A well-structured nursing care plan is indispensable for delivering optimal patient care. It’s a systematic approach that pinpoints existing patient needs and anticipates potential risks. These plans act as a vital communication bridge between nurses, patients, and the broader healthcare team, ensuring everyone is aligned towards achieving specific health objectives. The absence of a robust nursing care planning process can compromise the quality and consistency of patient care.
The creation of a nursing care plan starts the moment a patient is admitted and is continuously refined based on changes in the patient’s condition and the ongoing evaluation of goal progress. Personalized, patient-centered care, driven by meticulous planning, is the cornerstone of outstanding nursing practice. At the heart of this personalized care is the nursing diagnosis, which directly informs the goals of care established for each patient.
Types of Nursing Care Plans
Nursing care plans come in two primary forms: informal and formal. An informal nursing care plan is a mental strategy used by a nurse, while a formal nursing care plan is a documented, either written or digital, guide for patient care.
Formal care plans are further classified into standardized and individualized plans. Standardized care plans are designed for groups of patients with common needs. Individualized care plans are customized to meet the unique needs of a specific patient, particularly those needs not covered by standardized plans.
Standardized Care Plans
Standardized care plans are pre-established protocols developed by nursing staff and healthcare institutions to ensure consistent care for patients with similar conditions. They ensure essential care standards are met and improve efficiency by eliminating the need to create repetitive plans for common patient needs.
However, standardized care plans are not designed for individual patient goals and needs. They often serve as a starting point for creating an individualized care plan.
The care plans provided in this guide are examples of standard care plans, intended as a framework for developing personalized care.
Individualized Care Plans
An individualized care plan is adapted from a standardized plan to address the specific needs and goals of each patient, incorporating strategies known to be effective for that individual. This approach enables more tailored and holistic care, better suited to the patient’s unique circumstances, strengths, and objectives.
Moreover, individualized care plans can enhance patient satisfaction. Patients who feel their care is personalized are more likely to feel valued and understood, leading to greater satisfaction with their healthcare experience. In today’s healthcare environment, patient satisfaction is increasingly important as a measure of care quality.
Tips for personalizing a nursing care plan:
- Actively involve the patient and their family in the planning process.
- Consider the patient’s cultural background, beliefs, and values.
- Adapt interventions to suit the patient’s preferences and lifestyle.
- Regularly review and update the plan based on the patient’s changing needs and progress.
Objectives of Nursing Care Plans
The objectives of creating nursing care plans are:
- To promote evidence-based nursing care, ensuring a comfortable and familiar environment in healthcare settings.
- To support holistic care, addressing the patient’s physical, psychological, social, and spiritual needs in disease management and prevention.
- To develop structured care programs like care pathways and bundles. Care pathways ensure team consensus on care standards and expected outcomes, while care bundles focus on best practices for specific conditions.
- To clearly define goals and expected outcomes for patient care.
- To improve communication and documentation of the care plan among healthcare providers.
- To establish metrics for evaluating the effectiveness of nursing care.
Purposes of Nursing Care Plans
The purposes and importance of nursing care plans include:
- Defining the nurse’s role. Care plans clarify the unique and independent role of nurses in addressing patients’ overall health and well-being, beyond physician orders.
- Providing direction for individualized patient care. They serve as a guide for personalized care, encouraging critical thinking in developing tailored interventions.
- Ensuring continuity of care. Consistent, high-quality interventions are delivered across different nursing shifts and departments, maximizing treatment benefits for patients.
- Coordinating care. All healthcare team members are informed of patient needs and required actions, preventing gaps in care.
- Documentation. Care plans accurately document observations, nursing actions, and instructions for patients or family members. Proper documentation is crucial to demonstrate care delivery.
- Guiding staff assignments. Care plans help in assigning staff with specific skills to patients with complex needs.
- Monitoring progress. They facilitate tracking patient progress and adjusting care plans as health status and goals evolve.
- Supporting reimbursement. Insurance companies use medical records, including care plans, to determine coverage for hospital care.
- Defining patient goals. Care plans engage patients in their treatment and care, benefiting both patients and nurses.
Components of a Nursing Care Plan
A typical nursing care plan (NCP) includes nursing diagnoses, patient problems, expected outcomes, nursing interventions, and rationales. These components are detailed below:
Nursing Diagnoses: The Foundation for Goals of Care
Nursing diagnoses are crucial as they precisely identify patient health issues and responses to illness or life situations. They are the clinical judgments that nurses make about actual or potential health problems. Importantly, nursing diagnoses are the basis upon which goals of care are established. A well-formulated nursing diagnosis leads directly to the development of patient-centered, measurable goals.
For example, if a patient is diagnosed with “Impaired Physical Mobility related to post-operative pain as evidenced by inability to ambulate without assistance,” the goals of care will directly address this diagnosis. These goals might include: “Patient will ambulate 50 feet with the assistance of one person within 24 hours” and “Patient will report pain level of 3 or less on a scale of 0-10 within 24 hours.”
Desired Outcomes and Goals: Defining Success
Desired outcomes and goals are statements that describe the intended results of nursing care. They are derived directly from the nursing diagnoses and define what the nurse and patient hope to achieve. These goals must be:
- Specific: Clearly defined and focused on a particular aspect of the patient’s health.
- Measurable: Quantifiable so progress can be tracked and evaluated.
- Attainable: Realistic and achievable given the patient’s current condition and resources.
- Relevant: Meaningful and important to the patient’s overall health and well-being.
- Time-bound: Include a timeframe for achievement, providing a sense of urgency and direction.
In essence, nursing diagnoses identify the problems, and goals of care define the solutions and desired improvements. The link between them is direct and essential for effective care planning.
Nursing Interventions: Actions to Achieve Goals
Nursing interventions are the specific actions nurses will take to help the patient achieve the established goals. These interventions should be evidence-based, tailored to the patient’s needs, and directly address the etiology of the nursing diagnosis.
Rationales: The Why Behind the Actions
Rationales are the scientific reasons behind each nursing intervention. They explain why a particular intervention is chosen and how it will help the patient reach their goals. Rationales are particularly important for student nurses to understand the principles underlying nursing care.
Evaluation: Measuring Goal Achievement
Evaluation is the process of assessing the patient’s progress toward achieving the goals of care. It’s an ongoing process that determines the effectiveness of the nursing care plan. Based on the evaluation, the care plan may be continued, modified, or discontinued.
Care Plan Formats
Nursing care plans are typically organized in formats with columns for nursing diagnoses, desired outcomes and goals, nursing interventions, and evaluation. Common formats include three-column and four-column plans.
Three-Column Format
This format combines outcomes and evaluation into a single column alongside nursing diagnoses and interventions.
Three-column nursing care plan format example.
Four-Column Format
This format separates goals and outcomes from evaluation, providing distinct columns for nursing diagnoses, goals and outcomes, interventions, and evaluation.
Four-column nursing care plan template example.
Download sample templates for different nursing care plan formats:
Download: Printable Nursing Care Plan Templates and Formats
Student Care Plans
Student care plans are more detailed for learning purposes, often including a “Rationale” column to explain the scientific basis for interventions. They are typically handwritten and more comprehensive than those used by practicing nurses.
Student nursing care plans are designed for in-depth learning and are more detailed.
Writing a Nursing Care Plan: Step-by-Step
Creating an effective nursing care plan involves a systematic approach:
Step 1: Data Collection and Assessment
Begin by gathering comprehensive patient data using various assessment techniques:
- Physical assessment: Conducting a thorough examination.
- Health history: Reviewing the patient’s medical background.
- Interviews: Talking to the patient and family.
- Medical records review: Examining existing documentation.
- Diagnostic studies: Analyzing test results.
This data collection creates a patient database, including all relevant health information. This step is crucial for identifying related or risk factors and defining characteristics needed to formulate nursing diagnoses. Critical thinking is essential in patient assessment, integrating medical knowledge and professional guidelines to inform evaluations and decision-making.
Step 2: Data Analysis and Organization
Analyze, cluster, and organize the collected data to identify patterns and formulate nursing diagnoses, prioritize issues, and define desired outcomes.
Step 3: Formulating Nursing Diagnoses
Nursing diagnoses are standardized statements identifying patient needs and responses to health problems. They are actual or potential health issues that nurses can independently address.
Refer to resources like “Nursing Diagnosis (NDx): Complete Guide and List” for detailed guidance on formulating nursing diagnoses.
Step 4: Setting Priorities Based on Nursing Diagnoses
Prioritize nursing diagnoses based on their urgency and impact on the patient’s health. This involves establishing a preferential order for addressing diagnoses and interventions. Life-threatening problems should always be high priority.
Maslow’s Hierarchy of Needs is a useful framework for prioritizing diagnoses, ensuring basic physiological needs are met before addressing higher-level needs like self-esteem.
Maslow’s Hierarchy of Needs:
- Basic Physiological Needs: Airway, breathing, circulation (ABCs), nutrition, elimination, sleep, shelter, exercise, and sex.
- Safety and Security: Injury prevention, trust and safety, patient education on modifiable risk factors.
- Love and Belonging: Supportive relationships, avoiding social isolation, therapeutic communication.
- Self-Esteem: Community acceptance, personal achievement, self-empowerment, and body image acceptance.
- Self-Actualization: Empowering environment, spiritual growth, realizing one’s potential.
Virginia Henderson’s 14 Needs applied to Maslow’s Hierarchy of Needs. Learn more here.
Consider patient values, beliefs, available resources, and urgency when setting priorities. Patient involvement is crucial for cooperation.
Step 5: Establishing Client Goals and Desired Outcomes from Nursing Diagnoses
For each prioritized nursing diagnosis, set goals and desired outcomes. These statements describe what the nurse aims to achieve through nursing interventions. Goals guide intervention planning, serve as evaluation criteria, and motivate both patient and nurse.
Examples of well-written goals and desired outcomes.
Goals should be SMART:
- Specific
- Measurable
- Attainable
- Realistic
- Time-oriented
They should also adhere to REEPIG standards for high-quality care:
- Realistic
- Explicitly stated
- Evidence-based
- Prioritized
- Involve patient and team
- Goal-centered
Goals can be short-term (achievable within hours or days) or long-term (achievable over weeks or months). In acute care, short-term goals are more common, while long-term goals are used for chronic conditions or home care.
Components of Goals and Desired Outcomes:
Goals typically include four components:
- Subject: The patient (often implied).
- Verb: The action the patient will perform.
- Conditions/Modifiers: Circumstances under which the behavior will occur.
- Criterion of desired performance: The standard for evaluating performance (optional).
Breakdown of the components of effective goals and desired outcomes.
Tips for writing goals and desired outcomes:
- Focus on patient responses, not nurse activities. Start goals with “Client will […].”
- Focus on what the patient will do, not nurse actions.
- Use observable, measurable terms. Avoid vague language.
- Ensure outcomes are realistic given patient resources and timeframe.
- Ensure goals align with other healthcare therapies.
- Each goal should address only one nursing diagnosis.
- Ensure goals are important and valued by the patient.
Step 6: Selecting Nursing Interventions to Achieve Goals
Nursing interventions are actions nurses perform to help patients reach their goals. Interventions should aim to eliminate or reduce the causes of the nursing diagnosis. For risk diagnoses, interventions should focus on reducing risk factors.
Types of Nursing Interventions:
- Independent interventions: Actions nurses initiate based on their judgment and skills (e.g., education, emotional support).
- Dependent interventions: Actions carried out under physician orders (e.g., medication administration, treatments).
- Collaborative interventions: Actions performed with other healthcare team members (e.g., physical therapy, dietary consults).
Examples of independent, dependent, and collaborative nursing interventions.
Nursing interventions should be:
- Safe and appropriate for the patient’s condition.
- Achievable with available resources.
- Aligned with patient values and beliefs.
- Consistent with other therapies.
- Based on nursing knowledge and evidence.
Tips for writing nursing interventions:
- Date and sign the care plan for accountability and future reference.
- Interventions should be specific and clear, starting with an action verb.
- Use only accepted abbreviations.
Step 7: Providing Rationales for Interventions
Rationales explain the scientific basis for each nursing intervention, linking them to pathophysiological and psychological principles. They are particularly helpful for students in understanding the reasoning behind care actions.
Example of nursing interventions with corresponding rationales.
Step 8: Evaluation of Goal Achievement
Evaluation is an ongoing assessment of the patient’s progress toward goals and the effectiveness of the care plan. It determines whether interventions should continue, change, or stop. Evaluation is crucial for adapting the care plan to meet the patient’s evolving needs and ensure goals of care are met.
Step 9: Documenting the Care Plan
Document the care plan according to institutional policy as part of the patient’s medical record. Different nursing programs and institutions may have varied care plan formats.
Nursing Care Plan List
Below is a list of sample nursing care plans (NCPs) and nursing diagnoses for various health conditions, categorized for easy navigation:
