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.

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.

Steps in writing a nursing 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

Step 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.

Step 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.

Step 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. 

Step 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.

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.

Step 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 a 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.

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.

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.

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 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.
2. Use observable, measurable terms for outcomes. Avoid using vague words that require interpretation or judgment of the observer.
3. Desired outcomes should be realistic for the client’s resources, capabilities, limitations, and on the designated time span of care.
4. Ensure that goals are compatible with the therapies of other professionals.
5. 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.
6. 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 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.

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:

1. Write the date and sign the plan. The date the plan is written is essential for for evaluation, review, and future planning. The nurse’s signature demonstrates accountability.
2. 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.”
3. Use only abbreviations accepted by the institution.

Step 7: Providing Rationale

Rationales do not appear on regular care plans, they are included to assist students in associating the pathophysiological and psychological principles with the selected nursing intervention.

Step 8: Evaluation

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.

Step 9: Putting it on Paper

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.

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What is a Nursing Diagnosis?

A nursing diagnosis may be part of the nursing process and is a clinical judgment about individual, family, or community experiences/responses to actual or potential health problems/life processes. Nursing diagnoses are developed based on data obtained during the nursing assessment.

Types of Nursing Diagnoses;

Here are the five categories/structures of nursing diagnosis provided by NANDA-I system:

Problem Diagnosis

A problem diagnosis (or also called actual diagnosis) is a client problem that is present at the time of the nursing assessment. These diagnoses are based on the presence of associated signs and symptoms. Examples: Ineffective Breathing Pattern and Anxiety, Acute Pain, and Impaired Skin Integrity.

Risk Nursing Diagnosis

A risk nursing diagnosis is a clinical judgment that a problem does not exist, but the presence of risk factors indicates that a problem is likely to develop unless nurses intervene. For example, all people admitted to a hospital have some possibility of acquiring an infection; however, a client with diabetes or a compromised immune system is at higher risk than others. Therefore, the nurse would appropriately use the label Risk for Infection to describe the client’s health status.

Wellness Diagnosis

Wellness Diagnoses (or also called health promotion diagnosis) describe human responses to levels of wellness in an individual, family or community that have a readiness for enhancement. Examples of wellness diagnosis would be Readiness for Enhanced Spiritual Well Being or Readiness for Enhanced Family Coping.

Syndrome Diagnosis

A syndrome diagnosis is associated with a cluster of problem or risk nursing diagnoses that are predicted to present because of a certain situation or event. Example is Rape Trauma Syndrome.

Possible Nursing Diagnosis

Possible nursing diagnoses are statements describing a suspected problem for which additional data are needed to confirm or rule out the suspected problem. A possible nursign diagnosis also provides the nurse the ability to communicate to other nurses that a diagnosis may be present but additional data collection is indicated to rule out or confirm the diagnosis. Examples include: Possible Chronic Low Self-Esteem, Possible Social Isolation.

Writing Nursing Diagnostic Statements

Diagnostic statement describe the health status of an individual and the factors that have contributed to the status. Diagnostic statements can be one-part, two-part, or three-part statements.

One-Part Statements

Wellness nursing diagnoses are written as one-part statements because related factors are always the same: motivated to achieve a higher level of wellness. Syndrome diagnoses also have no related factors. Examples include:

• Readiness for Enhance Breastfeeding
• Readiness for Enhanced Coping 
• Rape Trauma Syndrome

Two-Part Statements

Risk and possible nursing diagnoses have two-part statements: the first part is the diagnostic label and the second is the validation for a risk nursing diagnosis or the presence of risk factors. It’s not possible to have a third part for risk or possible diagnoses because signs and symptoms do not exist. Examples include:

• Risk for Infection related to compromised host defenses
• Risk for Injury related to abnormal blood profile
• Possible Social Isolation related to unknown etiology

Three-part Statements

An actual or problem nursing diagnosis have three-part statements: diagnostic label, contributing factor (“related to”), and signs and symptoms (“as evidenced by”). Three-part nursing diagnosis statement is also called the PES format which includes the Problem, Etiology, and Signs and Symptoms. Examples include:

Impaired Physical Mobility related to decrease muscle control as evidenced by inability to control lower extremities.
Acute Pain related to tissue ischemia as evidenced by statement of “I feel severe pain on my chest!” 
Variations on Basic Statement Formats

Variations in writing statement formats include the following:

• Using “secondary to” to divide the etiology into two parts to make the diagnostic statement more descriptive and useful. Following the “secondary to” is often a pathophysiologic or diseases process or a medical diagnosis. For example: Risk for Decreased Cardiac Output related to reduced preload secondary to myocardial infarction.
• Using “complex factors” when there are too many etiologic factors or when they are too complex to state in a brief phrase. For example: Chronic Low Self-Esteem related to complex factors.
• Using “unknown etiology” when the defining characteristics are present but the nurse does not know the cause or contributing factors. For example: Ineffective Coping related to unknown etiology.
• Specifying a second part to the general response or NANDA label to make it more precise. For example: Impaired Skin Integrity (Right Anterior Chest) related to disruption of skin surface secondary to burn injury.

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Nursing Diagnosis Samples;

These are individualized nursing care plans for various nursing diagnoses.

• Activity Intolerance
• Acute Confusion
• Acute Pain
• Anxiety
• Caregiver Role Strain
• Constipation
• Chronic Pain
• Decreased Cardiac Output
• Deficient Fluid Volume
• Deficient Knowledge
• Diarrhea
• Disturbed Body Image
• Disturbed Thought Processes
• Excess Fluid Volume
• Fatigue
• Hyperthermia
• Imbalanced Nutrition: Less Than Body Requirements
• Imbalanced Nutrition: More Than Body Requirements
• Impaired Gas Exchange
• Impaired Oral Mucous Membrane
• Impaired Physical Mobility
• Impaired Swallowing
• Impaired Tissue (Skin) Integrity
• Impaired Urinary Elimination
• – Functional Urinary Incontinence
• – Reflex Urinary Incontinence
• – Stress Urinary Incontinence
• – Urge Urinary Incontinence
• Impaired Verbal Communication
• Ineffective Airway Clearance
• Ineffective Breathing Pattern
• Ineffective Coping
• Ineffective Tissue Perfusion
• Latex Allergy Response
• Risk for Aspiration
• Risk for Falls
• Risk for Infection
• Risk for Injury
• Risk for Unstable Blood Glucose Level
• Self-Care Deficit
• Urinary Retention