How to Write a Nursing Care Plan

Step 1: Assessment

The first step in writing an organized care plan includes gathering subjective and objective nursing data. Subjective data is what the patient tells us their symptoms are, including feelings, perceptions, and concerns. Objective data is observable and measurable.

Assessment Information Sources

• Verbal statements from the patient and family
• Vital signs
• Physical complaints
• Body conditions
• Medical history
• Height and weight
• Intake and output
• Patient feelings, concerns, perceptions
• Laboratory data
• Diagnostic testing

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 the objectives for the patient’s hospitalization. 

According to North American Nursing Diagnosis Association (NANDA), a nursing diagnosis is defined 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 interventions are determined in the next step. 

 4 Types of Nursing Diagnoses 

1. Problem-focused - Patient problem present during a nursing assessment is known as a problem-focused diagnosis
2. Risk - Risk factors require intervention from the nurse and healthcare team prior to a real problem developing
3. Health promotion - Improve the overall well-being of an individual, family, or community
4. Syndrome - A cluster of nursing diagnoses that occur in a pattern or can all be addressed through the same or similar nursing interventions

After determining which type of the four diagnoses you will use, start building out the nursing diagnosis statement. 

3 Components of a Nursing Diagnosis

1. Problem and its definition - The patient’s current health problem and the nursing interventions needed to care for the patient.
2. Etiology or risk factors - Possible reasons for the problem or the conditions in which it developed
3. Defining characteristics or risk factors - Signs and symptoms that allow for applying a specific diagnostic label/used in the place of defining characteristics for risk nursing diagnosis

Step 3: Outcomes and Planning

After determining the nursing diagnosis, it is time to create a SMART goal based on evidence-based practices. SMART is an acronym that stands for:

• Specific
• Measurable
• Achievable
• Relevant
• Time-Bound

It is important to consider the patient’s medical diagnosis, overall condition, and all of the data collected. A medical diagnosis is made by a physician or advanced healthcare practitioner.  It’s important to remember that a medical diagnosis does not change if the condition is resolved, and it remains part of the patient’s health history forever. 

It is also during this time that 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. 

Examples of SMART goals include, 

• The patient will ambulate seven times around the unit by the end of the shift. 
• The patient will rate their pain as less than four on a scale of 0-10 during the shift. 
• The patient will urinate within ten hours of the Foley catheter being removed without the need for a straight catheter placement. 
• The patient will have a bowel movement by the end of the shift without the assistance of additional medications.

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. 

7 Nursing Intervention Categories

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

Nursing Intervention Examples

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 be determined if the goals and interventions need to be altered. Ideally, by the time of discharge, all nursing care plans, including goals, should be met. Unfortunately, this is not always the case, especially if a patient is being discharged to hospice, home care, or a long-term care facility.

Initially, you will find that most care plans will have ongoing goals that might be met within a few days or may take weeks. It depends on the status of the patient as well as the desired goals. 

Consider picking goals that are achievable and can be met by the patient. This will help the patient feel like they are making progress, but also provide relief to the nurse because they can track the patient’s overall progress. 

Nursing Care Plan Example

Assessment

Subjective:
Patient states “Shortness of breath, Increased edema of left leg, increased lethargy” 

Objective:

• Heart rate: 101
• Respiratory Rate: 35
• Blood Pressure: 117/71 (93) RUE
• Temperature: 38.9 C oral
• Oxygen Saturation: 88% Room Air 
• Dyspnea on exertion
• Productive cough
• Clubbing lower extremities
• +1 putting edema LLE and RLE
• Irregular heart sounds
• Decreased bilateral breath sounds in the bases
• Overall generalized weakness

Diagnosis

Excess fluid volume is related to the new diagnosis of cardiomyopathy. 

Outcomes

• The patient will take medication as ordered. 
• The patient will show no signs of edema.  
• The patient will verbalize understanding of the new diagnosis. 

Interventions

• Coordinate with cardiology to develop a plan of care for the patient.  
• Educated patient and family on all medications and new diagnosis. 
• Ensure the patient wears compression socks and SCDs while in bed. 
• Ambulate the patient around the unit a minimum of 5x during the shift. 

Evaluation

• The patient and family will verbalize understanding of all new medications and diagnoses. 
• The patient will be compliant with taking medication as prescribed.