Crafting an effective nursing care plan is a cornerstone of quality patient care. It’s a systematic approach that not only pinpoints current patient needs but also anticipates potential health risks. These plans serve as a vital communication tool among nurses, patients, and the broader healthcare team, ensuring everyone is aligned in achieving optimal health outcomes. Without a well-structured care planning process, the consistency and quality of patient care would be significantly compromised.
The nursing care planning journey begins the moment a patient is admitted and remains a dynamic process, continuously evolving as the patient’s condition changes and goals are met or modified. This dedication to personalized, patient-centered care is the bedrock of excellence in nursing practice.
Understanding Nursing Care Plans
A nursing care plan (NCP) is essentially a blueprint for patient care. It’s a formalized system that meticulously identifies a patient’s existing health needs and proactively addresses potential or emerging risks. Care plans are crucial for fostering clear communication among all stakeholders – nurses, patients, and other healthcare professionals – working collaboratively towards defined health goals. The absence of a robust nursing care planning framework would inevitably lead to fragmented and inconsistent patient care.
The process of nursing care planning is initiated upon patient admission and is a living document, constantly updated to reflect the patient’s evolving condition and the ongoing evaluation of goal attainment. This commitment to individualized, patient-centric care is the very essence of exceptional nursing practice.
Types of Nursing Care Plans: Formal vs. Informal
Nursing care plans can be broadly categorized as informal or formal, each serving distinct purposes in patient management.
Informal Nursing Care Plans: These are mental strategies, existing within the nurse‘s mind. They represent a nurse’s immediate thought process and planned actions based on a quick assessment of patient needs. Informal plans are not written down and are often used for routine care or in rapidly changing situations requiring immediate responses.
Formal Nursing Care Plans: In contrast, formal nursing care plans are documented guides, either written or computerized, that systematically organize a patient’s care information. They provide a structured approach to care, ensuring consistency and comprehensiveness. Formal care plans are further divided into two main types: standardized and individualized care plans.
Delving Deeper: Standardized vs. Individualized Care Plans
Formal care plans are further differentiated into standardized and individualized approaches, catering to diverse patient needs and complexities.
Standardized Care Plans: These are pre-developed, agency-approved guides that outline nursing care for patients with common, recurring needs. They are designed to ensure a baseline of acceptable care for specific conditions, promoting efficiency by eliminating the need to recreate plans for frequently encountered patient scenarios. Standardized plans are particularly valuable for maintaining consistency across different nurses and shifts.
However, it’s crucial to recognize that standardized care plans are not designed to address the unique nuances of each patient. They serve as an excellent starting point, a foundational framework that often requires adaptation to create a truly individualized care plan.
The care plans presented in this guide are examples of standard care plans, intended to serve as a template or direction for developing personalized care strategies.
Individualized Care Plans: An individualized care plan takes a standardized plan and customizes it to meet a specific patient’s unique health requirements and personal goals. This involves incorporating approaches that are known to be effective for the individual, considering their specific circumstances, preferences, and strengths. This tailored approach fosters more personalized and holistic care, aligning with the patient’s unique needs and aspirations.
Moreover, individualized care plans have been shown to enhance patient satisfaction. When patients perceive their care as being specifically designed for them, they feel more valued and understood, leading to a greater sense of satisfaction with their overall healthcare experience. In today’s healthcare environment, where patient satisfaction is increasingly recognized as a key indicator of quality, individualized care plans are paramount.
Key Tips for Individualizing Nursing Care Plans:
- Thorough Assessment: Begin with a comprehensive assessment to understand the patient’s unique physical, psychological, social, cultural, and spiritual needs.
- Patient Involvement: Actively involve the patient in the care planning process. Their input is crucial in setting realistic and meaningful goals.
- Flexibility: Be prepared to adapt the plan as the patient’s condition evolves or new needs emerge.
- Focus on Strengths: Identify and build upon the patient’s strengths and resources to promote resilience and recovery.
- Cultural Sensitivity: Incorporate cultural considerations and preferences into the care plan to ensure culturally competent care.
Objectives of Nursing Care Plans
The objectives of developing nursing care plans are multifaceted, all aimed at enhancing the quality and effectiveness of patient care:
- Promoting Evidence-Based Care: Care plans ensure that nursing interventions are grounded in the best available evidence, leading to more effective and safer patient care within healthcare settings.
- Supporting Holistic Care: Nursing care plans emphasize a holistic care approach, addressing the patient as a whole person – encompassing their physical, psychological, social, and spiritual dimensions – in the prevention and management of illness.
- Establishing Care Pathways and Bundles: Care plans facilitate the development of structured programs like care pathways, which promote team consensus on care standards and expected outcomes, and care bundles, which standardize best practices for specific conditions.
- Defining Goals and Expected Outcomes: Care plans clearly articulate specific, measurable goals and expected outcomes for each patient, providing a roadmap for care and a benchmark for progress evaluation.
- Enhancing Communication and Documentation: Care plans improve communication among healthcare providers and provide a standardized format for documenting care, ensuring continuity and accountability.
- Measuring Nursing Care Effectiveness: By outlining expected outcomes and providing a framework for evaluation, care plans enable the measurement of nursing care effectiveness and facilitate quality improvement initiatives.
Purposes and Importance of Nursing Care Plans
Nursing care plans serve several critical purposes, highlighting their indispensable role in modern healthcare:
- Defining the Nurse’s Role: Care plans clarify the unique and independent role of nurses in addressing patients’ overall health and well-being. They empower nurses to act proactively, beyond simply following physician’s orders, to deliver comprehensive care.
- Guiding Individualized Patient Care: They act as a detailed roadmap, guiding nurses in delivering care that is specifically tailored to each patient’s needs. This personalized approach encourages critical thinking and ensures interventions are directly relevant to the individual.
- Ensuring Continuity of Care: Care plans provide a consistent source of information for nurses across different shifts and departments. This ensures that all caregivers are aware of the patient’s needs and can deliver the same high standard of care, maximizing treatment benefits.
- Coordinating Care Among Teams: By making patient needs and planned actions explicit, care plans ensure that all members of the healthcare team are on the same page, preventing gaps in care and promoting a unified approach.
- Facilitating Accurate Documentation: Care plans mandate thorough documentation of observations, nursing actions, and patient/family instructions. This documentation serves as legal evidence that care was provided and is crucial for accountability and legal protection. If care isn’t documented in the care plan, it’s essentially undocumented.
- Guiding Staff Assignments: In situations where patients require specialized skills, care plans help in assigning appropriate staff based on the outlined needs, ensuring optimal resource allocation and patient safety.
- Monitoring Patient Progress: Care plans enable the systematic tracking of patient progress against set goals. This monitoring allows for timely adjustments to the care plan in response to changes in health status or evolving goals, ensuring dynamic and responsive care.
- Supporting Reimbursement Processes: Insurance companies often rely on medical records, including care plans, to determine the justification and appropriateness of hospital care for reimbursement purposes. Well-documented care plans are thus essential for financial viability of healthcare services.
- Defining Patient Goals and Promoting Engagement: Care plans empower both nurses and patients by involving patients actively in their treatment and care decisions. This collaborative approach fosters patient ownership and enhances adherence to the plan.
Key Components of a Nursing Care Plan
A comprehensive nursing care plan (NCP) typically includes several essential components that work together to guide patient care. These core elements are nursing diagnoses, patient problems, expected outcomes, nursing interventions, and rationales. Each component plays a vital role in the planning and delivery of effective nursing care.
Care Plan Formats: Structuring for Clarity
Nursing care plan formats are designed to organize information logically and facilitate easy access and understanding. Common formats typically arrange components into columns, with three, four, and five-column variations seen in practice.
Three-Column Format: Concise and Efficient
The three-column plan is a streamlined format that combines related elements for efficiency. It usually includes columns for:
- Nursing Diagnosis: Clearly stated patient health problems or risks.
- Outcomes and Evaluation: Desired patient outcomes, goals, and space for evaluating progress towards those outcomes.
- Interventions: Specific nursing actions planned to achieve the desired outcomes.
Example of a three-column nursing care plan format, demonstrating the concise organization of diagnosis, outcomes/evaluation, and interventions.
Four-Column Format: Detailed and Comprehensive
The four-column format provides a more detailed structure, separating outcomes and evaluation into distinct columns. This format typically includes:
- Nursing Diagnosis: Patient health problems or risks, as with the three-column format.
- Goals and Outcomes: Specific, measurable, achievable, relevant, and time-bound (SMART) goals and desired patient outcomes.
- Interventions: Detailed nursing actions to achieve the goals and outcomes.
- Evaluation: A dedicated column for recording the evaluation of patient progress toward goals and the effectiveness of interventions.
Example of a four-column nursing care plan template, showcasing the separation of goals/outcomes and evaluation for enhanced clarity.
Below is a downloadable document containing sample templates for various nursing care plan formats, which can be freely edited, modified, and shared:
Download: Printable Nursing Care Plan Templates and Formats
Student Care Plans: A Learning Tool
Student care plans are intentionally more extensive and detailed than those used by practicing nurses. They are designed as a learning exercise to help student nurses develop critical thinking and care planning skills.
Example of a student nursing care plan format, highlighting the greater detail and inclusion of rationales for learning purposes.
Student care plans are often required to be handwritten and typically include an additional column for “Rationale” or “Scientific Explanation” following the nursing interventions. Rationales are the scientific principles that justify the selection of specific nursing interventions, reinforcing the evidence-based nature of nursing practice.
Step-by-Step Guide to Writing a Nursing Care Plan
Creating a nursing care plan (NCP) is a systematic process. Follow these steps to develop a comprehensive and patient-centered plan for your client.
Step 1: Comprehensive Data Collection and Assessment
The foundational step in crafting a nursing care plan is building a robust client database through thorough assessment and data collection. This involves utilizing various assessment techniques and methods, including physical assessments, obtaining a detailed health history, conducting patient interviews, reviewing medical records, and analyzing diagnostic studies. The client database becomes a repository of all gathered health information. This step is crucial for identifying related or risk factors and defining characteristics that will form the basis for formulating accurate nursing diagnoses. Specific assessment formats may be mandated by agencies or nursing schools.
Critical thinking is paramount in patient assessment. It requires integrating knowledge from diverse scientific disciplines and professional guidelines to inform clinical evaluations. This process, essential for complex clinical decision-making, aims to effectively identify patients’ healthcare needs within a supportive environment that provides reliable information.
Step 2: Data Analysis and Organization
Once comprehensive patient data is collected, the next step involves rigorous analysis, clustering, and organization. This process is essential to synthesize the information and identify patterns, leading to the formulation of relevant nursing diagnoses, prioritization of needs, and definition of desired patient outcomes.
Step 3: Formulating Accurate Nursing Diagnoses
Nursing diagnoses provide a standardized language for identifying, focusing on, and addressing specific patient needs and responses to both actual and potential health problems. They represent actual or potential health issues that nurses can independently prevent or resolve through nursing interventions.
For a detailed guide on formulating nursing diagnoses, refer to this resource: Nursing Diagnosis (NDx): Complete Guide and List.
Step 4: Prioritizing Nursing Diagnoses
Setting priorities is crucial for effective care planning. It involves establishing a preferential order for addressing identified nursing diagnoses and implementing corresponding interventions. In this step, nurses collaborate with patients to determine which problems require immediate attention. Diagnoses can be categorized and ranked based on priority levels: high, medium, or low. Life-threatening problems always take top priority.
Nursing diagnosis prioritization is often guided by Maslow’s Hierarchy of Needs, a framework that helps nurses plan and prioritize care based on patient-centered outcomes. Developed by Abraham Maslow in 1943, this hierarchy posits that basic physiological needs must be met before higher-level needs, such as self-esteem and self-actualization, can be addressed. Physiological and safety needs are foundational for nursing care and interventions, forming the base of Maslow’s pyramid and establishing the groundwork for both physical and emotional well-being.
Maslow’s Hierarchy of Needs in Nursing Practice:
- Basic Physiological Needs: These are the most fundamental needs for survival: nutrition (food and water), elimination (toileting), airway management (suctioning), breathing support (oxygen therapy), circulation monitoring (pulse, cardiac monitor, blood pressure), sleep, sexual health, adequate shelter, and physical exercise.
- Safety and Security Needs: Once physiological needs are met, safety becomes paramount. This includes injury prevention (side rails, call lights, hand hygiene, isolation protocols, suicide precautions, fall prevention strategies, car seat safety, helmets, seat belt use), fostering a safe and trusting environment (therapeutic relationships), and patient education on modifiable risk factors for conditions like stroke and heart disease.
- Love and Belonging Needs: Addressing social and emotional well-being is crucial. This involves fostering supportive relationships, implementing strategies to prevent social isolation (bullying prevention), utilizing active listening techniques, practicing therapeutic communication, and supporting healthy sexual intimacy.
- Self-Esteem Needs: Promoting self-worth and confidence includes fostering community acceptance, supporting workforce participation, recognizing personal achievements, encouraging a sense of control and empowerment, and promoting acceptance of one’s physical appearance and body image.
- Self-Actualization Needs: Reaching one’s full potential is the highest level. This is supported by creating empowering environments, fostering spiritual growth, encouraging the ability to consider diverse perspectives, and facilitating the pursuit of individual potential.
Visual representation of Virginia Henderson’s 14 Needs integrated with Maslow’s Hierarchy of Needs, demonstrating a holistic approach to patient care prioritization. Learn more about Virginia Henderson’s Need Theory here.
Patient health values, beliefs, personal priorities, available resources, and the urgency of the health situation are all critical factors nurses must consider when assigning priorities to nursing diagnoses. Actively involving the patient in this prioritization process enhances patient cooperation and adherence to the care plan.
Step 5: Setting Client Goals and Desired Outcomes
Following the prioritization of nursing diagnoses, nurses and patients collaboratively establish goals for each identified priority. Goals or desired outcomes articulate what the nurse aims to achieve through the implementation of nursing interventions derived from the nursing diagnoses. Goals provide direction for planning interventions, serve as measurable criteria for evaluating patient progress, enable nurses and patients to determine when problems are resolved, and offer motivation by providing a sense of accomplishment.
Examples of well-formulated goals and desired outcomes in nursing care plans, illustrating specificity, measurability, and patient-centered focus.
Typically, one overarching goal is defined for each nursing diagnosis. The terms “goal outcomes” and “expected outcomes” are often used interchangeably in clinical practice.
Effective goal setting follows the SMART criteria, as outlined by Hamilton and Price (2013). SMART goals are:
- Specific: Clearly defined, significant, and focused to ensure clarity of purpose.
- Measurable: Quantifiable or qualifiable to allow for progress monitoring and outcome evaluation.
- Attainable: Realistic and achievable given the patient’s current condition and resources.
- Relevant: Aligned with the patient’s needs, values, and overall care plan goals.
- Time-Oriented: Defined with a specific timeframe for achievement, providing a sense of urgency and structure.
Hogston (2011) proposes the REEPIG standards to further ensure high-quality care planning:
- Realistic: Goals must be achievable with available resources and patient capabilities.
- Explicitly Stated: Goals should be clearly and unambiguously articulated to prevent misinterpretation.
- Evidence-Based: Interventions should be supported by research and best practices.
- Prioritized: The most critical and urgent problems should be addressed first.
- Involve: Care planning should be a collaborative process involving the patient and the multidisciplinary healthcare team.
- Goal-Centered: All planned care activities should directly contribute to achieving the defined patient goals.
Short-Term and Long-Term Goals in Care Planning
Goals and expected outcomes must always be measurable and patient-centered. Goal setting focuses on problem prevention, resolution, and patient rehabilitation. Goals are classified as either short-term or long-term. In acute care settings, most goals are short-term due to the focus on immediate patient needs. Long-term goals are more common for patients with chronic conditions or those in home care, nursing homes, or extended care facilities.
- Short-Term Goal: Describes an expected change in patient behavior or condition that can be achieved relatively quickly, typically within hours or days.
- Long-Term Goal: Defines an objective to be achieved over a more extended period, usually weeks or months, focusing on sustained improvement and rehabilitation.
- Discharge Planning Goals: Discharge planning inherently involves long-term goals, aiming to promote continued recovery and problem resolution through home health services, physical therapy, or other community resources.
Components of Well-Defined Goals and Desired Outcomes
Effective goals and desired outcome statements typically include four key components: a subject, a verb, conditions or modifiers, and a criterion of desired performance.
Breakdown of the components of effective goals and desired outcomes in nursing care plans, illustrating the structure for clear and measurable goal setting.
- Subject: Typically the patient, a part of the patient (e.g., leg, wound), or a patient attribute (e.g., pulse rate, temperature, urinary output). The subject is often implied as “the client” unless otherwise specified (e.g., family, significant other).
- Verb: Specifies the action the patient is expected to perform, learn, or experience (e.g., demonstrate, verbalize, ambulate).
- Conditions or Modifiers: Describe the “what, when, where, or how” that clarifies the circumstances under which the behavior is to be performed (e.g., “using crutches,” “after medication,” “in the clinic”).
- Criterion of Desired Performance: Indicates the standard for evaluating performance or the level at which the patient will perform the specified behavior. This component is often optional but adds precision (e.g., “without pain,” “independently,” “three times daily”).
Key Tips for Writing Effective Goals and Desired Outcomes:
- Frame goals and outcomes in terms of patient responses, not nursing activities. Start each goal with “Client will […].” to maintain patient-centered focus.
- Avoid phrasing goals as what the nurse hopes to achieve; instead, focus on what the patient will do or achieve.
- Use observable and measurable terms for outcomes. Avoid vague language that requires subjective interpretation.
- Ensure desired outcomes are realistic given the patient’s resources, capabilities, limitations, and the timeframe of care.
- Verify that goals are compatible with therapies prescribed by other healthcare professionals to ensure a cohesive care approach.
- Ensure each goal is directly derived from only one nursing diagnosis to facilitate clear evaluation of care and ensure interventions are targeted.
- Finally, confirm that the patient considers the goals important and values them to foster patient engagement and cooperation in achieving the desired outcomes.
Step 6: Selecting Appropriate Nursing Interventions
Nursing interventions are the specific actions that nurses perform to help patients achieve their established goals. Interventions should be selected to directly address the etiology of the prioritized nursing problem or diagnosis. For risk diagnoses, interventions should focus on reducing or managing the identified risk factors. 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: Independent, Dependent, and Collaborative
Nursing interventions can be categorized into three main types: independent, dependent, and collaborative, each reflecting different levels of nursing autonomy and teamwork.
Diagram illustrating the three types of nursing interventions—independent, dependent, and collaborative—and examples of each within a nursing care plan.
- Independent Nursing Interventions: These are actions that nurses are licensed to initiate based on their professional judgment and skills. They include ongoing patient assessment, providing emotional support, ensuring patient comfort, patient education, physical care measures, and making referrals to other healthcare professionals.
- Dependent Nursing Interventions: These are actions that require a physician’s order or supervision to implement. They typically include administering medications, managing intravenous therapy, performing diagnostic tests, providing specific treatments, and managing diet and activity orders. Nurses are also responsible for assessment and patient education related to these dependent interventions.
- Collaborative Interventions: These 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 consultation and aim to integrate diverse professional perspectives into patient care.
Key Criteria for Selecting Nursing Interventions:
Nursing interventions should always be:
- Safe and appropriate for the patient’s age, overall health status, and specific condition.
- Achievable with the resources and time available within the healthcare setting.
- Consistent with the patient’s personal values, cultural background, and beliefs.
- Compatible with other therapies the patient is receiving to ensure holistic and coordinated care.
- Grounded in established nursing knowledge, clinical experience, and relevant scientific evidence.
Tips for Writing Clear and Effective Nursing Interventions:
- Date and sign the care plan. Dating the plan is essential for tracking its currency, facilitating evaluation, and informing future planning. The nurse’s signature establishes accountability for the plan.
- Nursing interventions should be specific, clearly worded, and begin with an action verb that precisely describes what the nurse is to do. Action verbs should be precise, and qualifiers specifying how, when, where, frequency, and amount should provide necessary context for the planned activity. Examples: “Educate parents on how to accurately take their child’s temperature and when to notify healthcare providers of changes,” or “Assess urine for color, amount, odor, and turbidity every shift.”
- Use only abbreviations that are officially accepted and recognized by the healthcare institution to maintain clarity and avoid errors.
Step 7: Providing Rationales: The Why Behind the What
Rationales, also known as scientific explanations or supporting evidence, are crucial for student care plans. They explain the scientific basis for each nursing intervention chosen for the NCP.
Example of nursing interventions paired with their corresponding rationales in a care plan, illustrating the scientific basis for nursing actions.
Rationales are typically not included in standard care plans used by practicing nurses in clinical settings. However, they are invaluable in educational settings as they help nursing students link pathophysiological and psychological principles to the nursing interventions they select, reinforcing evidence-based practice.
Step 8: Evaluation: Assessing Effectiveness and Progress
Evaluation is a systematic, ongoing, and purposeful process. It involves assessing the patient’s progress toward achieving the established goals or desired outcomes and determining the effectiveness of the implemented nursing care plan (NCP). Evaluation is an integral component of the nursing process because its findings dictate whether the nursing interventions should be continued, modified, or discontinued. It’s a critical feedback loop that ensures patient care remains dynamic and responsive to changing needs.
Step 9: Documenting the Care Plan
The final step is to formally document the patient’s care plan. This documentation should adhere to hospital policy and becomes a permanent part of the patient’s medical record, accessible for review by all members of the healthcare team, including oncoming nurses. Nursing programs often have specific care plan formats that students are required to use. Many formats are structured to guide students systematically through the interrelated steps of the nursing process, with the five-column format being commonly used in educational settings.
Comprehensive Nursing Care Plan List
This section provides an extensive list of sample nursing care plans (NCPs) and nursing diagnoses covering a wide range of diseases and health conditions. These are organized into categories for easy navigation.
(The list of Nursing Care Plans from the original article is included here, maintaining the same categories and links. This section is kept identical to the original for completeness as requested by the user to “keep original information”).
Basic Nursing and General Care Plans
| Basic Nursing & General Care Plans |
|---|
| Acute Confusion (Delirium) and Altered Mental Status |
| Acute Pain and Pain Management |
| Activity Intolerance and Generalized Weakness |
| Cancer (Oncology Nursing) |
| Caregiver Role Strain and Family Caregiver Support Systems |
| Chronic Confusion (Dementia) |
| End-of-Life Care (Hospice Care or Palliative) |
| Fall Risk and Fall Prevention |
| Fatigue and Lethargy |
| Geriatric Nursing (Older Adult) |
| Grieving and Loss |
| Hypothermia and Cold Injuries |
| Hyperthermia (Fever) |
| Impaired Swallowing (Dysphagia) |
| Insomnia and Sleep Deprivation |
| Prolonged Bed Rest |
| Risk for Injury and Patient Safety |
| Self-Care and Activities of Daily Living (ADLs) |
| Surgery (Perioperative Client) |
| Systemic Lupus Erythematosus |
| Total Parenteral Nutrition |
Surgery and Perioperative Care Plans
| Surgery and Perioperative Care Plans |
|---|
| Amputation |
| Appendectomy |
| Cholecystectomy |
| Fracture UPDATED! |
| Hemorrhoids |
| Hysterectomy |
| Ileostomy & Colostomy |
| Laminectomy (Disc Surgery) |
| Mastectomy |
| Subtotal Gastrectomy |
| Surgery (Perioperative Client) |
| Thyroidectomy |
| Total Joint (Knee, Hip) Replacement |
Cardiac Care Plans
| Cardiac Care Plans |
|---|
| Angina Pectoris (Coronary Artery Disease) |
| Cardiac Arrhythmia (Digitalis Toxicity) |
| Cardiac Catheterization |
| Cardiogenic Shock |
| Congenital Heart Disease |
| Decreased Cardiac Output & Cardiac Support |
| Heart Failure UPDATED! |
| Hypertension UPDATED! |
| Hypovolemic Shock |
| Impaired Tissue Perfusion & Ischemia |
| Myocardial Infarction |
| Pacemaker Therapy |
Endocrine and Metabolic Care Plans
| Endocrine and Metabolic Care Plans |
|---|
| Addison’s Disease |
| Cushing’s Disease |
| Diabetes Mellitus (Type 1, Type 2) UPDATED! |
| Diabetic Ketoacidosis (DKA) and Hyperglycemic Hyperosmolar Nonketotic Syndrome (HHNS) |
| Eating Disorders: Anorexia & Bulimia Nervosa |
| Fluid Volume Deficit (Dehydration & Hypovolemia) |
| Fluid Volume Excess (Hypervolemia) |
| Gestational Diabetes Mellitus |
| Hyperthyroidism |
| Hypothyroidism |
| Imbalanced Nutrition (Malnutrition) |
| Obesity & Overweight |
| Thyroidectomy |
| Unstable Blood Glucose Levels (Hyperglycemia & Hypoglycemia) |
| Acid-Base Imbalances |
|---|
| Metabolic Acidosis |
| Metabolic Alkalosis |
| Respiratory Acidosis |
| Respiratory Alkalosis |
| Electrolyte Imbalances |
|---|
| Calcium (Ca) Imbalances: Hypercalcemia and Hypocalcemia |
| Magnesium (Mg) Imbalances: Hypermagnesemia and Hypomagnesemia |
| Potassium (K) Imbalances: Hyperkalemia and Hypokalemia |
| Sodium (Na) Imbalances: Hypernatremia and Hyponatremia |
Gastrointestinal
| Gastrointestinal Care Plans |
|---|
| Appendectomy |
| Bowel Incontinence (Fecal Incontinence) |
| Cholecystectomy |
| Constipation |
| Diarrhea Nursing Care Plan and Management |
| Cholecystitis and Cholelithiasis |
| Gastroenteritis |
| Gastroesophageal Reflux Disease (GERD) |
| Hemorrhoids |
| Hepatitis |
| Ileostomy & Colostomy |
| Inflammatory Bowel Disease (IBD) |
| Intussusception |
| Liver Cirrhosis |
| Nausea & Vomiting |
| Pancreatitis |
| Peritonitis |
| Peptic Ulcer Disease |
| Subtotal Gastrectomy |
| Umbilical and Inguinal Hernia |
Hematologic and Lymphatic
| Hematologic & Lymphatic Care Plans |
|---|
| Anaphylactic Shock |
| Anemia UPDATED! |
| Aortic Aneurysm |
| Bleeding Risk & Hemophilia |
| Deep Vein Thrombosis |
| Disseminated Intravascular Coagulation |
| Hemophilia |
| Kawasaki Disease |
| Leukemia |
| Lymphoma |
| Sepsis and Septicemia |
| Sickle Cell Anemia Crisis |
Infectious Diseases
| Infectious Diseases Care Plans |
|---|
| Acquired Immunodeficiency Syndrome (AIDS) (HIV Positive) |
| Acute Rheumatic Fever |
| Dengue Hemorrhagic Fever |
| Herpes Zoster (Shingles) |
| Influenza (Flu) |
| Pulmonary Tuberculosis |
| Risk for Infection & Infection Control |
Integumentary
| Integumentary Care Plans |
|---|
| Burn Injury |
| Dermatitis |
| Herpes Zoster (Shingles) |
| Pressure Ulcer (Bedsores) |
| Wound Care and Skin/Tissue Integrity |
Maternal and Newborn Care Plans
| Maternal and Newborn Care Plans |
|---|
| Abortion (Termination of Pregnancy) |
| Cervical Insufficiency (Premature Dilation of the Cervix) |
| Cesarean Birth |
| Cleft Palate and Cleft Lip |
| Gestational Diabetes Mellitus |
| Hyperbilirubinemia (Jaundice) |
| Labor Stages, Induced, Augmented, Dysfunctional, Precipitous Labor |
| Neonatal Sepsis |
| Perinatal Loss (Miscarriage, Stillbirth) |
| Placental Abruption |
| Placenta Previa |
| Postpartum Hemorrhage |
| Postpartum Thrombophlebitis |
| Prenatal Hemorrhage |
| Preeclampsia and Gestational Hypertension |
| Prenatal Infection |
| Preterm Labor |
| Puerperal & Postpartum Infections |
| Substance (Alcohol and Drug) Abuse in Pregnancy |
Mental Health and Psychiatric
| Mental Health and Psychiatric Care Plans |
|---|
| Alcohol Withdrawal |
| Anxiety & Fear |
| Anxiety and Panic Disorders |
| Bipolar Disorders |
| Body Image Disturbance & Self-Esteem |
| Impaired Thought Processes & Cognitive Impairment |
| Major Depression |
| Personality Disorders |
| Schizophrenia |
| Sexual Assault |
| Substance Dependence and Abuse |
| Suicide Behaviors |
Musculoskeletal
| Musculoskeletal Care Plans |
|---|
| Amputation |
| Congenital Hip Dysplasia |
| Fracture UPDATED! |
| Impaired Physical Mobility & Immobility |
| Juvenile Rheumatoid Arthritis |
| Laminectomy (Disc Surgery) |
| Osteoarthritis |
| Osteogenic Sarcoma (Osteosarcoma) |
| Osteoporosis |
| Rheumatoid Arthritis |
| Scoliosis |
| Spinal Cord Injury |
| Total Joint (Knee, Hip) Replacement |
Neurological
| Neurological Care Plans |
|---|
| Alzheimer’s Disease UPDATED! |
| Brain Tumor |
| Cerebral Palsy |
| Cerebrovascular Accident (Stroke) UPDATED! |
| Guillain-Barre Syndrome |
| Meningitis |
| Multiple Sclerosis |
| Parkinson’s Disease |
| Seizure Disorder |
| Spinal Cord Injury |
Ophthalmic
| Ophthalmic Care Plans |
|---|
| Cataracts |
| Glaucoma |
| Macular Degeneration |
Pediatric Nursing Care Plans
| Pediatric Nursing Care Plans |
|---|
| Child Abuse |
| Cleft Lip and Cleft Palate |
| Dying Child |
| Febrile Seizure |
| Hospitalized Child |
| Hydrocephalus |
| Otitis Media |
| Spina Bifida |
| Tonsillitis and Adenoiditis |
Reproductive
| Reproductive Care Plans |
|---|
| Cryptorchidism (Undescended Testes) |
| Hysterectomy |
| Hypospadias and Epispadias |
| Mastectomy |
| Menopause |
| Prostatectomy |
Respiratory
| Respiratory Care Plans |
|---|
| Airway Clearance Therapy & Coughing |
| Apnea |
| Asthma UPDATED! |
| Aspiration Risk & Aspiration Pneumonia |
| Bronchiolitis UPDATED! |
| Bronchopulmonary Dysplasia (BPD) UPDATED! |
| Chronic Obstructive Pulmonary Disease (COPD) UPDATED! |
| Croup Syndrome |
| Cystic Fibrosis UPDATED! |
| Epiglottitis |
| Hemothorax and Pneumothorax UPDATED! |
| Ineffective Breathing Pattern (Dyspnea) |
| Impairment of Gas Exchange |
| Influenza (Flu) UPDATED! |
| Lung Cancer UPDATED! |
| Mechanical Ventilation |
| Near-Drowning |
| Pleural Effusion |
| Pneumonia |
| Pulmonary Embolism |
| Pulmonary Tuberculosis |
| Tracheostomy |
Urinary
| Urinary Care Plans |
|---|
| Acute Glomerulonephritis |
| Acute Renal Failure |
| Benign Prostatic Hyperplasia (BPH) |
| Chronic Renal Failure |
| Hemodialysis |
| Nephrotic Syndrome |
| Peritoneal Dialysis |
| Urolithiasis (Renal Calculi) |
| Urinary Elimination (Urinary Incontinence & Urinary Retention) |
| Urinary Tract Infection |
| Vesicoureteral Reflux (VUR) |
| Wilms Tumor (Nephroblastoma) |
Recommended Resources for Nursing Care Planning
Enhance your nursing care planning skills with these recommended books and resources:
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Ackley and Ladwig’s Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care
Highly praised for its evidence-based approach, this handbook offers a three-step system for client assessment, nursing diagnosis, and care planning. It provides clear instructions on implementing care and evaluating outcomes, fostering diagnostic reasoning and critical thinking skills.
Nursing Care Plans – Nursing Diagnosis & Intervention (10th Edition)
This comprehensive resource includes over 200 care plans based on the latest evidence-based guidelines. The newest edition features ICNP diagnoses, care plans addressing LGBTQ health issues, and expanded coverage on electrolytes and acid-base balance.
Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales
A quick and essential reference tool for identifying correct diagnoses and planning efficient patient care. The 16th edition includes the most current nursing diagnoses and interventions, with an alphabetized listing of diagnoses for over 400 disorders.
Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care
This manual is invaluable for planning, individualizing, and documenting care for over 800 diseases and disorders. It uniquely provides subjective and objective data, sample clinical applications, prioritized actions/interventions with rationales, and detailed documentation guidance for each diagnosis.
All-in-One Nursing Care Planning Resource – E-Book: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health
This e-book offers over 100 care plans across medical-surgical, maternity/OB, pediatrics, and psychiatric-mental health nursing. It emphasizes interprofessional “patient problems” to enhance communication and understanding of patient needs across disciplines.
References and Sources
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