroke) UPDATED! |
| Guillain-Barre Syndrome |
| Meningitis |
| Multiple Sclerosis |
| Parkinson’s Disease |
| Seizure Disorder |
| Spinal Cord Injury |
Ophthalmic Care Plans: Eye Health and Vision
Care plans relating to eye disorders.
| Ophthalmic Care Plans |
|---|
| Cataracts |
| Glaucoma |
| Macular Degeneration |
Pediatric Nursing Care Plans: Child and Adolescent Health
Nursing care plans (NCP) for pediatric conditions and diseases.
| Pediatric Nursing Care Plans |
|---|
| Child Abuse |
| Cleft Lip and Cleft Palate |
| Dying Child |
| Febrile Seizure |
| Hospitalized Child |
| Hydrocephalus |
| Otitis Media |
| Spina Bifida |
| Tonsillitis and Adenoiditis |
Reproductive Care Plans: Sexual and Reproductive Health
Care plans related to reproductive and sexual function disorders.
| Reproductive Care Plans |
|---|
| Cryptorchidism (Undescended Testes) |
| Hysterectomy |
| Hypospadias and Epispadias |
| Mastectomy |
| Menopause |
| Prostatectomy |
Respiratory Care Plans: Lung and Breathing Support
Care plans for respiratory system disorders.
| Respiratory Care Plans |
|---|
| Airway Clearance Therapy & Coughing |
| Apnea |
| Asthma UPDATED! |
| Aspiration Risk & Aspiration Pneumonia |
| Bronchiolitis UPDATED! |
| Bronchopulmonary Dysplasia (BPD) UPDATED! |
| Chronic Obstructive Pulmonary Disease (COPD) UPDATED! |
| Croup Syndrome |
| Cystic Fibrosis UPDATED! |
| Epiglottitis |
| Hemothorax and Pneumothorax UPDATED! |
| Ineffective Breathing Pattern (Dyspnea) |
| Impairment of Gas Exchange |
| Influenza (Flu) UPDATED! |
| Lung Cancer UPDATED! |
| Mechanical Ventilation |
| Near-Drowning |
| Pleural Effusion |
| Pneumonia |
| Pulmonary Embolism |
| Pulmonary Tuberculosis |
| Tracheostomy |
Urinary Care Plans: Kidney and Urinary Tract Health
Care plans related to the kidney and urinary system disorders.
| Urinary Care Plans |
|---|
| Acute Glomerulonephritis |
| Acute Renal Failure |
| Benign Prostatic Hyperplasia (BPH) |
| Chronic Renal Failure |
| Hemodialysis |
| Nephrotic Syndrome |
| Peritoneal Dialysis |
| Urolithiasis (Renal Calculi) |
| Urinary Elimination (Urinary Incontinence & Urinary Retention) |
| Urinary Tract Infection |
| Vesicoureteral Reflux (VUR) |
| Wilms Tumor (Nephroblastoma) |
Recommended Resources for Nursing Diagnosis and Care Planning
Recommended nursing diagnosis and nursing care plan books and resources for further learning and clinical practice.
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Ackley and Ladwig’s Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning CareThis handbook is highly recommended for its evidence-based approach to nursing interventions. It offers a user-friendly, three-step system for client assessment, nursing diagnosis, and care planning. It includes detailed instructions on implementing care and evaluating outcomes, enhancing diagnostic reasoning and critical thinking skills.
Nursing Care Plans – Nursing Diagnosis & Intervention (10th Edition)This comprehensive resource features over two hundred care plans based on the latest evidence-based guidelines. The new edition includes ICNP diagnoses, care plans addressing LGBTQ health issues, and topics on electrolytes and acid-base balance.
Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales A quick and essential reference tool for identifying accurate diagnoses and planning efficient patient care. The sixteenth edition includes the most current nursing diagnoses and interventions, with an alphabetized listing of nursing diagnoses covering over 400 disorders.
Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care This manual helps identify interventions for planning, individualizing, and documenting care for more than 800 diseases and disorders. It provides subjective and objective data for each diagnosis, sample clinical applications, prioritized actions/interventions with rationales, and documentation guidelines.
All-in-One Nursing Care Planning Resource – E-Book: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health This resource includes over 100 care plans across medical-surgical, maternity/OB, pediatrics, and psychiatric-mental health nursing. It uses interprofessional “patient problems” to enhance communication and patient interaction skills.
References and Further Reading
Recommended reading materials and sources for this NCP guide.
