Table of Contents
Understanding Nursing Care Plans
A nursing care plan (NCP) is a structured and systematic approach used by nurses to identify patient needs, potential risks, and outline strategies to address them. It serves as a vital communication tool among nurses, patients, and the interdisciplinary healthcare team, ensuring consistent and quality patient care to achieve desired health outcomes. Without meticulous nursing care planning, the coherence and effectiveness of patient care can be significantly compromised.
The process of nursing care planning is initiated upon a patient’s admission and is a dynamic, ongoing process. Care plans are regularly revised and updated in response to changes in a patient’s condition and the evaluation of their progress towards established goals. This patient-centered approach to care is fundamental to excellence in nursing practice.
Types of Nursing Care Plans: Formal vs. Informal
Nursing care plans can be broadly categorized as informal or formal, depending on their documentation and structure.
- Informal Nursing Care Plans: These are mental strategies or action plans that a nurse develops in their mind. They are not written down and are based on the nurse’s immediate assessment and understanding of the patient’s needs.
- Formal Nursing Care Plans: These are documented, either in written or electronic format, and serve as comprehensive guides for patient care. Formal care plans ensure that all members of the healthcare team have access to the same information and follow a consistent approach.
Formal care plans are further classified into standardized and individualized care plans, offering different levels of customization to meet patient needs:
Standardized Care Plans: Consistency in Care
Standardized care plans are pre-written guides developed by healthcare agencies and nursing staff to ensure consistent care for patients with common needs or medical conditions. They outline the routine care requirements for specific patient populations, ensuring that minimum standards of care are met efficiently. By providing a framework for common nursing activities, standardized care plans save nurses time and ensure consistency across care delivery.
It’s crucial to recognize that standardized care plans are not designed to address the unique needs of each patient. Instead, they serve as a foundational starting point that can be adapted and expanded into individualized care plans.
The care plans presented in this guide are primarily standardized care plans, intended to provide a framework and direction for developing individualized plans that cater to the specific needs of each patient.
Individualized Care Plans: Tailoring Care to the Patient
An individualized care plan is developed by modifying a standardized care plan to address the specific and unique needs, preferences, and goals of an individual patient. This involves considering the patient’s specific medical condition, personal circumstances, strengths, and preferences to ensure that the care provided is most effective and patient-centered. This personalized approach to care is essential for providing holistic care, recognizing the patient as a whole person with unique needs.
Individualized care plans play a significant role in enhancing patient satisfaction. When patients perceive that their care is tailored to their specific situation, they feel more valued, understood, and involved in their care process. This heightened sense of engagement and personalized attention directly contributes to increased satisfaction with the overall healthcare experience. In today’s healthcare environment, where patient satisfaction is a key metric of quality care, individualized care plans are increasingly important.
Key strategies for individualizing a nursing care plan include:
- Comprehensive Patient Assessment: Thoroughly assess the patient’s physical, psychological, social, cultural, and spiritual needs.
- Patient Involvement: Actively involve the patient and their family in the care planning process, ensuring their preferences and values are considered.
- Goal Setting Collaboration: Collaborate with the patient to establish realistic and patient-centered goals.
- Customized Interventions: Select nursing interventions that are specifically tailored to address the patient’s unique needs and challenges.
- Regular Review and Adaptation: Continuously review and revise the care plan based on the patient’s changing condition and progress towards goals.
Objectives of Nursing Care Plans
The primary objectives of developing and implementing nursing care plans are multifaceted, all aimed at enhancing the quality and effectiveness of patient care:
- Promoting Evidence-Based Practice: To ensure nursing care is grounded in the latest research and best practices, creating a comfortable and familiar environment for patients within healthcare settings.
- Supporting Holistic Patient Care: To address the patient as a whole, encompassing their physical, psychological, social, and spiritual dimensions in disease management and prevention.
- Establishing Care Pathways and Bundles: To develop structured, multidisciplinary approaches to care, such as care pathways for standardized care and care bundles focusing on best practices for specific conditions.
- Defining Goals and Expected Outcomes: To clearly identify and differentiate between broad goals and specific, measurable expected outcomes for patient care.
- Enhancing Communication and Documentation: To improve communication among healthcare providers and ensure accurate and comprehensive documentation of the care plan.
- Measuring Nursing Care Effectiveness: To provide a framework for evaluating the effectiveness of nursing interventions and overall care delivery.
Purposes and Importance of Nursing Care Plans
Nursing care plans serve several crucial purposes, underscoring their importance in modern healthcare:
- Defining the Nurse’s Role: Care plans clarify the distinct and independent role of nurses in addressing patients’ overall health and well-being, going beyond simply following physician’s orders.
- Guiding Individualized Patient Care: They act as a roadmap for patient care, enabling nurses to apply critical thinking in developing interventions specifically tailored to each patient’s unique needs.
- Ensuring Continuity of Care: By providing a documented plan, care plans enable nurses across different shifts and departments to deliver consistent, high-quality interventions, maximizing the benefits of treatment for patients.
- Coordinating Interdisciplinary Care: Care plans ensure that all members of the healthcare team are aware of the patient’s needs and the necessary actions, preventing gaps and overlaps in care.
- Facilitating Comprehensive Documentation: Care plans serve as essential documentation, outlining observations, nursing actions, and patient/family instructions. Accurate documentation in the care plan is critical evidence that care was provided.
- Aiding Staff Assignment: In situations where patients require specialized skills, care plans assist in assigning staff with the appropriate expertise to meet specific patient needs.
- Monitoring Patient Progress: Care plans facilitate the tracking of patient progress and enable necessary adjustments to the plan as the patient’s condition and goals evolve.
- Supporting Reimbursement Processes: Insurance companies utilize medical records, including care plans, to determine appropriate reimbursement for hospital care.
- Defining Patient-Centered Goals: Care plans benefit both nurses and patients by actively involving patients in their treatment and care decisions, promoting patient autonomy and engagement.
Key Components of a Nursing Care Plan
A comprehensive nursing care plan (NCP) typically encompasses several essential components, each playing a vital role in guiding patient care: nursing diagnoses, patient problems, expected outcomes, nursing interventions, and rationales. Understanding these components is crucial for effective care planning.
Care Plan Formats: 3-Column, 4-Column, and Student Plans
Nursing care plan formats can vary slightly, often organized into columns to clearly present the key components. The most common formats are three-column and four-column plans, with student care plans often including additional elements.
Three-Column Format: Concise and Efficient
The three-column format is a streamlined approach, typically including columns for:
- Nursing Diagnosis: Identifies the patient’s health problems or needs based on assessment data.
- Outcomes and Evaluation: Specifies the desired patient outcomes and provides a space for evaluating goal achievement.
- Interventions: Outlines the nursing actions planned to achieve the desired outcomes.
!3-column nursing care plan format
Alt Text: Example of a three-column nursing care plan format, showing columns for Nursing Diagnosis, Outcomes/Evaluation, and Interventions.
Four-Column Format: Detailed and Comprehensive
The four-column format provides a more detailed structure, typically including columns for:
- Nursing Diagnosis: States the identified nursing diagnosis.
- Goals and Outcomes: Clearly defines both broad goals and specific, measurable outcomes.
- Interventions: Lists the planned nursing interventions.
- Evaluation: Provides a dedicated column for evaluating the effectiveness of interventions and patient progress.
!4-Column Nursing Care Plan Format
Alt Text: Template of a four-column nursing care plan format, with columns for Nursing Diagnosis, Goals/Outcomes, Interventions, and Evaluation.
For practical use, sample templates for various nursing care plan formats are available for download and customization:
Download: Printable Nursing Care Plan Templates and Formats
Student Care Plans: Emphasizing Learning and Rationale
Student care plans are designed to be more in-depth and detailed than those used by practicing nurses. They serve as a valuable learning tool for student nurses, helping them develop critical thinking and care planning skills.
!Student nursing care plans are more detailed.
Alt Text: Image illustrating a student nursing care plan format, highlighting its detailed nature and focus on rationales.
Typically, student care plans are handwritten and include an additional column for “Rationale” or “Scientific Explanation” after the nursing interventions column. Rationales require students to articulate the scientific principles underpinning each nursing intervention, reinforcing their understanding of the evidence-based nature of nursing practice.
Step-by-Step Guide to Writing a Nursing Care Plan
Creating an effective nursing care plan involves a systematic approach, following a series of logical steps. This step-by-step guide will walk you through the process:
Step 1: Comprehensive Data Collection and Assessment
The initial step in developing a nursing care plan is to gather comprehensive patient data through various assessment techniques and data collection methods. This includes:
- Physical Assessment: Conducting a thorough physical assessment to evaluate the patient’s current health status.
- Health History: Obtaining a detailed health history to understand the patient’s past medical conditions and relevant health information.
- Patient Interview: Conducting interviews with the patient and, when appropriate, family members to gather subjective data and understand their perspectives.
- Medical Records Review: Reviewing the patient’s medical records, including previous diagnoses, treatments, and progress notes.
- Diagnostic Studies: Analyzing results from relevant diagnostic tests and procedures.
This comprehensive patient database forms the foundation of the care plan. During this phase, nurses identify relevant related factors, risk factors, and defining characteristics that will be used to formulate nursing diagnoses. Many healthcare facilities and nursing schools have specific assessment formats to guide this data collection process.
Critical thinking is paramount during patient assessment. Nurses must integrate knowledge from various scientific disciplines and professional guidelines to make informed evaluations. This process is essential for complex clinical decision-making, aiming to accurately identify patients’ healthcare needs within a supportive environment and utilizing reliable information.
Step 2: Data Analysis and Organization for Nursing Diagnosis
Once patient data is collected, the next step is to analyze, cluster, and organize this information. This involves:
- Identifying Significant Cues: Recognizing relevant data points that indicate potential health problems or needs.
- Clustering Data: Grouping related cues together to identify patterns and potential nursing diagnoses.
- Analyzing Data Clusters: Interpreting the clustered data to formulate potential nursing diagnoses, prioritize patient problems, and determine desired outcomes.
Step 3: Formulating Accurate Nursing Diagnoses
Nursing diagnoses are standardized statements that describe a patient’s health problems or conditions that nurses are qualified and licensed to treat. They provide a consistent and uniform language for identifying and addressing specific patient needs and responses to actual or potential health issues. Nursing diagnoses focus on problems that can be prevented, reduced, or resolved through independent nursing interventions.
For a detailed guide on formulating nursing diagnoses, refer to “Nursing Diagnosis (NDx): Complete Guide and List“. This resource provides comprehensive information and examples to assist in accurately identifying and stating nursing diagnoses.
Step 4: Prioritizing Nursing Diagnoses
Setting priorities involves ranking nursing diagnoses in order of importance to address the most critical patient needs first. This step requires collaboration between the nurse and the patient to determine which problems require immediate attention. Diagnoses are often categorized as high, medium, or low priority based on their potential impact on the patient’s well-being. Life-threatening issues are always assigned high priority.
Maslow’s Hierarchy of Needs is a valuable framework for prioritizing nursing diagnoses. Developed by Abraham Maslow, this hierarchy organizes human needs into a pyramid, starting with basic physiological needs at the base and progressing to higher-level needs like self-esteem and self-actualization. According to Maslow’s theory, basic physiological needs must be met before higher-level needs can be effectively addressed.
Maslow’s Hierarchy of Needs in Nursing:
-
Basic Physiological Needs: These are the most fundamental needs for survival, including:
- Nutrition (water and food intake)
- Elimination (bowel and bladder function)
- Airway, Breathing, Circulation (ABCs) – ensuring patent airway, adequate respiration, and circulatory function (including suction if needed, oxygen administration, monitoring pulse, cardiac function, and blood pressure)
- Rest and sleep
- Shelter
- Exercise
- Sexual health
-
Safety and Security Needs: Once physiological needs are met, safety and security become paramount:
- Injury prevention measures (using side rails, ensuring call lights are accessible, hand hygiene, implementing isolation precautions when necessary, suicide and fall precautions, promoting car seat and helmet use, seat belt use)
- Creating a safe and trusting environment (therapeutic relationship)
- Patient education on safety measures and modifiable risk factors (e.g., for stroke, heart disease)
-
Love and Belonging Needs: These needs focus on social connection and acceptance:
- Fostering supportive relationships
- Strategies to prevent social isolation (addressing bullying)
- Employing active listening and therapeutic communication techniques
- Addressing needs for intimacy and sexual expression
-
Self-Esteem Needs: These relate to feelings of self-worth and accomplishment:
- Promoting community acceptance and workforce participation
- Recognizing personal achievements
- Fostering a sense of control and empowerment
- Encouraging acceptance of one’s body image and physical appearance
-
Self-Actualization Needs: Representing the highest level of needs, focused on personal growth and fulfillment:
- Creating an empowering environment
- Supporting spiritual growth
- Developing the ability to understand diverse perspectives
- Facilitating the patient’s reaching their full potential
!Virginia Henderson’s 14 Needs as applied to Maslow’s Hierarchy of Needs.
Alt Text: Diagram illustrating Virginia Henderson’s 14 Needs of nursing mapped onto Maslow’s Hierarchy of Needs, showing the relationship between fundamental nursing needs and human needs theory.
Patient’s health values, beliefs, available resources, and the urgency of the situation are critical factors nurses must consider when prioritizing diagnoses. Involving the patient in this prioritization process enhances their cooperation and commitment to the care plan.
Step 5: Setting Client-Centered Goals and Desired Outcomes
After prioritizing nursing diagnoses, the nurse and patient collaborate to establish goals for each priority diagnosis. Goals or desired outcomes are statements that describe the intended changes in patient health status that the nurse aims to achieve through nursing interventions. Well-defined goals:
- Provide direction for planning nursing interventions.
- Serve as criteria for evaluating patient progress.
- Enable the nurse and patient to determine when problems are resolved.
- Motivate both the patient and nurse by providing a sense of accomplishment.
!Desired Goals and Outcomes
Alt Text: Examples of well-written nursing goals and desired outcomes in a care plan, demonstrating specific, measurable, achievable, relevant, and time-bound criteria.
For each nursing diagnosis, one overarching goal is established. 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):
- Specific: Goals should be clearly defined, significant to the patient, and focused.
- Measurable: Progress towards goals should be quantifiable and trackable, allowing for objective evaluation.
- Attainable: Goals should be achievable and realistic for the patient, considering their capabilities and resources.
- Relevant: Goals should be pertinent to the patient’s health needs and overall care plan.
- Time-bound: Goals should have a defined timeframe for achievement, creating a sense of urgency and focus.
Hogston (2011) proposes the REEPIG standards to further ensure high-quality care plans:
- Realistic: Goals and interventions should be feasible given available resources and patient circumstances.
- Explicitly stated: Instructions and expectations should be clear and unambiguous, minimizing misinterpretations.
- Evidence-based: Interventions should be supported by research and best practices.
- Prioritized: The care plan should address the most urgent problems first.
- Involve: Care planning should involve the patient and all relevant members of the multidisciplinary healthcare team.
- Goal-centered: Planned care should directly contribute to achieving the established patient goals.
Short-Term and Long-Term Goals
Goals and expected outcomes must be measurable and patient-centered. Goals are framed around problem prevention, resolution, and rehabilitation. They can be categorized as short-term or long-term, depending on the expected timeframe for achievement. In acute care settings, most goals are short-term, addressing immediate patient needs. Long-term goals are more common for patients with chronic conditions or those receiving care in home, nursing home, or extended-care settings.
- Short-term goal: Describes a change in patient behavior or status expected within a short period, typically hours or days.
- Long-term goal: Indicates an objective to be achieved over a more extended period, usually weeks or months.
- Discharge planning: Involves establishing long-term goals to ensure continued restorative care and problem resolution through home health services, physical therapy, or other referrals.
Components of Well-Formulated Goals and Desired Outcomes
Well-written goal and desired outcome statements typically include four key components:
!Components of Desired outcomes and goals
Alt Text: Diagram outlining the components of desired outcomes and goals in nursing care plans, including subject, verb, conditions/modifiers, and criterion of performance.
- Subject: The subject is the patient, a part of the patient, or a patient attribute (e.g., pulse rate, body temperature, urinary output). Often, the subject is implied as “the patient” unless otherwise specified (e.g., family, significant other).
- Verb: The verb specifies the action the patient is expected to perform, learn, or experience.
- Conditions or modifiers: These clarify the “what, when, where, or how” of the expected behavior, specifying the circumstances under which the behavior should occur.
- Criterion of desired performance: This defines the standard for evaluating performance or the level at which the patient will perform the specified behavior. This component is optional but adds specificity to the goal.
Tips for writing effective goals and desired outcomes:
- Frame goals and outcomes in terms of patient responses, not nurse activities. Start each goal with “Client will […]” to emphasize patient behavior and responses.
- Focus on what the patient will achieve, not what the nurse hopes to accomplish.
- Use observable and measurable terms for outcomes, avoiding vague language that requires subjective interpretation.
- Ensure desired outcomes are realistic given the patient’s resources, abilities, limitations, and the planned duration of care.
- Confirm goals are compatible with therapies prescribed by other healthcare professionals.
- Each goal should be derived from only one nursing diagnosis to facilitate clear evaluation of care and ensure interventions are directly relevant to the diagnosis.
- Prioritize goals that the patient considers important and values to foster patient cooperation and engagement.
Step 6: Selecting Appropriate Nursing Interventions
Nursing interventions are specific actions or activities that nurses implement to help patients achieve their established goals and desired outcomes. Interventions should be chosen to directly address the root cause or contributing factors (etiology) of the prioritized nursing 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:
!Types of Nursing Interventions
Alt Text: Diagram illustrating the types of nursing interventions in care plans: Independent, Dependent, and Collaborative, with examples of each type.
-
Independent Nursing Interventions: These are actions that nurses are authorized to initiate based on their professional judgment and skills. They include:
- Ongoing patient assessment
- Providing emotional support
- Offering comfort measures
- Patient education
- Physical care and assistance
- Making referrals to other healthcare professionals
-
Dependent Nursing Interventions: These are actions that require a physician’s order or supervision to be implemented. Examples include:
- Administering medications
- Providing intravenous therapy
- Ordering and performing diagnostic tests
- Implementing specific medical treatments
- Managing diet and activity orders
- Providing explanations related to medical orders
-
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 shared decision-making to leverage the expertise of different disciplines.
Effective nursing interventions should be:
- Safe and appropriate for the patient’s age, health condition, and overall status.
- Achievable given available resources, time constraints, and patient circumstances.
- Consistent with the patient’s values, cultural background, and beliefs.
- Aligned with other therapies the patient is receiving.
- Based on current nursing knowledge, clinical experience, and relevant scientific evidence.
Key tips for writing clear and effective nursing interventions:
- Date and sign the care plan to indicate accountability and provide a timeframe for review and evaluation.
- Interventions should be specific and clearly worded, starting with an action verb that clearly indicates what the nurse is expected to do. Use precise action verbs and include qualifiers specifying how, when, where, time, frequency, and amount of the intervention. Examples: “Educate parents on proper temperature measurement techniques and when to report changes,” or “Assess urine characteristics including color, amount, odor, and turbidity.”
- Use only standard abbreviations that are accepted within the healthcare institution to ensure clarity and avoid confusion.
Step 7: Providing Rationales for Nursing Interventions
Rationales, also known as scientific explanations, are justifications for why specific nursing interventions are chosen for the NCP. They explain the scientific principles or evidence that supports the effectiveness of the selected interventions in achieving the desired patient outcomes.
!Nursing Interventions and Rationale
Alt Text: Example of nursing interventions with corresponding rationales, demonstrating the link between nursing actions and their scientific basis in a care plan.
Rationales are typically included in student care plans as a learning tool to help students connect pathophysiological and psychological principles to nursing practice. They are less commonly included in care plans used by practicing nurses in clinical settings, where the rationale is often implicit in professional nursing knowledge.
Step 8: Ongoing Evaluation of the Care Plan
Evaluation is a critical, ongoing, and systematic process within the nursing process. It involves assessing the patient’s progress toward achieving the established goals and desired outcomes, and determining the effectiveness of the implemented nursing care plan (NCP). Evaluation is essential because the conclusions drawn from this step dictate whether the current nursing interventions should be:
- Terminated: If goals have been fully achieved and the problem is resolved.
- Continued: If progress is being made, but goals are not yet fully met.
- Modified: If progress is insufficient, or the patient’s condition has changed, requiring adjustments to the care plan, nursing diagnoses, goals, or interventions.
Step 9: Documenting the Nursing Care Plan
The final step is to formally document the patient’s care plan according to the policies of the healthcare facility. The documented care plan becomes a part of the patient’s permanent medical record, accessible to all members of the healthcare team. Different nursing programs and healthcare settings may use varying care plan formats. However, most formats are designed to guide nurses through the logical and interconnected steps of the nursing process, often utilizing a structured format such as the five-column approach, which includes assessment cues in addition to the diagnosis, outcomes, interventions, and evaluation columns.
Comprehensive 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 care plans are organized into categories for easy navigation:
Basic Nursing and General Care Plans
General care plans applicable across various patient populations and healthcare settings:
| Basic Nursing & General Care Plans |
|---|
| Acute Confusion (Delirium) and Altered Mental Status |
| Acute Pain and Pain Management |
| Activity Intolerance and Generalized Weakness |
| Cancer (Oncology Nursing) |
| Caregiver Role Strain and Family Caregiver Support Systems |
| Chronic Confusion (Dementia) |
| End-of-Life Care (Hospice Care or Palliative) |
| Fall Risk and Fall Prevention |
| Fatigue and Lethargy |
| Geriatric Nursing (Older Adult) |
| Grieving and Loss |
| Hypothermia and Cold Injuries |
| Hyperthermia (Fever) |
| Impaired Swallowing (Dysphagia) |
| Insomnia and Sleep Deprivation |
| Prolonged Bed Rest |
| Risk for Injury and Patient Safety |
| Self-Care and Activities of Daily Living (ADLs) |
| Surgery (Perioperative Client) |
| Systemic Lupus Erythematosus |
| Total Parenteral Nutrition |
Surgery and Perioperative Care Plans
Care plans specifically designed for patients undergoing surgical procedures:
| 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
Care plans focused on cardiovascular health and conditions:
| 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
Care plans addressing endocrine 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
Care plans for disorders of the 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
Care plans addressing blood and lymphatic system disorders:
| 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
Care plans for communicable and infectious conditions:
| 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
Care plans addressing skin and tissue conditions:
| Integumentary Care Plans |
|---|
| Burn Injury |
| Dermatitis |
| Herpes Zoster (Shingles) |
| Pressure Ulcer (Bedsores) |
| Wound Care and Skin/Tissue Integrity |
Maternal and Newborn Care Plans
Care plans for pregnancy, childbirth, and newborn care:
| 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
Care plans for mental health and psychiatric conditions:
| 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
Care plans for musculoskeletal system disorders:
| 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
Care plans for 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 Care Plans
Care plans for eye disorders:
| Ophthalmic Care Plans |
|---|
| Cataracts |
| Glaucoma |
| Macular Degeneration |
Pediatric Nursing Care Plans
Care plans specifically for pediatric patients:
| 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
Care plans for reproductive and sexual health disorders:
| Reproductive Care Plans |
|---|
| Cryptorchidism (Undescended Testes) |
| Hysterectomy |
| Hypospadias and Epispadias |
| Mastectomy |
| Menopause |
| Prostatectomy |
Respiratory Care Plans
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
Care plans for 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 Plans
Enhance your understanding and skills in nursing diagnosis and care planning with these recommended books and resources:
Disclosure: The following are affiliate links from Amazon.com. Nurseslabs may earn a small commission from purchases made through these links, at no additional cost to you. For more information, please see our privacy policy.
Ackley and Ladwig’s Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care
This handbook offers an evidence-based approach to nursing interventions and utilizes a clear three-step system for client assessment, nursing diagnosis, and care plan development. It provides step-by-step guidance on implementing care, evaluating outcomes, and building critical thinking and diagnostic reasoning skills.
!Ackley and Ladwig’s Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care
Alt Text: Cover image of “Ackley and Ladwig’s Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care,” a recommended resource for nursing diagnosis and care plan development.
Nursing Care Plans – Nursing Diagnosis & Intervention (10th Edition)
This comprehensive resource features over 200 care plans reflecting current evidence-based guidelines. The latest edition includes ICNP diagnoses, care plans addressing LGBTQ health issues, and expanded coverage on electrolytes and acid-base balance.
!Nursing Care Plans – Nursing Diagnosis & Intervention (10th Edition)
Alt Text: Cover image of “Nursing Care Plans – Nursing Diagnosis & Intervention (10th Edition),” a valuable book for nursing students and professionals.
Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales
A quick-reference tool essential for identifying accurate diagnoses and efficient patient care planning. The sixteenth edition includes the most recent nursing diagnoses and interventions, with an alphabetized listing covering over 400 disorders.
!Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales
Alt Text: Cover image of “Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales,” a handy pocket guide for nursing care planning.
Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care
This manual assists in planning, individualizing, and documenting care for over 800 diseases and disorders. It provides subjective and objective data, sample clinical applications, prioritized actions/interventions with rationales, and documentation guidelines for each diagnosis.
!Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care
Alt Text: Cover image of “Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care,” a detailed manual for comprehensive nursing care planning.
All-in-One Nursing Care Planning Resource – E-Book: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health
This e-book includes over 100 care plans across medical-surgical, maternity/OB, pediatrics, and psychiatric-mental health nursing. Interprofessional “patient problems” sections enhance understanding of patient communication and collaborative care.
!All-in-One Nursing Care Planning Resource – E-Book: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health
Alt Text: Cover image of “All-in-One Nursing Care Planning Resource – E-Book,” a resource covering various nursing specialties for care planning.
References and Sources
Original article and linked resources within the Nurseslabs website.
