The Ultimate Guide to Nursing Care Plans
If you aspire to become a nurse, you'll want to familiarize yourself with what nursing care plans (NCPs) are all about. Nursing care plans provide a means of communication among nurses, their patients, and other healthcare providers to achieve healthcare outcomes.
What is a Nursing Care Plan?
A nursing care plan contains relevant information about a patient’s diagnosis, the goals of treatment, the specific nursing orders (including what observations are needed and what actions must be performed), and an evaluation plan.
Over the course of the patient’s stay, the plan is updated with any changes and new information as it presents itself. In fact, most hospitals require nurses to update the care plan during and after each shift.
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What is the Purpose of a Nursing Care Plan?
Nursing care plans help define nursing guidelines and some treatment guidelines (as ordered) for a specific patient.
Essentially, it is a plan of action. It helps guide nurses throughout their shift in caring for the patient. It also allows nurses to provide attentive and focused care.
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Types of Nursing Care Plans
There are four main types of nursing care plans.
- Informal - A care plan that exists in the nurse’s mind and is actions the nurse wishes to accomplish during their shift.
- Formal - This is a written or computerized plan that organizes and coordinates the patient’s care information and plan.
- Standardized - Nursing care for groups of patients with everyday needs.
- Individualized - A care plan tailored to the specific needs of the patient.
What are the Components of a Nursing Care Plan?
Nursing care plans follow a five-step process:
- Assessment
- Diagnosis
- Expected outcomes
- Interventions
- Rationale and Evaluation
>> Related: The Nursing Process Explained
How to Write a Nursing Care Plan
When writing a nursing care plan, you first have to determine what type of care plan you are interested in. If it is for your own use throughout the shift, then an informal one may be beneficial; however, if it is for the patient’s chart and required during your shift then an individualized care plan is the way to go.
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Step 1: Assessment
The first step in writing an organized care plan includes gathering subjective and objective nursing data. This information can come from,
- Verbal statements from patient and family
- Vital signs
- Physical complaints
- Body conditions
- Medical history
- Height and weight
- Intake and output
Step 2: Diagnosis
Using the information and data collected in Step 1, a nursing diagnosis is chosen that best fits the patient, the goals, and objectives for the patient’s hospitalization.
According to North American Nursing Diagnosis Association (NANDA), defines a nursing diagnosis as “a clinical judgment about the human response to health conditions/life processes, or a vulnerability for that response, by an individual, family, group or community.”
A nursing diagnosis is based on Maslow’s Hierarchy of Needs pyramid and helps prioritize treatments. Based on the nursing diagnosis chosen, the goals to resolve the patient’s problems through nursing implementations are determined in the next step.
Step 3: Outcomes and Planning
After determining the nursing diagnosis, it is time to create a SMART goal based on evidence-based practices. SMART goals stands for Specific, Measurable, Achievable, Relevant, and Time-Bound. It is important to consider the patient’s medical diagnosis, overall condition, and all of the data collected.
It is also during this time you will consider goals for the patient and outcomes for the short and long term. These goals must be realistic and desired by the patient. For example, if a goal is for the patient to seek counseling for alcohol dependency during the hospitalization but the patient is currently detoxing and having mental distress - this might not be a realistic goal.
Step 4: Implementation
Now that the goals have been set, you must put the actions into effect to help the patient achieve the goals. While some of the actions will show immediate results (ex. giving a patient with constipation a suppository to elicit a bowel movement) others might not be seen until later on in the hospitalization.
The implementation phase means performing the nursing interventions outlined in the care plan. Interventions are classified into seven categories:
- Family
- Behavioral
- Physiological
- Complex physiological
- Community
- Safety
- Health system interventions
Some interventions will be patient or diagnosis-specific, but there are several that are completed each shift for every patient:
- Pain assessment
- Position changes
- Fall prevention
- Providing cluster care
- Infection control
Step 5: Evaluation
The fifth and final step of the nursing care plan is the evaluation phase. This is when you evaluate if the desired outcome has been met during the shift. There are three possible outcomes,
- Met
- Ongoing
- Not Met
Based on the evaluation, it can determine if the goals and interventions need to be altered.
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Sample Nursing Care Plans
Nursing Diagnosis: Ineffective breathing pattern related to right pulmonary agenesis as evidenced by high carbon dioxide levels and absent breath sounds on right side of the chest.
Assessment:
- Vital signs: Monitor the patient’s heart rate, respiratory rate and SpO2 levels. Signs of respiratory distress include tachypnea, dyspnea and an SpO2 <95%.
- Breathing patterns: If the patient shows signs of respiratory distress, it should alarm the nurse, and interventions should take place. Signs of respiratory distress include nasal flaring, accessory muscles, grunting, shortness of breath, and retractions.
- CO2 lab values: When the body has an ineffective breathing pattern, inadequate gas exchange will take place. During this, the body retains CO2 and can enter into a stage of respiratory acidosis. Monitor for respiratory acidosis with blood gas lab values.
- Skin assessment: A person experiencing respiratory distress may experience pallor, cyanotic, and/or mottled skin.
SMART Goal: The patient will maintain a SpO2 level of >95%, RR of 30 to 55 breaths per minute, and heart rate of 80 to 140 beats per minute until the end of the shift.
Interventions:
- Check manual heart rate and respiratory rate every four hours.
- Check patient is on continuous SpO2 monitor with pulse oximetry on the same extremity throughout shift.
- Obtain blood gases as ordered.
- Monitor for signs and symptoms of increased work of breathing and respiratory distress.
Evaluate:
- The patient is observed and/or documented to have SpO2, HR, and RR all within normal limits by end of the shift.
- The patient is documented to have received blood gas results that contain a CO2 value that is within the normal range.
- The patient is observed and documented to not experience any symptoms of respiratory distress throughout the shift.
Nursing Care Plan FAQs
*This website is provided for educational and informational purposes only and does not constitute providing medical advice or professional services. The information provided should not be used for diagnosing or treating a health problem or disease.
