Nursing care plans are essential tools in healthcare, acting as a roadmap for nurses to deliver patient-centered care. Crafting the best nursing care plan demands a structured, step-by-step process, ensuring all critical components are accurately addressed. This guide provides a detailed walkthrough on developing effective care plans, serving as a comprehensive resource for both student and professional nurses. We offer an ultimate database and list of nursing care plans (NCP) and nursing diagnosis examples, all freely accessible. This resource includes care plan components, objectives, purposes, and examples, along with a detailed guide and templates to assist in writing excellent nursing care plans for any unit.
Table of Contents
What is a Nursing Care Plan?
A nursing care plan (NCP) is a structured, formal process designed to pinpoint a patient’s existing health needs and to anticipate potential future needs or risks. Care plans are vital for fostering clear communication among nurses, patients, and the broader healthcare team, all working together to achieve specific health outcomes. Without a robust nursing care planning process, the quality and consistency of patient care would significantly suffer.
The process of nursing care planning begins right upon a patient’s admission and is continuously refined and updated. This dynamic approach ensures the care plan adapts to the patient’s evolving condition and reflects ongoing evaluations of goal achievement. At its core, planning and delivering individualized, patient-centered care is the cornerstone of excellence in nursing practice. It ensures that each patient receives care that is specifically tailored to their unique circumstances and health goals.
Types of Nursing Care Plans
Nursing care plans can be broadly categorized as informal or formal, and further refined into standardized and individualized types. An informal nursing care plan is essentially a mental strategy, a nurse’s internal plan of action. In contrast, a formal nursing care plan is a documented guide, either written or digital, that systematically organizes all relevant patient care information. This formal documentation ensures that care is consistent, comprehensive, and easily communicated among the healthcare team.
Formal care plans are further divided into standardized and individualized approaches. Standardized care plans are pre-established guidelines detailing nursing care for patients with common, recurring needs. These plans ensure consistent baseline care for typical conditions. Individualized care plans, however, are specifically tailored to address a patient’s unique needs—needs that go beyond the scope of standardized plans or are not covered by them at all. These plans are crucial for addressing the complexities of individual patient situations and preferences.
Standardized Care Plans
Standardized care plans are essentially pre-designed templates developed by nursing staff and healthcare organizations to guarantee that patients with similar conditions receive consistent, baseline care. These plans are designed to meet a minimum acceptable standard of care efficiently, optimizing nurses’ time by eliminating the need to repeatedly create plans for common patient needs within a nursing unit. They are particularly useful for routine conditions and procedures, ensuring that fundamental aspects of care are consistently addressed.
While standardized care plans offer a solid starting point, they are intentionally not tailored to individual patient needs and goals. They serve as a foundational framework, a stepping stone toward developing a more personalized approach through an individualized care plan. Think of them as a baseline from which more specific and patient-centered care strategies can be built.
The care plans presented in this guide are examples of standard care plans. They are intended to serve as a framework or direction, guiding nurses in the development of individualized care plans that are specifically adapted to meet the unique needs of each patient.
Individualized Care Plans
An individualized care plan takes a standardized care plan and customizes it to meet the precise needs and goals of a specific patient. This involves incorporating approaches known to be particularly effective for that individual, considering their unique health status, preferences, and circumstances. This personalized approach ensures more targeted and holistic care, aligning interventions with the patient’s specific strengths, challenges, and desired outcomes. It recognizes that each patient is unique and deserves a care strategy that reflects that uniqueness.
Furthermore, individualized care plans are known to enhance patient satisfaction. When patients perceive that their care is directly tailored to their personal needs, they feel more valued, understood, and involved in their healthcare journey. This heightened sense of engagement and personalization often translates to greater satisfaction with their overall care experience. In today’s healthcare landscape, where patient satisfaction is increasingly used as a critical metric for quality, the role of individualized care plans is more important than ever.
Tips on how to individualize a nursing care plan: (This section is intentionally kept as a placeholder to be expanded upon with detailed tips in a more comprehensive version of the article, focusing on actionable advice for nurses.)
Objectives
Writing a nursing care plan serves several key objectives, all aimed at enhancing the quality and effectiveness of patient care:
- Promote evidence-based nursing care and establish a comfortable and familiar environment within hospitals or health centers. By grounding care plans in the latest research and best practices, nurses ensure they are delivering the most effective interventions. Creating a familiar environment helps reduce patient anxiety and promotes healing.
- Support holistic care, addressing the patient as a whole—physical, psychological, social, and spiritual dimensions—in both disease management and prevention. This comprehensive approach recognizes that health is multifaceted and care should extend beyond just physical symptoms.
- Establish structured care programs like care pathways and care bundles. Care pathways facilitate a team consensus on care standards and expected outcomes, ensuring coordinated and efficient care delivery. Care bundles, on the other hand, are sets of best practices for specific conditions, streamlining the application of evidence-based interventions.
- Clearly define goals and expected outcomes. This ensures that everyone on the healthcare team understands what is being aimed for and what success looks like. Well-defined goals provide direction for care and a benchmark for evaluating progress.
- Improve communication and documentation of the care plan. A well-written care plan serves as a central communication tool, ensuring all team members are informed and coordinated. Clear documentation also supports continuity of care across different shifts and settings.
- Provide metrics for evaluating nursing care. Care plans include measurable outcomes, which are essential for assessing the effectiveness of nursing interventions and making necessary adjustments 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 patient care and nursing practice:
- Defines nurse’s role. Care plans clarify the unique and independent contributions of nurses to patient health and well-being. They emphasize the nurse’s role as a proactive caregiver, not just someone who follows physician’s orders, but as a key decision-maker in patient care.
- Provides direction for individualized patient care. A care plan acts as a detailed roadmap for patient care, guiding nurses to think critically and develop interventions that are specifically tailored to each patient’s unique needs. This ensures care is personal and effective.
- Ensures continuity of care. By documenting the care plan, nurses across different shifts and departments can maintain consistent, high-quality interventions. This continuity is crucial for patients to receive the maximum benefit from their treatment, without gaps or overlaps in care.
- Coordinates care among the healthcare team. Care plans ensure that all members of the healthcare team are informed of the patient’s needs and the strategies to meet them. This coordinated approach prevents fragmented care and ensures everyone is working towards common goals.
- Serves as critical documentation. Care plans accurately record essential observations, planned nursing actions, and patient/family instructions. Proper documentation is crucial; if care isn’t documented in the care plan, it’s as if it wasn’t provided, which has legal and quality of care implications.
- Guides staff assignments. In situations where patients require specialized skills, care plans help in assigning nursing staff with the appropriate expertise. This ensures patients receive care from professionals best suited to meet their specific needs.
- Monitors patient progress. Care plans are tools for tracking a patient’s progress and for making necessary adjustments as the patient’s health status and goals evolve. Regular review and adaptation of the care plan ensure it remains relevant and effective.
- Supports reimbursement processes. Insurance companies often use medical records, including care plans, to determine the appropriateness and necessity of hospital care for reimbursement. Well-documented care plans justify the care provided and facilitate proper billing.
- Defines client’s goals and promotes patient involvement. Care plans benefit both nurses and patients by actively involving patients in their treatment and care decisions. This collaborative approach empowers patients, enhances adherence, and aligns care with patient preferences and values.
Components
A typical nursing care plan (NCP) integrates several key components to ensure comprehensive and effective patient care. These usually include nursing diagnoses, patient problems, expected outcomes, nursing interventions, and rationales. Each component plays a crucial role in guiding nursing actions and achieving desired patient results.
Care Plan Formats
Nursing care plan formats are generally structured into columns to organize information clearly. The most common formats are three-column and four-column plans, although some agencies may use variations. A typical four-column format includes: (1) nursing diagnoses, (2) desired outcomes and goals, (3) nursing interventions, and (4) evaluation. A three-column plan often merges goals and evaluation into a single column. Some facilities might also use a five-column plan that adds a column for assessment cues, further detailing the assessment phase.
Three-Column Format
The three-column format is a streamlined approach, organizing care plan elements into three key sections. The first column lists the nursing diagnoses, which are identified health problems or risks. The second column combines outcomes and evaluation, specifying the goals for patient improvement and how progress will be measured. The third column details the interventions, outlining the specific nursing actions planned to achieve the desired outcomes. This format is concise and focuses on the essential aspects of care planning.
Three-column nursing care plan format
Four-Column Format
The four-column format offers a more detailed structure for nursing care plans, separating key elements for clarity. The first column lists nursing diagnoses, identifying the patient’s health issues. The second column specifies goals and outcomes, detailing what is expected in terms of patient improvement. The third column outlines interventions, describing the nursing actions to achieve these outcomes. Finally, the fourth column is for evaluation, where the effectiveness of the interventions and the patient’s progress toward goals are assessed. This format provides a comprehensive overview of the care process, from problem identification to outcome evaluation.
Four-column nursing care plan template
Below is a downloadable document containing sample templates for various nursing care plan formats. These templates are designed to be easily editable and shareable, providing practical tools for nurses in different settings.
Download: Printable Nursing Care Plan Templates and Formats
Student Care Plans
Student care plans are typically more detailed and extensive compared to those used by practicing nurses. This is because they serve as a critical learning tool for nursing students, helping them understand the comprehensive process of care planning and the rationale behind each intervention. The increased detail encourages students to think critically and deeply about patient care.
Student nursing care plans are more detailed.
Often, student nurses are required to handwrite their care plans and include an additional column for “Rationale” or “Scientific Explanation.” This rationale column, placed after the nursing interventions, requires students to articulate the scientific principles that justify each chosen intervention. This reinforces their understanding of the evidence-based practice and the underlying science of nursing care.
Writing a Nursing Care Plan
How do you effectively write a nursing care plan (NCP)? Follow these step-by-step guidelines to develop a comprehensive and patient-centered care plan for your clients.
Step 1: Data Collection or Assessment
The initial step in crafting a nursing care plan is thorough data collection, forming a comprehensive patient database. This involves employing various assessment techniques and data collection methods, including physical examinations, detailed health history interviews, reviews of medical records, and diagnostic studies. The patient database aggregates all relevant health information gathered. During this stage, nurses identify related or risk factors and defining characteristics that will be crucial in formulating accurate nursing diagnoses. It’s important to note that many healthcare facilities or nursing schools provide specific assessment formats to guide this process, ensuring consistency and completeness.
Critical thinking is paramount in patient assessment. It requires integrating knowledge from various scientific disciplines and professional guidelines to inform evaluations effectively. This cognitive process is crucial for making complex clinical decisions, aiming to precisely identify patients’ healthcare needs within a supportive environment that fosters reliable information gathering and analysis.
Step 2: Data Analysis and Organization
Once patient health information is collected, the next critical step is data analysis and organization. This involves a systematic review of the gathered data to identify patterns, trends, and significant findings. The process includes clustering related data points together to reveal potential health issues or needs. Effective data analysis is crucial for formulating accurate nursing diagnoses, setting appropriate priorities, and defining realistic desired outcomes. This step transforms raw data into actionable insights that guide the subsequent stages of care planning.
Step 3: Formulating Your Nursing Diagnoses
Nursing diagnoses are standardized, precise statements that identify and focus on specific patient health needs and responses to both current and potential health problems. They are distinct from medical diagnoses, which identify diseases; instead, nursing diagnoses address patient responses to illness or risk factors that nurses are qualified and authorized to treat. These diagnoses encompass actual health problems, as well as high-risk situations that nursing interventions can prevent or resolve independently.
For a detailed guide on formulating nursing diagnoses, refer to this comprehensive resource: Nursing Diagnosis (NDx): Complete Guide and List. This guide offers in-depth information and examples to help nurses accurately identify and articulate patient needs in diagnostic terms.
Step 4: Setting Priorities
Setting priorities in nursing care involves establishing a strategic order for addressing identified nursing diagnoses and planned interventions. This step requires nurses to work collaboratively with patients to determine which health problems require immediate attention and which can be addressed subsequently. Diagnoses are typically categorized by priority level—high, medium, or low—to reflect their urgency and potential impact on patient well-being. Life-threatening issues are, of course, given the highest priority to ensure immediate and effective intervention.
Maslow’s Hierarchy of Needs is a foundational concept in nursing for setting priorities. Developed by Abraham Maslow in 1943, this hierarchy organizes human needs into a pyramid, starting from basic physiological needs at the base, ascending to safety, love/belonging, esteem, and self-actualization at the peak. According to Maslow’s theory, basic physiological needs must be met before higher-level needs can be effectively addressed. In nursing, this means prioritizing interventions that address fundamental survival needs like airway, breathing, and circulation (ABCs) before focusing on psychosocial or self-esteem issues. This hierarchy provides a structured approach to prioritizing care, ensuring that the most critical needs are addressed first, while also considering the patient’s holistic well-being.
Maslow’s Hierarchy of Needs
- Basic Physiological Needs: These are the most fundamental needs essential for survival, including nutrition (water and food), elimination, airway management (suctioning), breathing support (oxygen therapy), circulation maintenance (pulse monitoring, cardiac monitoring, blood pressure management), sleep, sex, shelter, and exercise. These needs form the base of the pyramid and must be adequately met to sustain life.
- Safety and Security: Once physiological needs are reasonably satisfied, safety and security needs become paramount. These include injury prevention (using side rails, call lights, practicing hand hygiene, implementing isolation protocols, suicide precautions, fall precautions, ensuring car seat use, helmet use, and seat belt use). Fostering a climate of trust and safety through therapeutic relationships and providing patient education on modifiable risk factors for conditions like stroke and heart disease are also crucial aspects of safety.
- Love and Belonging: After physiological and safety needs, the need for love and belonging emerges. This involves fostering supportive relationships, implementing strategies to prevent social isolation (especially addressing bullying), employing active listening and therapeutic communication techniques, and supporting healthy sexual intimacy. These interventions help patients feel connected and valued.
- Self-Esteem: Once individuals feel a sense of belonging, they seek self-esteem, which encompasses acceptance within their community and workforce, personal achievements, a sense of control or empowerment, and acceptance of their physical appearance and body image. Nursing interventions aim to bolster self-esteem by recognizing patient strengths and achievements.
- Self-Actualization: At the pinnacle of Maslow’s hierarchy is self-actualization, the drive to reach one’s full potential. This is supported by creating empowering environments, encouraging spiritual growth, and fostering the ability to consider diverse perspectives. Self-actualization focuses on personal growth and fulfillment.
Virginia Henderson’s 14 Needs as applied to Maslow’s Hierarchy of Needs. Learn more about it here.
When prioritizing nursing care, it is crucial to consider the patient’s health values, personal beliefs, and individual priorities, as well as the resources available and the urgency of the situation. Engaging the patient in the prioritization process is essential to foster cooperation and ensure that the care plan aligns with their needs and preferences.
Step 5: Establishing Client Goals and Desired Outcomes
After prioritizing nursing diagnoses, the next step involves collaborative goal setting between the nurse and the patient for each identified priority. Goals or desired outcomes are specific statements that describe the intended results of nursing interventions, derived directly from the patient’s nursing diagnoses. These goals serve multiple crucial functions: they provide clear direction for planning nursing interventions, establish measurable criteria for evaluating patient progress, help both the patient and nurse ascertain when problems are resolved, and provide motivation by offering a sense of accomplishment as goals are achieved.
Examples of goals and desired outcomes. Notice how they’re formatted and written.
Typically, one overarching goal is established for each nursing diagnosis. The terms “goal outcomes” and “expected outcomes” are often used interchangeably in clinical practice.
According to the SMART criteria for goal setting, effective goals should be Specific, Measurable, Attainable, Realistic, and Time-oriented.
- Specific: A goal must be clear, well-defined, and easily understood by everyone involved. Vagueness can lead to misinterpretations and ineffective action.
- Measurable: It’s essential that a goal is quantifiable, allowing for progress tracking and determination of when the goal has been achieved. Measurability ensures accountability and clarity in assessing outcomes.
- Attainable: Goals should be realistically achievable given the patient’s current condition, resources, and potential barriers. Setting unattainable goals can lead to discouragement and failure.
- Realistic: Goals must be relevant to the patient’s health needs and overall situation. They should take into account the patient’s capabilities, limitations, and the context of their life.
- Time-oriented: Every goal needs a defined timeframe, including a start date and a target completion date. Timelines create a sense of urgency and help in structuring the care process effectively.
The REEPIG standards further refine the criteria for high-quality care planning, ensuring that nursing care plans are:
- Realistic: Goals and interventions must be feasible given the available resources, including staff, equipment, and time.
- Explicitly stated: Care plans should be clear and unambiguous, leaving no room for misinterpretation of instructions or expected actions.
- Evidence-based: Nursing interventions should be supported by current research and best practices, ensuring that care is effective and up-to-date.
- Prioritized: The care plan should clearly address the most urgent problems first, reflecting the established priorities in nursing diagnoses.
- Involve: Effective care planning is collaborative, involving the patient, their family (when appropriate), and all members of the multidisciplinary healthcare team who will be involved in implementing the care.
- Goal-centered: The entire care plan should be focused on achieving the set goals, with all interventions directly contributing to the desired patient outcomes.
Short-Term and Long-Term Goals
Goals and expected outcomes must be measurable and patient-centered. They are formulated with a focus on problem prevention, resolution, and rehabilitation. Goals are categorized as either short-term or long-term, depending on the expected timeframe for achievement. In acute care settings, most goals are short-term because the immediate focus is on addressing urgent health issues. Long-term goals are more commonly used for patients with chronic conditions or those in long-term care facilities, home care, or extended-care settings.
- Short-term goal: This type of goal specifies a change in patient behavior or status that is expected to be achieved relatively quickly, typically within hours to a few days. Short-term goals are useful for tracking immediate progress and managing acute health issues.
- Long-term goal: A long-term goal outlines an objective that is expected to be achieved over a more extended period, usually weeks or months. These goals are essential for managing chronic conditions, rehabilitation, and overall health improvement over time.
- Discharge planning: Discharge planning inherently involves setting long-term goals, as it focuses on continued restorative care and problem resolution beyond the acute care setting. This includes coordinating home health services, physical therapy, or referrals to other appropriate resources to support the patient’s ongoing needs.
Components of Goals and Desired Outcomes
Goal or desired outcome statements typically consist of four essential components: a subject, a verb, conditions or modifiers, and a criterion of desired performance. These components ensure that goals are clear, measurable, and effectively guide nursing care.
Components of goals and desired outcomes in a nursing care plan.
- Subject: The subject of the goal statement is typically the patient, a part of the patient, or a specific attribute of the patient (e.g., pulse rate, body temperature, urinary output). While often omitted for brevity—as it’s assumed to be the patient unless otherwise stated—it can also refer to family members or significant others when relevant to the goal.
- Verb: The verb specifies the action that the patient is expected to perform or achieve. It describes what the patient will do, learn, or experience. Examples of verbs include “demonstrate,” “verbalize,” “maintain,” or “increase.”
- Conditions or modifiers: These are additional details that clarify the circumstances under which the behavior is to be performed. They specify the “what, when, where, or how” of the expected action. For example, “after teaching,” “during ambulation,” or “using a walker.”
- Criterion of desired performance: The criterion indicates the standard by which the performance is evaluated, defining the level at which the patient will perform the specified behavior. It sets measurable targets and can include elements like quantity, quality, speed, accuracy, or distance. While optional, including a criterion enhances the goal’s measurability and clarity.
When formulating goals and desired outcomes, nurses should adhere to the following guidelines to ensure effectiveness and patient-centeredness:
- Frame goals and outcomes in terms of patient responses, not nurse activities. Begin each goal statement with “Client will […],” which helps maintain focus on patient behavior and responses to interventions.
- Avoid stating goals based on what the nurse hopes to achieve. Instead, concentrate on what the patient will actively do or achieve as a result of nursing care.
- Use observable and measurable terms for outcomes. Employ concrete, specific language that can be objectively verified. Avoid vague words that are open to interpretation or require subjective judgment.
- Ensure desired outcomes are realistic considering the patient’s resources, capabilities, limitations, and the designated timeframe for care. Goals should be achievable and appropriate within the context of the patient’s situation.
- Verify that goals are compatible with the therapies prescribed by other healthcare professionals. Care plans should be integrated and complementary to the overall treatment plan, avoiding conflicts or redundancies.
- Ensure each goal is derived from only one nursing diagnosis. This one-to-one correspondence facilitates clear evaluation of care by ensuring that planned nursing interventions are directly and logically related to the specific diagnosis.
- Finally, confirm that the patient considers the goals important and values them. Patient buy-in is crucial for cooperation and adherence to the care plan. Goals that are meaningful and relevant to the patient are more likely to be achieved successfully.
Step 6: Selecting Nursing Interventions
Nursing interventions are the specific actions or activities that nurses perform to help patients achieve their established goals. The interventions selected should directly address the etiology or contributing factors of the priority nursing problem or diagnosis. For risk diagnoses, interventions should focus on reducing or managing the patient’s risk factors to prevent the problem from developing. It is crucial to note that while nursing interventions are identified and documented during the planning phase of the nursing process, they are actually carried out during the implementation phase.
Types of Nursing Interventions
Nursing interventions can be classified into three main types: independent, dependent, and collaborative, each reflecting the level of autonomy and interaction required in their execution.
Types of nursing interventions in a care plan.
- Independent nursing interventions are actions that nurses are authorized to initiate based on their professional judgment, knowledge, and skills. These interventions do not require direct orders from a physician or other healthcare provider. Examples include conducting ongoing patient assessments, providing emotional support, offering comfort measures, educating patients and families, performing physical care, and making referrals to other healthcare professionals or community resources. These interventions reflect the autonomous role of nursing in patient care.
- Dependent nursing interventions are actions that require orders or supervision from a physician or another healthcare provider. These interventions are carried out in response to medical diagnoses and treatments. Common examples include administering medications, managing intravenous therapy, performing diagnostic tests, providing specific medical treatments, and implementing prescribed dietary or activity regimens. While executing these, nurses also play a crucial role in assessment and providing explanations to patients about their treatments.
- Collaborative interventions are actions that nurses carry out in partnership with other members of the healthcare team, such as physicians, social workers, dietitians, and therapists. These interventions are developed through interdisciplinary consultation to leverage the expertise of various professionals and provide holistic care. Collaborative interventions ensure a coordinated approach to patient care, addressing complex needs that may require input from multiple disciplines.
Nursing interventions should always be:
- Safe and appropriate for the patient’s age, overall health status, and specific condition. Interventions must be carefully selected to ensure they are not harmful and are suitable for the individual patient.
- Achievable with the resources available, including staffing levels, equipment, and time constraints. Practicality is key to effective implementation.
- In line with the patient’s values, culture, and beliefs. Patient-centered care requires respecting individual preferences and ensuring that interventions are culturally sensitive and ethically sound.
- Consistent with other planned therapies. Nursing interventions should complement and not conflict with other treatments the patient is receiving from different healthcare providers.
- Based on established nursing knowledge, clinical experience, and evidence from relevant scientific disciplines. Interventions should be grounded in best practices and current research to ensure effectiveness and promote positive patient outcomes.
When documenting nursing interventions, adhere to these best practices for clarity and legal soundness:
- Record the date and sign the care plan. Dating the plan is essential for tracking its currency, facilitating future reviews, and ensuring accountability. The nurse’s signature confirms responsibility and accountability for the planned care.
- Nursing interventions should be specific and clearly articulated. Begin each intervention statement with an action verb that precisely indicates what the nurse is expected to do. The action verb should be followed by qualifiers specifying how, when, where, the timing, frequency, and amount of the activity. For example, “Educate parents on how to accurately measure temperature and when to notify healthcare provider of any changes,” or “Assess urine every shift for color, amount, odor, and turbidity.”
- Use only abbreviations that are officially accepted and recognized by the institution. Standardized abbreviations ensure clear communication and prevent misunderstandings among healthcare team members, promoting patient safety.
Step 7: Providing Rationale
Rationales, also known as scientific explanations, are a critical component in student nursing care plans, although they are typically omitted from care plans used by practicing nurses. Rationales explain the scientific basis for choosing a particular nursing intervention for a specific nursing diagnosis. They serve to connect the intervention to underlying pathophysiological and psychological principles, enhancing the student’s understanding of the “why” behind nursing actions.
Sample nursing interventions and rationale for a care plan (NCP)
For example, if an intervention is to elevate a patient’s leg to reduce edema, the rationale would explain how elevation promotes venous return and reduces hydrostatic pressure in the capillaries, thereby decreasing fluid accumulation in the tissues. Including rationales helps nursing students develop critical thinking skills and a deeper understanding of evidence-based practice.
Step 8: Evaluation
Evaluation is a systematic, ongoing, and purposeful phase of the nursing process. It involves assessing the patient’s progress toward achieving the established goals and desired outcomes outlined in the nursing care plan. Evaluation is crucial for determining the effectiveness of the nursing care plan and the interventions implemented. The conclusions drawn from the evaluation step dictate whether the current nursing interventions should be continued, modified, or terminated. It is an essential feedback loop that ensures care remains patient-centered and responsive to changing needs.
Step 9: Putting it on Paper
The final step in the nursing care planning process is documenting the patient’s care plan. This documentation must adhere to hospital policies and typically becomes a permanent part of the patient’s medical record. The care plan is a vital communication tool, often reviewed by oncoming nurses to ensure continuity of care across shifts. Different nursing programs and healthcare facilities may have varying formats for care plans, but most are designed to systematically follow the interrelated steps of the nursing process. A commonly used format, especially in educational settings, is the five-column format, which organizes assessment data, nursing diagnoses, goals, interventions, and evaluation into a clear, structured document.
Nursing Care Plan List
This section provides a categorized list of sample nursing care plans (NCP) and nursing diagnoses for a wide range of diseases and health conditions. These are organized into categories for easy navigation and reference.
Basic Nursing and General Care Plans
This category includes miscellaneous nursing care plans examples that do not specifically fit into other categories, covering a broad spectrum of general patient care needs.
| 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 section includes care plans specifically designed for patients undergoing surgical intervention, focusing on both preoperative and postoperative care.
| 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 category focuses on nursing care plans for various diseases and conditions affecting 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
This section provides nursing care plans (NCP) related to disorders of the endocrine system and metabolic processes.
| 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 category provides 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
This section includes care plans related to the hematologic and lymphatic systems.
| Hematologic & Lymphatic Care Plans |
|---|
| Anaphylactic Shock |
| Anemia UPDATED! |
| Aortic Aneurysm |
| Bleeding Risk & Hemophilia |
| Deep Vein Thrombosis |
| Disseminated Intravascular Coagulation |
| Hemophilia |
| Kawasaki Disease |
| Leukemia |
| Lymphoma |
| Sepsis and Septicemia |
| Sickle Cell Anemia Crisis |
Infectious Diseases
This section provides 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
This section covers 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
This section includes nursing care plans focused on the care of pregnant mothers and their infants, 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
This section provides 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
This section includes 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
This section provides nursing care plans (NCP) related to nervous system disorders.
| 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
This section includes care plans relating to eye disorders.
| Ophthalmic Care Plans |
|---|
| Cataracts |
| Glaucoma |
| Macular Degeneration |
Pediatric Nursing Care Plans
This section provides 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
This section includes care plans related to reproductive and sexual function disorders.
| Reproductive Care Plans |
|---|
| Cryptorchidism (Undescended Testes) |
| Hysterectomy |
| Hypospadias and Epispadias |
| Mastectomy |
| Menopause |
| Prostatectomy |
Respiratory
This section provides 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
This section includes care plans related to 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
Explore these recommended nursing diagnosis and nursing care plan books and resources to deepen your understanding and skills in care planning.
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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 employs a user-friendly, three-step system to guide you through client assessment, nursing diagnosis, and care plan development. It offers step-by-step instructions on implementing care and evaluating outcomes, enhancing diagnostic reasoning and critical thinking skills.
Nursing Care Plans – Nursing Diagnosis & Intervention (10th Edition)This comprehensive guide includes over two hundred care plans reflecting the latest evidence-based guidelines. The newest edition features ICNP diagnoses, care plans addressing LGBTQ health issues, and expanded content on electrolytes and acid-base balance.
Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales This quick-reference tool is invaluable for identifying accurate diagnoses and planning efficient patient care. The sixteenth edition incorporates the most recent 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 aids in identifying appropriate interventions for planning, individualizing, and documenting care for over 800 diseases and disorders. For each diagnosis, it provides subjective and objective data, sample clinical applications, prioritized actions/interventions with rationales, and a dedicated documentation section, among other features.
All-in-One Nursing Care Planning Resource – E-Book: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health This resource includes over 100 care plans spanning medical-surgical, maternity/OB, pediatrics, and psychiatric and mental health nursing. Its interprofessional “patient problems” approach helps users familiarize themselves with patient communication.
References and Sources
Explore these recommended reading materials and sources for further information on nursing care plans and related topics.
