A nursing care plan (NCP) is a formal written plan that identifies a patient's existing and potential health needs. NCPs provide communication between nurses and other providers to achieve health outcomes. They begin when a patient is admitted and are updated continuously. NCPs can be standardized for common needs or individualized. They define the nurse's role, provide individualized patient care, ensure continuity of care, and guide reimbursement. Key components include nursing diagnoses, expected outcomes, interventions, and evaluations. NCPs are used to guide patient care and document care provided.
A nursing care plan (NCP) is a formal written plan that identifies a patient's existing and potential health needs. NCPs provide communication between nurses and other providers to achieve health outcomes. They begin when a patient is admitted and are updated continuously. NCPs can be standardized for common needs or individualized. They define the nurse's role, provide individualized patient care, ensure continuity of care, and guide reimbursement. Key components include nursing diagnoses, expected outcomes, interventions, and evaluations. NCPs are used to guide patient care and document care provided.
A nursing care plan (NCP) is a formal written plan that identifies a patient's existing and potential health needs. NCPs provide communication between nurses and other providers to achieve health outcomes. They begin when a patient is admitted and are updated continuously. NCPs can be standardized for common needs or individualized. They define the nurse's role, provide individualized patient care, ensure continuity of care, and guide reimbursement. Key components include nursing diagnoses, expected outcomes, interventions, and evaluations. NCPs are used to guide patient care and document care provided.
Nursing Care Plans (NCP) care plans are further subdivided into
By: KPTS standardized care plans and
individualized care What is a nursing care plan? plans: Standardized care A nursing care plan (NCP) is a plans specify the nursing care for formal process that correctly groups of clients with everyday identifies existing needs and needs. Individualized care plans are recognizes potential needs or risks. tailored to meet the unique needs of Care plans provide communication a specific client or needs that are not among nurses, their patients, and addressed by the standardized care other healthcare providers to achieve plan. health care outcomes. Without the nursing care planning process, the Objectives quality and consistency of patient care would be lost. The following are the goals and objectives of writing a nursing care Nursing care planning begins when plan: the client is admitted to the agency and is continuously updated Promote evidence-based throughout in response to the client’s nursing care and render changes in condition and evaluation pleasant and familiar of goal achievement. Planning and conditions in hospitals or delivering individualized or patient- health centers. centered care is the basis for Support holistic care which excellence in nursing practice. involves the whole person, including physical, psychological, social, and Types of Nursing Care spiritual, with the management Plans and prevention of the disease. Establish programs such as Care plans can be informal or care pathways and care formal: An informal nursing care bundles. Care pathways involve plan is a strategy of action that exists a team effort to reach a in the nurse‘s mind. A formal consensus regarding standards nursing care plan is a written or of care and expected computerized guide that organizes outcomes. In contrast, care the client’s care information. Formal bundles are related to best practices concerning care clients to receive the most given for a specific disease. benefit from treatment. Identify and distinguish goals Documentation. It should and expected outcomes. accurately outline which Review communication and observations to make, what documentation of the care nursing actions to carry out, plan. and what instructions the client Measure nursing care. or family members require. If nursing care is not Purposes of a Nursing Care documented correctly in the care plan, there is no evidence Plan the care was provided. Serves as a guide for The following are the purposes and assigning a specific staff to a importance of writing a nursing care specific client. There are plan: instances when a client’s care needs to be assigned to staff Defines nurse’s role. It helps with particular and precise to identify the unique role of skills. nurses in attending to clients’ Serves as a guide for overall health and well-being reimbursement. The insurance without having to rely entirely companies use the medical on a physician’s orders or record to determine what they interventions. will pay concerning the Provides direction for hospital care received by the individualized care of the client. client. It allows the nurse to Defines client’s goals. It think critically about each benefits nurses and clients by client and develop involving them in their interventions directly tailored treatment and care. to the individual. Continuity of care. Nurses Components from different shifts or departments can use the data A nursing care plan (NCP) usually to render the same quality and includes nursing diagnoses, client type of interventions to care problems, expected outcomes, and for clients, therefore allowing nursing interventions and rationales. These components are elaborated evaluation are in the same column. below: Other agencies have a five-column plan that includes a column for 1. Client health assessment, assessment cues. medical results, and diagnostic reports are the first steps 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. 2. Expected client outcomes are outlined. These may be long and short-term. 3. Nursing interventions are documented in the care plan. 4. Rationale for interventions to be evidence-based care. Student Care Plans 5. Evaluation. This documents the Student care plans are lengthier and outcome of nursing detailed than care plans used by interventions. working nurses because they are a Care Plan Formats learning activity for the students
Nursing care plan formats are usually
categorized or organized into four columns: (1) nursing diagnoses, (2) desired outcomes and goals, (3) nursing interventions, and (4) evaluation. Some agencies use a three-column plan wherein goals and Care plans by student nurses are Step 2: Data Analysis and usually required to be handwritten and Organization have an additional column for “Rationale” or “Scientific Explanation” Now that you have information about after the nursing interventions the client’s health analyze, cluster, column. Rationales are scientific and organize the data to formulate principles that explain the reasons for your nursing diagnosis, priorities, and selecting a particular nursing desired outcomes. intervention. Step 3: Formulating Your Writing a Nursing Care Nursing Diagnoses Plan NANDA nursing diagnoses are a How do you write a nursing care plan uniform way of identifying, focusing (NCP)? Just follow the steps below to on, and dealing with specific client develop a care plan for your client. needs and responses to actual and high-risk problems. Actual or Step 1: Data Collection or potential health problems that can be Assessment prevented or resolved by independent nursing intervention are The first step in writing a nursing care termed nursing diagnoses. We’ve plan is to create a client database detailed the steps on how to using assessment techniques and formulate your nursing diagnoses in data collection methods (physical this guide: Nursing Diagnosis assessment, health history, interview, (NDx): Complete Guide and List medical records review, diagnostic studies). A client database includes Step 4: Setting Priorities all the health information gathered. In this step, the nurse can Setting priorities deals with identify the related or risk factors and establishing a preferential sequence defining characteristics that can be for addressing nursing diagnoses and used to formulate a nursing interventions. In this step, the nurse diagnosis. Some agencies or nursing and the client begin planning which schools have specific assessment nursing diagnosis requires attention formats you can use. first. Diagnoses can be ranked and grouped as having a high, medium, or low priority. Life-threatening Safety and Security: Injury problems should be given high prevention (side rails, call priority. lights, hand hygiene, isolation, suicide precautions, A nursing diagnosis encompasses fall precautions, car seats, Maslow’s Hierarchy of Needs and helmets, seat belts), fostering a helps to prioritize and plan care climate of trust and safety based on patient-centered outcomes. (therapeutic relationship), In 1943, Abraham Maslow developed patient education (modifiable a hierarchy based on basic risk factors for stroke, heart fundamental needs innate to all disease). individuals. Basic physiological Love and Belonging: Foster needs/goals must be met before supportive relationships, higher needs/goals can be achieved, methods to avoid social such as self-esteem and self- isolation (bullying), employ actualization. Physiological and safety active listening needs provide the basis for techniques, therapeutic implementing nursing care and communication, and sexual nursing interventions. Thus, they are intimacy. at the base of Maslow’s pyramid, Self-Esteem: Acceptance in the laying the foundation for physical community, workforce, and emotional health. personal achievement, sense of control or empowerment, Maslow’s Hierarchy of accepting one’s physical appearance or body habitus. Needs Self-Actualization: Empoweri ng environment, spiritual Basic Physiological growth, ability to recognize the Needs: Nutrition (water and point of view of others, food), elimination (Toileting), reaching one’s maximum airway (suction)-breathing potential. (oxygen)-circulation (pulse, cardiac monitor, blood pressure) (ABCs), sleep, sex, shelter, and exercise. The client’s health values and beliefs, priorities, resources available, and urgency are factors the nurse must consider when assigning priorities. One overall goal is determined for Involve the client in the process to each nursing diagnosis. The enhance cooperation. terms goal, outcome, and expected outcome are often used Step 5: Establishing Client interchangeably. Goals and Desired Outcomes According to Hamilton and Price (2013), goals should be SMART. After assigning priorities for your SMART goals analysis strategy stands nursing diagnosis, the nurse and the for – Specific, Measurable, Attainable, client set goals for each determined Realistic, and Time-Bound goals. priority. Goals or desired outcomes describe what the nurse Specific. It should be clear, hopes to achieve by implementing significant, and sensible for a the nursing interventions derived goal to be effective. from the client’s nursing diagnoses. Measurable or Goals provide direction for planning Meaningful. Making sure a interventions, serve as criteria for goal is measurable makes it evaluating client progress, enable the easier to monitor progress and client and nurse to determine which know when it reaches the problems have been resolved, and desired result. help motivate the client and nurse by Attainable or Action- providing a sense of achievement. Oriented. Goals should be flexible but remain possible. Realistic or Results-Oriented. Goal centered. That the care This is important to look planned will meet and achieve forward to effective and the goal set. successful outcomes by keeping in mind the available Short Term and Long Term resources at hand. Goals Timely or Time- Oriented. Every goal needs a Goals and expected outcomes must designated time parameter, a be measurable and client-centered. deadline to focus on, and Goals are constructed by focusing on something to work toward. problem prevention, resolution, and Hogston (2011) suggests using rehabilitation. Goals can be short- the REEPIG standards to ensure that term or long-term. Most goals are care is of the highest standards. By short-term in an acute care setting this means, nursing care plans should since much of the nurse’s time is be: spent on the client’s immediate needs. Long-term goals are often Realistic. Given available used for clients who have chronic resources. health problems or live at home, Explicitly stated. Be clear in nursing homes, or in extended-care precisely what must be done facilities. so there is no room for misinterpretation of Short-term goal. A statement instructions. distinguishing a shift in Evidence-based. That there is behavior that can be research that supports what is completed immediately, being proposed. usually within a few hours or Prioritized. The most urgent days. problems being dealt with Long-term goal. Indicates an first. objective to be completed over Involve. Involve both the a longer period, usually over patient and other members of weeks or months. the multidisciplinary team who Discharge planning. Involves are going to be involved in naming long-term goals, implementing the care. therefore promoting continued restorative care and problem resolution through home explain the circumstances health, physical therapy, or under which the behavior is to various other referral sources. be performed. Components of Goals and Criterion of desired performance. The criterion Desired Outcomes indicates the standard by which a performance is Goals or desired outcome statements evaluated or the level at which usually have four components: a the client will perform the subject, a verb, conditions or specified behavior. These are modifiers, and a criterion of desired optional. performance.
When writing goals and desired
outcomes, the nurse should follow these tips:
1. Write goals and outcomes in
terms of client responses and not as activities of the nurse. Begin each goal with “Client Subject. The subject is the will […]” help focus the goal client, any part of the client, or on client behavior and some attribute of the client responses. (i.e., pulse, temperature, urinary 2. Avoid writing goals on what output). That subject is often the nurse hopes to accomplish, omitted in writing goals and focus on what the client because it is assumed that the will do. subject is the client unless 3. Use observable, measurable indicated otherwise (family, terms for outcomes. Avoid significant other). using vague words that require Verb. The verb specifies an interpretation or judgment of action the client is to perform, the observer. for example, what the client is 4. Desired outcomes should be to do, learn, or experience. realistic for the client’s Conditions or resources, capabilities, modifiers. These are the limitations, and on the “what, when, where, or how” designated time span of care. that are added to the verb to 5. Ensure that goals are Types of Nursing compatible with the therapies Interventions of other professionals. 6. Ensure that each goal is Nursing interventions can be derived from only one nursing independent, dependent, or diagnosis. Keeping it this way collaborative: facilitates evaluation of care by ensuring that planned nursing interventions are clearly related to the diagnosis set. 7. Lastly, make sure that the client considers the goals important and values them to ensure cooperation. Step 6: Selecting Nursing Interventions Nursing interventions are activities or actions that a nurse performs to Types of nursing achieve client goals. Interventions interventions in a care chosen should focus on eliminating plan. or reducing the etiology of the Independent nursing nursing diagnosis. As for risk nursing interventions are activities diagnoses, interventions should focus that nurses are licensed to on reducing the client’s risk factors. initiate based on their sound In this step, nursing interventions are judgement and skills. Includes: identified and written during the ongoing assessment, planning step of the nursing process; emotional support, providing however, they are actually performed comfort, teaching, physical during the implementation step. 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 1. Write the date and sign the medications, intravenous plan. The date the plan is therapy, diagnostic tests, written is essential for treatments, diet, and activity or evaluation, review, and future rest. Assessment and providing planning. The nurse’s signature explanation while demonstrates accountability. administering medical orders 2. Nursing interventions should are also part of the dependent be specific and clearly stated, nursing interventions. beginning with an action verb Collaborative interventions a indicating what the nurse is re actions that the nurse carries expected to do. Action verb out in collaboration with other starts the intervention and health team members, such as must be precise. Qualifiers of physicians, social workers, how, when, where, time, dietitians, and therapists. These frequency, and amount provide actions are developed in the content of the planned consultation with other health activity. For example: care professionals to gain their “Educate parents on how to professional viewpoint. take temperature and notify of any changes,” or “Assess urine Nursing interventions should be: for color, amount, odor, and turbidity.” Safe and appropriate for the 3. Use only abbreviations client’s age, health, and accepted by the institution. condition. Achievable with the resources Step 7: Providing Rationale and time available. Inline with the client’s values, Rationales, also known as scientific culture, and beliefs. explanations, explain why the nursing Inline with other therapies. intervention was chosen for the NCP. Based on nursing knowledge and experience or knowledge from relevant sciences.
When writing nursing interventions,
follow these tips: nursing intervention should be terminated, continued, or changed.
Step 9: Putting it on Paper
The client’s care plan 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 Sample nursing interventions and process, and many use a five-column rationale for a care plan (NCP) format. Rationales do not appear in regular care plans. They are included to assist nursing students in associating the Nursing Care Plan List pathophysiological and psychological This section lists the sample nursing care plans (NCP) and NANDA principles with the selected nursing nursing diagnoses for various intervention. disease and health conditions. They are segmented into categories: Step 8: Evaluation Evaluating is a planned, ongoing, Basic Nursing and General purposeful activity in which the Care Plans client’s progress towards achieving goals or desired outcomes and the Miscellaneous nursing care plans effectiveness of the nursing care plan examples that don’t fit other (NCP). Evaluation is an essential categories: aspect of the nursing process because conclusions drawn Cancer (Oncology Nursing) from this step determine whether the End-of-Life Care (Hospice Care or Palliative) Geriatric Nursing (Older Adult) Cardiac Arrhythmia (Digitalis Prolonged Bed Rest Toxicity) Surgery (Perioperative Client) Cardiac Catheterization Systemic Lupus Erythematosus Cardiogenic Shock Total Parenteral Nutrition Congenital Heart Disease Heart Failure UPDATED! Surgery and Perioperative Hypertension UPDATED! Hypovolemic Shock Care Plans Myocardial Infarction Pacemaker Therapy Care plans that involve surgical intervention. Endocrine and Metabolic Amputation Care Plans Appendectomy Cholecystectomy Nursing care plans (NCP) related Fracture UPDATED! to the endocrine system and Hemorrhoids metabolism: Hysterectomy Ileostomy & Colostomy Acid-Base Balance Laminectomy (Disc Surgery) Respiratory Acidosis Mastectomy Respiratory Alkalosis Subtotal Gastrectomy Metabolic Acidosis Surgery (Perioperative Client) Metabolic Alkalosis Thyroidectomy Addison’s Disease Total Joint (Knee, Hip) Cushing’s Disease Replacement Diabetes Mellitus Type 1 Diabetes Mellitus Type 2 UPDATED! Cardiac Care Plans Diabetic Ketoacidosis (DKA) and Hyperglycemic Nursing care plans about the Hyperosmolar Nonketotic different diseases of Syndrome (HHNS) the cardiovascular system: Eating Disorders: Anorexia & Bulimia Nervosa Angina Pectoris (Coronary Fluid and Electrolyte Artery Disease) Imbalances: – Fluid Balance: Hypervolemia & Hypovolemia – Potassium (K) Imbalances: Peritonitis Hyperkalemia and Peptic Ulcer Disease Hypokalemia Subtotal Gastrectomy – Sodium (Na) Imbalances: Hypernatremia and Hyponatremia Genitourinary – Magnesium (Mg) Imbalances: Hypermagnesemia and Care plans related to the Hypomagnesemia reproductive and urinary – Calcium (Ca) Imbalances: system disorders: Hypercalcemia and Hypocalcemia Acute Glomerulonephritis Gestational Diabetes Mellitus Acute Renal Failure Hyperthyroidism Benign Prostatic Hyperplasia Hypothyroidism (BPH) Obesity Chronic Renal Failure Thyroidectomy Hemodialysis Hysterectomy Gastrointestinal Mastectomy Menopause Care plans (NCP) covering the Nephrotic Syndrome disorders of the gastrointestinal Peritoneal Dialysis and digestive system: Prostatectomy Urolithiasis (Renal Calculi) Appendectomy Urinary Tract Infection Cholecystectomy Vesicoureteral Reflux (VUR) Cholecystitis and Cholelithiasis Gastroenteritis Hematologic and Gastroesophageal Reflux Disease (GERD) Lymphatic Hemorrhoids Care plans related to the Hepatitis hematologic and lymphatic Ileostomy & Colostomy system: Inflammatory Bowel Disease Intussusception Anaphylactic Shock Liver Cirrhosis Anemia UPDATED! Pancreatitis Aortic Aneurysm Maternal and Newborn Deep Vein Thrombosis Disseminated Intravascular Care Plans Coagulation Nursing care plans about the care Hemophilia of the pregnant mother and her Leukemia infant. See care plans for maternity Lymphoma and obstetric nursing: Sepsis and Septicemia Sickle Cell Anemia Crisis Abruptio Placenta Cesarean Birth UPDATED! Infectious Diseases Cleft Palate and Cleft Lip Dysfunctional Labor (Dystocia) NCPs for communicable and Elective Termination infectious diseases: Gestational Diabetes Mellitus UPDATED! Acquired Immunodeficiency Hyperbilirubinemia Syndrome (AIDS) (HIV Positive) Labor Stages, Induced and Acute Rheumatic Fever Augmented Labor Dengue Hemorrhagic Fever Neonatal Sepsis Herpes Zoster (Shingles) Perinatal Loss Influenza (Flu) Placenta Previa Pulmonary Tuberculosis Postpartum Hemorrhage UPDATED! Postpartum Thrombophlebitis Integumentary Prenatal Hemorrhage Precipitous Labor All about disorders and conditions Preeclampsia and Gestational affecting the integumentary Hypertensive Disorders UPDATED! system: Premature Dilation of the Cervix Burn Injury Prenatal Infection Dermatitis Preterm Labor Herpes Zoster (Shingles) Puerperal Infection Pressure Ulcer (Bedsores) Substance Abuse in Pregnancy Mental Health and Neurological Psychiatric Nursing care plans (NCP) Care plans for mental health and for related to nervous psychiatric nursing: system disorders: