This guide will explain the different components of a nursing care plan including the step-by-step guide on how to write a nursing care plan.
- 1 What is a Nursing Care Plan?
- 2 Objectives of a Care Plan
- 3 Purposes
- 4 Components of a Care Plan
- 5 Steps in Writing a Care Plan
What is a Nursing Care Plan?
A nursing care plan is a process that includes correctly identifying existing needs, as well as recognizing potential needs or risks. Care plans also provide a means of communication among nurses, their patients, and other healthcare providers to achieve health care outcomes. Without the planning process, quality and consistency in patient care would be lost. Care plans include the interventions of the nurse to address the client’s nursing diagnoses and produce the desired outcomes.
Nursing care planning begins when the client is admitted to the agency and is continuously updated throughout in response to client’s changes in condition and evaluation of goal achievement. Planning and delivering individualized or patient-centered care is the basis for excellence in nursing practice.
If you are looking for the list of sample nursing care plans for different health conditions, visit our Nursing Care Plan page.
Care plans can be informal or formal: Informal nursing care plan is a strategy of action that exists in the nurse’s mind. Formal nursing care plan is a written or computerized guide that organizes information about the client’s care.
Formal care plans are further subdivided into standardized care plan, and individualized care plan: Standardized care plans specify the nursing care for groups of clients with everyday needs. Individualized care plans are tailored to meet the unique needs of a specific client or needs that are not addressed by the standardized care plan.
Objectives of a Care Plan
The following are the objectives of writing a nursing care plan:
- Promote evidence-based nursing care and to render pleasant and familiar conditions in hospitals or health centers.
- Support holistic care which involves the whole person including physical, psychological, social and spiritual in relation to management and prevention of the disease.
- Establish programs such as care pathways and care bundles. Care pathways involve a team effort in order to come to a consensus with regards to standards of care and expected outcomes while care bundles are related to best practice with regards to care given for a specific disease.
- Identify and distinguish goals and expected outcome.
- Review communication and documentation of the care plan.
- Measure nursing care.
The following are the purposes of writing a nursing care plan:
- Defines nurse’s role. It helps to identify the unique role of nurses in attending the overall health and well-being of clients without having to rely entirely on a physician’s orders or interventions.
- Provides direction for individualized care of the client. It allows the nurse to think critically about each client and to develop interventions that are directly tailored to the individual.
- Continuity of care. Nurses from different shifts or different floors can use the data to render the same quality and type of interventions to care for clients, therefore allowing clients to receive the most benefit from treatment.
- Documentation. It should accurately outline which observations to make, what nursing actions to carry out, and what instructions the client or family members require. If nursing care is not documented correctly in the care plan, there is no evidence the care was provided.
- Serves as guide for assigning a specific staff to a specific client. There are instances when client’s care needs to be assigned to a staff with particular and precise skills.
- Serves as guide for reimbursement. The medical record is used by the insurance companies to determine what they will pay in relation to the hospital care received by the client.
- Defines client’s goals. It does not only benefit nurses but also the clients by involving them in their own treatment and care.
Components of a Care Plan
A care plan includes the following components:
- Client health assessment, medical results, and diagnostic reports. This is the first measure in order to be able to design a care plan. In particular, client assessment is related to the following areas and abilities: physical, emotional, sexual, psychosocial, cultural, spiritual/transpersonal, cognitive, functional, age-related, economic and environmental. Information in this area can be subjective and objective.
- Expected client outcomes are outlined. These may be long and short term.
- Nursing interventions are documented in the care plan.
- Rationale for interventions in order to be evidence-based care.
- Evaluation. This documents the outcome of nursing interventions.
Steps in Writing a Care Plan
How do you write a nursing care plan? The following are the steps in developing a care plan for your client.
- Step 1: Data Collection or Assessment
- Step 2: Data Analysis and Organization
- Step 3: Formulating Your Nursing Diagnoses
- Step 4: Setting Priorities
- Step 5: Establishing Client Goals and Desired Outcomes
- Step 6: Selecting Nursing Interventions
- Step 7: Providing Rationale
- Step 8: Evaluation
- Step 9: Putting it on Paper
1. Data Collection or Assessment
Create a client database using assessment techniques and data collection methods (physical assessment, health history, interview, medical records review, diagnostic studies). A client database includes all the health information gathered. In this step, the nurse can identify the related or risk factors and defining characteristics that can be used to formulate a nursing diagnosis. Some agencies or nursing schools have their own assessment formats you can use.
2. Data Analysis and Organization
Now that you have information about the client’s health, analyze, cluster, and organize the data to formulate your nursing diagnosis, priorities, and desired outcomes.
3. Formulating Your Nursing Diagnoses
Nursing diagnoses are a uniform way of identifying, focusing on, and dealing with specific client needs and responses to actual and high-risk problems. Actual or potential health problems that can be prevented or resolved by independent nursing intervention are termed nursing diagnoses.
We’ve detailed the steps on how to formulate your nursing diagnoses in this guide: What is a Nursing Diagnosis?
4. Setting Priorities
Setting priorities is the process of establishing a preferential sequence for address nursing diagnoses and interventions. In this step, the nurse and the client begin planning which nursing diagnosis requires attention first. Diagnoses can be ranked and grouped as to having a high, medium, or low priority. Life-threatening problems should be given high priority. Maslow’s hierarchy of needs is frequently used when setting priorities.
Take into account Maslow’s Hierarchy of Needs:
- Priority 1: Physiological Needs – ability to breathe, maintaining patent airway, adequate circulation, hydration, elimination, temperature regulation, nutrition, pain, nausea, and other physical irritation.
- Priority 2: Safety and Security – anxiety, fear, environmental hazards, physical activity deficit, violence towards self or others.
- Priority 3: Love and Belonging – sensory-perceptual losses, inability to maintain family and significant other relationships, isolation, loss of a loved one.
- Priority 4: Self-Esteem – inability to perform activities of daily living (ADLs), change in physiological structure or function of body or body part.
- Priority 5: Self-Actualization – positive personal assessment of life events, achieving personal goals.
Client’s health values and beliefs, client’s own priorities, resources available, and urgency are some of the factors the nurse must consider when assigning priorities. Involve the client in the process to enhance cooperation.
5. Establishing client goals and desired outcomes
After assigning priorities for your nursing diagnosis, the nurse and the client set goals for each. Goals or desired outcomes describe what the nurse hopes to achieve by implementing the nursing interventions and are derived from the client’s nursing diagnoses. Goals provide direction for planning interventions, serve as criteria for evaluating client progress, enable the client and nurse to determine which problems have been resolved, and help motivate the client and nurse by providing a sense of achievement.
One overall goal is determined for each nursing diagnosis. The terms goal, outcome, and expected outcome are oftentimes used interchangeably.
- Goal – indicates the plan or desired change in the client’s health status, function, or behavior.
- Expected outcome – more specific, detailing the methods through which the goal will be achieved.
Short Term and Long Term Goals
Goals and expected outcomes must be measurable and client-centered. Goals are constructed by focusing on problem prevention, resolution, and/or rehabilitation. Goals can be short term or long term. In an acute care setting, most goals are short-term since much of the nurse’s time is spent on the client’s immediate needs. Long-term goals are often used for clients who have chronic health problems or who live at home, in nursing homes, or extended care facilities.
- Short-term goal – a statement distinguishing a shift in behavior that can be completed immediately, usually within a few hours or days.
- Long-term goal – indicates an objective to be completed over a longer period, usually over weeks or months.
- Discharge planning – involves naming long-term goals, therefore promoting continued restorative care and problem resolution through home health, physical therapy, or various other referral sources.
Components of Goals and Desired Outcomes
Goals or desired outcome statements usually have the four components: a subject, a verb, conditions or modifiers, and criterion of desired performance.
- Subject. The subject is the client, any part of the client, or some attribute of the client (i.e., pulse, temperature, urinary output). That subject is often omitted in writing goals because it is assumed that the subject is the client unless indicated otherwise (family, significant other).
- Verb. The verb specifies an action the client is to perform, for example, what the client is to do, learn, or experience.
- Conditions or modifiers. These are the “what, when, where, or how” that are added to the verb to explain the circumstances under which the behavior is to be performed.
- Criterion of desired performance. The criterion indicates the standard by which a performance is evaluated or the level at which the client will perform the specified behavior. These are optional.
When writing goals and desired outcomes, the nurse should follow these tips:
- Write goals and outcomes in terms of client responses and not as activities of the nurse. Begin each goal with “Client will […]” help focus the goal on client behavior and responses.
- Avoid writing goals on what the nurse hopes to accomplish, and focus on what the client will do.
- Use observable, measurable terms for outcomes. Avoid using vague words that require interpretation or judgment of the observer.
- Desired outcomes should be realistic for the client’s resources, capabilities, limitations, and on the designated time span of care.
- Ensure that goals are compatible with the therapies of other professionals.
- Ensure that each goal is derived from only one nursing diagnosis. Keeping it this way facilitates evaluation of care by ensuring that planned nursing interventions are clearly related to the diagnosis set.
- Lastly, make sure that the client considers the goals important and values them to ensure cooperation.
6. Selecting Nursing Interventions
Nursing interventions are activities or actions that a nurse performs to achieve client goals. Interventions chosen should focus on eliminating or reducing the etiology of the nursing diagnosis. As for risk nursing diagnoses, interventions should focus on reducing the client’s risk factors. In this step, nursing interventions are identified and written during the planning step of the nursing process; however, they are actually performed during the implementation step.
Nursing interventions can be independent, dependent, or collaborative:
- Independent nursing interventions are activities that nurses are licensed to initiate based on their sound judgement and skills. Includes: ongoing assessment, emotional support, providing comfort, teaching, physical care, and making referrals to other health care professionals.
- Dependent nursing interventions are activities carried out under the physician’s orders or supervision. Includes orders to direct the nurse to provide medications, intravenous therapy, diagnostic tests, treatments, diet, and activity or rest. Assessment and providing explanation while administering medical orders are also part of the dependent nursing interventions.
- Collaborative interventions are actions that the nurse carries out in collaboration with other health team members, such as physicians, social workers, dietitians, and therapists. These actions are developed in consultation with other health care professionals to gain their professional viewpoint.
Nursing interventions should be:
- Safe and appropriate for the client’s age, health, and condition.
- Achievable with the resources and time available.
- Inline with the client’s values, culture, and beliefs.
- Inline with other therapies.
- Based on nursing knowledge and experience or knowledge from relevant sciences.
When writing nursing interventions, follow these tips:
- Write the date and sign the plan. The date the plan is written is essential for evaluation, review, and future planning. The nurse’s signature demonstrates accountability.
- Nursing interventions should be specific and clearly stated, beginning with an action verb indicating what the nurse is expected to do. Action verb starts the intervention and must be precise. Qualifiers of how, when, where, time, frequency, and amount provide the content of the planned activity. For example: “Educate parents on how to take temperature and notify of any changes,” or “Assess urine for color, amount, odor, and turbidity.”
- Use only abbreviations accepted by the institution.
7. Providing Rationale
Rationales, also known as scientific explanation, are the underlying reasons for which the intervention was chosen.
Rationales do not appear in regular care plans, they are included to assist students in associating the pathophysiological and psychological principles with the selected nursing intervention.
Evaluating is a planned, ongoing, purposeful activity in which the client’s progress towards the achievement of goals or desired outcomes, and the effectiveness of the nursing care plan. Evaluation is an important aspect of the nursing process because conclusions drawn from this step determine whether the nursing intervention should be terminated, continued, or changed.
9. Putting it on Paper
The client’s plan of care is documented according to hospital policy and becomes part of the client’s permanent medical record which may be reviewed by the oncoming nurse. Different nursing programs have different care plan formats, most are designed so that the student systematically proceeds through the interrelated steps of the nursing process, and many use a five-column format.