how to write a care plan nursing home

How to Write a Nursing Care Plan

Nursing care plan components, nursing care plan fundamentals.

Knowing how to write a nursing care plan is essential for nursing students and nurses. Why? Because it gives you guidance on what the patient’s main nursing problem is, why the problem exists, and how to make it better or work towards a positive end goal. In this article, we'll dig into each component to show you exactly how to write a nursing care plan. 

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A nursing care plan has several key components including, 

• Nursing diagnosis
• Expected outcome
• Nursing interventions and rationales

Each of the five main components is essential to the overall nursing process and care plan. A properly written care plan must include these sections otherwise, it won’t make sense!

• Nursing diagnosis - A clinical judgment that helps nurses determine the plan of care for their patients
• Expected outcome - The measurable action for a patient to be achieved in a specific time frame. 
• Nursing interventions and rationales - Actions to be taken to achieve expected outcomes and reasoning behind them.
• Evaluation - Determines the effectiveness of the nursing interventions and determines if expected outcomes are met within the time set.

>> Related: What is the Nursing Process?

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Before writing a nursing care plan, determine the most significant problems affecting the patient. Think about medical problems but also psychosocial problems. At times, a patient's psychosocial concerns might be more pressing or even holding up discharge instead of the actual medical issues. 

After making a list of problems affecting the patient and corresponding nursing diagnosis, determine which are the most important. Generally, this is done by considering the ABCs (Airway, Breathing, Circulation). However, these will not ALWAYS be the most significant or even relevant for your patient. 

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.

This information can come from, 

Verbal statements from the patient and family

Vital signs

Blood pressure

Respirations

Temperature

Oxygen Saturation

Physical complaints

Body conditions

Head-to-toe assessment findings

Medical history

Height and weight

Intake and output

Patient feelings, concerns, perceptions

Laboratory data

Diagnostic testing

Echocardiogram

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), 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. 

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There are 4 types of nursing diagnoses.  

Problem-focused - Patient problem present during a nursing assessment is known as a problem-focused diagnosis

Risk - Risk factors require intervention from the nurse and healthcare team prior to a real problem developing

Health promotion - Improve the overall well-being of an individual, family, or community

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. 

The three main components of a nursing diagnosis are:

Problem and its definition - Patient’s current health problem and the nursing interventions needed to care for the patient.

Etiology or risk factors - Possible reasons for the problem or the conditions in which it developed

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

PROBLEM-FOCUSED DIAGNOSIS

Problem-Focused Diagnosis related to ______________________ (Related Factors) as evidenced by _________________________ (Defining Characteristics).

RISK DIAGNOSIS

The correct statement for a NANDA-I nursing diagnosis would be: Risk for _____________ as evidenced by __________________________ (Risk Factors).

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,

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. 

Examples of medical diagnosis include, 

Chronic Lung Disease (CLD)

Alzheimer’s Disease

Endocarditis

Plagiocephaly 

Congenital Torticollis 

Chronic Kidney Disease (CKD)

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: 

Physiological

Complex physiological

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, 

Based on the evaluation, it can determine 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. 

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Nursing care plans contain information about a patient’s diagnosis, goals of treatment, specific nursing interventions, and an evaluation plan. The nursing plan is constantly updated with changes and new subjective and objective data. 

Key aspects of the care plan include,

Outcome and Planning

Implementation

Through subjective and objective data, constantly assessing your patient’s physical and mental well-being, and the goals of the patient/family/healthcare team, a nursing care plan can be a helpful and powerful tool.

*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.

Kathleen Gaines (nee Colduvell) is a nationally published writer turned Pediatric ICU nurse from Philadelphia with over 13 years of ICU experience. She has an extensive ICU background having formerly worked in the CICU and NICU at several major hospitals in the Philadelphia region. After earning her MSN in Education from Loyola University of New Orleans, she currently also teaches for several prominent Universities making sure the next generation is ready for the bedside. As a certified breastfeeding counselor and trauma certified nurse, she is always ready for the next nursing challenge.

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Nursing Care Plans Explained: Types, Tutorial & Examples

Nursing care plans are written tools that outline nursing diagnoses , interventions, and goals. Care plans are especially useful for student nurses as they learn to utilize the nursing process. By creating a nursing care plan based on a patient’s assessment, the nurse learns how to prioritize, plan goals and interventions, and evaluate outcomes related to specific disease processes. Care plans are essential for communication between nurses and other care team members in order to provide high-quality, continuous, evidence-based care.

In this article:

• What is a Nursing Care Plan?
• Why Use Nursing Care Plans?
• Types of Nursing Care Plans
• Nursing Care Plan Considerations
• Creating SMART Goals
• Nursing Interventions
• Tips for Effective Care Planning
• Nursing Care Plan Examples

Nursing care plans are a structured framework for delivering patient care. Nursing care plans are often called the “plan of care” and provide directions to nurses and the interprofessional team. Care plans are often described as the roadmap of patient care 2 , as they help nurses plan, prioritize, rationalize, and evaluate interventions.

Listed below are some of the benefits of using care plans in nursing practice.

1. Follows the client from admission to discharge . Care plans are continually updated depending on the patient’s status, goals, and outcomes and follow the patient across facility transfers and to different care settings.

2. Helps nurses plan interventions and revise care . Care plans provide structure to interventions, allowing the nurse to assess the intervention’s outcome and potentially revise care based on the outcome.

3. Evaluates interventions . Care plans include a combination of short and long-term goals that are specific, measurable, and timely. The nurse can evaluate if interventions are effective by evaluating goal progression.

4. Communication and continuity between nurses . The plan of care is a document that assists nurses in providing continuous and consistent care, working toward shared goals.

5. Coordinates other disciplines . The care plan may include input or interventions other interdisciplinary team members provide. A care plan communicates priorities between interprofessional team members to coordinate on common goals.

6. Engage with the patient/patient-centered care . Whenever possible, the patient should be involved in creating their plan of care. Nursing care plans are best used collaboratively with patients and families to account for a patient’s preferences, values, culture, and lifestyle. 2

7. Documentation purposes . Care plans are an opportunity for nurses to demonstrate that safe and ethical care was provided in accordance with professional regulations. Documentation may be used for communication, quality improvement, research, or legal proceedings.

8. Offers a framework for consistent care. A nursing diagnosis supports the care plan and outlines appropriate interventions. Nursing diagnoses should align with a NANDA-I nursing diagnosis, creating consistency in nursing diagnosis terminology and facilitating effective communication. 1

9. Prevents future health hazards. Some care plans may include nursing diagnoses the patient is at risk for, like falls or infection. Care plan interventions and goals can be created to prevent complications.

There is some variation in how care plans are used in practice. The structure and format of a care plan depend on the purpose of the care plan and the care setting.

Formal vs. Informal Care Planning

Generally, informal care plans are not formally documented. Informal care plans might include the nurse’s goals for their shift. These goals can be modified depending on the day’s priorities or changes in the patient’s condition.

Formal care plans are documented as part of the patient record used to coordinate, prioritize, and maintain continuity of care. While formal care plans are also modifiable depending on new priorities or the outcomes of interventions, they are often related to the longer-term goals of the patient. The formal care plan might include goals to meet before discharge from the hospital or the service. Both formal and informal care plans are used within the framework of the nursing process.

Standardized vs. Individualized Care Planning

Care plans can be either standardized or individualized for the patient. Many care settings will use standardized care plans for specific patient conditions to deliver consistent care. One example of a standardized care plan is the post-operative care pathway used in post-surgical units. These post-operative care plans outline expected goals for each post-operative day. However, standardized care plans should be tailored when possible to the needs of the individual patient.

In contrast, individualized care plans are created for individual patient needs. Individualized care plans should include input from the patient whenever possible to create personalized goals and support patient adherence. When creating an individualized care plan, consider the patient’s health status, history, and motivational factors and inquire about what matters most to them.

The Nursing Process

Care plans enter the nursing process at the planning stage but are influenced by all other steps. The steps of the nursing process can be remembered with the acronym ADPIE. 3

• Implementation/Interventions

Here is a breakdown of the nursing process:

1. Assessment: Assessing the client’s needs, gathering data In the assessment phase of the nursing process, the nurse collects and analyzes objective and subjective data . Then, the nurse uses their nursing knowledge and critical thinking skills to decide if further assessments are necessary to identify a nursing diagnosis.

2. Diagnosis: What’s going on? Crafting a nursing diagnosis Based on data collected during the assessment phase, the nurse crafts a nursing diagnosis that can be used to direct care planning. 4 The nurse should assign a nursing diagnosis using the standardized terminology laid out by NANDA-I. A nursing diagnosis is a clinical judgment that describes actual or potential health problems or opportunities for health improvement of a patient, family, or community.

3. Planning: Time to create goals In step three of the nursing process, the nurse, ideally in collaboration with the patient, creates goals of care based on the nursing diagnosis. A care plan, including interventions and expected outcomes, is created to achieve these goals.

4. Implementation: Time to act In the implementation phase of the nursing process, the nurse takes actions and performs the interventions described in the care plan to achieve the goals of care. The nurse uses their knowledge, experience, and critical thinking to decide which interventions are a priority. Often, interventions are based on orders from the physician.

5. Evaluate: What are the outcomes? In the evaluation phase of the nursing process, the nurse reassesses the patient to determine if the intervention has the desired outcome. Next, the nurse should evaluate if the goals of care have been met or require more time. If the intervention does not have the desired effect, the nurse should consider if the care plan needs revision or if the goals of care need to be updated.

Nursing Process Example

Here is an example of how the steps of the nursing process fit together. 

The nurse assesses the client who was in a motor vehicle accident. The client reports a pain level of 9/10 in their right shoulder. Through an x-ray, the client is determined to have a dislocated shoulder, and the nursing diagnosis of acute pain is applied. The nurse begins planning treatment and goals to reduce pain and instill comfort. The nurse administers IV pain medication as ordered and supports the right arm with pillows. The nurse evaluates the effectiveness of interventions by asking the client to rate their pain on a scale of 0-10. Depending on the outcome, the nurse may determine that the intervention was successful or requires revision.

How To Write a Nursing Care Plan

With experience, nursing care plans become second nature as part of nursing practice. Since nursing care planning can be formal or informal, a nursing care plan may look very different depending on the care context and the patient’s needs. While informal care plans may not be written in the patient chart, writing effective formal care plans takes practice. Formal care plans are important for communicating significant changes in the patient’s condition to the care team.

Care plans will appear differently depending on each electronic health record, computer platform, setting (home health, doctor’s office, etc.), and nursing specialty (case management, PACU, etc.). Regardless, the nursing process stays the same. One way to improve the skill of care plan writing is to read examples of high-quality care plans. Nurses can also ask experienced colleagues for feedback on their care plans. Some care settings will have templates of expected formal care plans. 

Overall, the care plan should flow seamlessly as part of the nursing process, taking into account relevant nursing diagnoses, expected outcomes, and the effectiveness of the planned interventions. If necessary, goals are revised, and the care plan is repeated until goals are met or are no longer applicable.

While rationales are not included in traditional nursing care plans, they are used in student care plans. When learning to write care plans, adding the rationale behind the diagnosis and interventions can be helpful. Students can explain the pathophysiology behind their assessment and why their intervention is necessary to guide their understanding.

Consider the hierarchy of needs.

In any care setting, there are often competing priorities that nurses must handle. When deciding on how to prioritize care needs for patients, a useful framework to organize care is Maslow’s hierarchy of needs. 5 The highest priority needs are at the bottom of the pyramid including physiological needs such as air, nutrition, and sleep. The nurse must prioritize physical needs over those closer to the top of the pyramid, such as the need for a sense of connection.

S.M.A.R.T. goals are specific, measurable, attainable, realistic, and time-bound. SMART goals are helpful in care planning because they increase the likelihood that the goal created will be practical and achievable. Conversely, goals that are too vague or not realistic are less likely to be achieved, which can discourage the goal-setter.

Specific Specific goals are not overly broad. A shared goal of “walking more” is not specific. However, “Walk three laps of the unit three times a day” is specific.

Measurable Related to being specific, there should be some way to measure whether the goal has been met or is at least progressing. There should be a benchmark that signals that the goal has been met. Benchmarks could be behavioral, physical, or expressed by the patient. 

Attainable Goals might take work to meet, but attainable goals are within reach. Goals that are too difficult or require multiple steps to reach are more likely to discourage rather than encourage. 

Realistic An achievable goal is also realistic. Attainable goals are possible to meet, while realistic goals take into consideration the context and potential barriers to meeting the goal.

Time-bound  Setting a time limit on the goal grounds the goal in reality and allows for measurement. The chosen period should depend on the goal’s size and should support progress and focus.

Examples of Collaborative SMART Goals

Here are two examples of how SMART goals can be used in care planning: 

Goal: “The client will rate their pain three or less on a scale of 0-10 by discharge.”

• Specific: The goal includes an exact number on the pain scale acceptable to the patient.
• Measurable: The goal can be tracked over time and measured on the pain scale.
• Attainable: This depends on the specific patient context, but for the example, we will assume this is an achievable goal for the patient.
• Realistic: Similarly, this goal must be realistic, which will depend on the patient’s pain tolerance.
• Time-bound: In the inpatient setting, ‘by discharge’ is an appropriate time frame.

Goal: The patient will demonstrate independently using a glucometer to check their blood sugar and how to self-administer necessary insulin after three diabetes education sessions. 

• Specific: The goal includes specific behaviors and outcomes of the education sessions.
• Measurable: The nurse can assess if the goal is complete by asking the patient to demonstrate their skills. 
• Attainable: The patient has the motor and cognitive ability to learn these skills. 
• Realistic: Enough time has been given for practice and education so that the patient feels comfortable and confident. 
• Time-bound: This goal is set to be achieved after three education sessions. At the end of the third session, the nurse can assess if the goal has been met or if more support or time is needed to meet this goal.

Short vs. Long-Term Goals

When creating goals of care, it can be helpful to categorize goals into short-term or long-term goals. Short-term goals are commonly found in acute care settings, where care interactions are shorter than in the community. However, both long and short-term goals are used across care settings. 

Short-term goals can be completed within a few hours or days. Although there is no precise cut-off for what makes a short-term care goal, short-term goals tend to focus on issues that need to be immediately addressed. An example of a short-term care goal is to improve the patient’s shortness of breath by identifying the cause and administering an intervention to relieve the shortness of breath.

In contrast, long-term goals are usually completed over weeks or months. Long-term care goals tend to be aimed at more chronic health challenges, prevention, and improvement. While important, they may be less urgent than short-term care goals. An example of a long-term care goal is the reduction of HbA1c over several months for a patient at risk for diabetes.

Once goals and a plan of care are established, the nurse will perform interventions. There are three main categories of nursing interventions :

Independent: Independent nursing interventions are within the nurse’s scope of practice and do not require the participation of another health professional, such as a physician, to carry out the intervention. Nurses can initiate, implement, and evaluate independent nursing interventions. An example of an independent nursing intervention is providing patient education. 

Dependent: Dependent nursing interventions require the participation of another health professional to carry out the intervention. Dependent interventions are often ordered by physicians and then implemented by nurses. Collecting blood work that a physician has ordered is an example of a dependent nursing intervention.

Collaborative: Collaborative nursing interventions are carried out with other healthcare professionals through collaboration or consultation. Collaborating with a physical therapist on exercises to improve patient mobility is an example of a collaborative nursing intervention.

1. Create goals with the patient when possible. The patient should be included in their care plan to ensure goals are congruent with their lifestyle, values, and preferences. This includes patient involvement in planning interventions and defining the intervention’s successful outcome. Including the patient in the care planning process will increase their motivation to actively participate in their care. 

2. Revise goals if necessary. If the goal is not met within the original timeframe, the goal may need revision to ensure that it is achievable and realistic, or the timeframe may need to be extended.

3. Continue to assess and reassess the patient. It is essential to continually evaluate the patient’s status to ensure that the goals and interventions are still appropriate for their condition. 

4. If a goal is not met, assess why. Interventions that are not working or care plan goals that are not met require revision. This may include revising the interventions, updating the goals of care, reviewing the patient diagnosis, assessing the client’s motivation or lack thereof, and furthering patient education. 

5. Ensure that progress towards a goal is recognized even if a goal is not met . In some situations, the goal’s timeline may need to be extended for a goal to be met. Consider that a goal may be ‘met’ even if the outcome is not what was intended.

Below you’ll find a list of over 400 care plans. All our care plans are written and reviewed by registered nurses.

• Atrial Fibrillation
• Bradycardia
• Cardiomyopathy
• Chest Pain (Angina)
• Coronary Artery Disease
• Heart Failure
• Hypertension
• Hypotension
• Myocardial Infarction
• Pulmonary Embolism
• Tachycardia
• Tetralogy of Fallot

Endocrine & Metabolic

• Diabetes Mellitus
• Diabetic Foot Ulcer
• Diabetic Ketoacidosis
• Hyperglycemia
• Hyperlipidemia
• Hypocalcemia & Hypercalcemia
• Hypoglycemia
• Hypokalemia & Hyperkalemia
• Hyponatremia & Hypernatremia
• Hypothyroidism
• Malnutrition
• Metabolic Acidosis
• Metabolic Alkalosis
• Syndrome of inappropriate antidiuretic hormone (SIADH)

Gastrointestinal

• Abdominal Pain
• Appendicitis
• Bowel Perforation
• Clostridioides Difficile
• Colon Cancer
• Colostomy & Ileostomy
• Crohn’s Disease
• Diverticulitis
• Gastrointestinal Bleed
• Liver Cirrhosis
• Nausea & Vomiting
• Pancreatic Cancer
• Pancreatitis
• Paralytic Ileus
• Peritonitis
• Small Bowel Obstruction
• Ulcerative Colitis

Genitourinary

• Acute Kidney Injury
• Benign Prostatic Hyperplasia (BPH)
• Chronic Kidney Disease
• End Stage Renal Disease (ESRD)
• Kidney Stones
• Pyelonephritis
• Urinary Tract Infection

Hematologic & Lymphatic

• Anaphylaxis
• Blood Transfusion
• Deep Vein Thrombosis
• Low Hemoglobin
• Neutropenia
• Peripheral Vascular Disease
• Sickle Cell Anemia
• Thrombocytopenia

Infectious Diseases

• Human Immunodeficiency Virus (HIV)
• Methicillin-resistant Staphylococcus aureus (MRSA)
• Respiratory syncytial virus (RSV)
• Tuberculosis

Integumentary

• Pressure Ulcers
• Wound Care & Infection

Maternal & Newborn

• Breastfeeding
• Hyperemesis Gravidarum
• Labor and Delivery
• Placenta Previa
• Postpartum Hemorrhage
• Preeclampsia
• Preterm Labor

Mental Health & Psychiatric

• Attention deficit hyperactivity disorder (ADHD)
• Altered Mental Status
• Antisocial Personality Disorder
• Bipolar Disorder
• Major Depression
• Mental Health
• Obsessive-Compulsive Disorder (OCD)
• Psychosocial
• Post-traumatic stress disorder (PTSD)
• Schizophrenia
• Substance Abuse

Musculoskeletal

• Compartment Syndrome
• Hip Fracture
• Knee Replacement Surgery
• Myasthenia Gravis
• Osteoarthritis
• Osteomyelitis
• Osteoporosis
• Rhabdomyolysis
• Rheumatoid Arthritis
• Spinal Cord Injury

Neurological

• Cerebral Palsy
• Diabetic Neuropathy
• Encephalopathy
• Headache & Migraine
• Multiple Sclerosis
• Parkinson’s Disease
• Peripheral Neuropathy
• Stroke (CVA)
• Transient Ischemic Attack (TIA)
• Traumatic Brain Injury

Respiratory

• Acute Respiratory Failure
• Acute respiratory distress syndrome (ARDS)
• Chest Tube Insertion
• Chronic obstructive pulmonary disease (COPD)
• Cystic Fibrosis
• Pleural Effusion
• Pneumothorax
• Pulmonary Edema
• Tracheostomy

Other Care Plans

Anything that didn’t match a specific category you’ll find here:

• Alcohol Withdrawal Syndrome
• Breast Cancer
• Chemotherapy
• Community Health
• End-of-Life (Hospice) Care
• Hearing Loss
• Sleep Apnea
• NANDA International. Our Story. Accessed January 7, 2023. https://nanda.org/who-we-are/our-story/
• Capriotti T, eBook Nursing Collection – Worldwide, Books@Ovid Purchased eBooks. Nursing Care Planning Made Incredibly Easy! Third. Wolters Kluwer; 2018. https://go.exlibris.link/P281xmcS
• Toney-Butler T, Thayer J. Nursing Process. Published 2022. https://www.ncbi.nlm.nih.gov/books/NBK499937/
• Carpenito LJ, Books@Ovid Purchased eBooks. Handbook of Nursing Diagnosis. 15th ed. Wolters Kluwer; 2017.
• Hayre-Kwan S, Quinn B, Chu T, Orr P, Snoke J. Nursing and Maslow’s Hierarchy; A Health Care Pyramid Approach to Safety and Security During a Global Pandemic. Nurse Lead. 2021;19(6):590-595. doi:10.1016/j.mnl.2021.08.013

How to Write a Nursing Care Plan (Steps and Tips)

Knowing how to write a good nursing care plan is critical for nursing students and practicing nurses. Care plans act as a tool that helps nursing students and nurses strategically manage the nursing process to solve different problems affecting a patient. Nursing care plans also allow effective communication within a nursing team for collaborative or individual decision-making.

In this guide, we take you through the basics of nursing care plans and steps to create the best and give examples/illustrations to make it simpler. With the best practices we outline in this guide, you can write a nursing care plan without worrying that your end product will be subpar.

This guide is valuable to nursing students as it comprehensively addresses what matters. Besides, it is written by professional nurse researchers collaborating with top talents/brains in the nursing industry. It is also updated regularly to capture any new developments as far as nursing care planning is concerned.

What is a Nursing Care Plan?

A nursing care plan, abbreviated as NCP, refers to a document that details the relevant information about the history and diagnosis of the patient, their current or potential care needs, treatment goals, risks, treatment priorities, and evaluation plan.

Nursing care plans are usually updated depending on the patient's stay at a facility, preferably during and after every shift.

As a nursing student, you will be assigned to write a nursing care plan based on a scenario. For example, your preceptor could also ask you to write a care plan based on a real patient hospitalized in a clinical center where you are doing your internship or practicum.

The process of care planning begins during admission. As we have said above, it gets updated throughout the patient's stay depending on the changes they exhibit and report and based on evaluation of the achievement of the set goals. When you can plan and execute a patient-centered care plan, you have mastered the art of giving quality and excellent nursing services to your patient.

Let's peek at why nursing care plans are written with a view of their professional and academic importance.

Reasons for Writing Nursing Care Plans

You must note that there are different types of nursing care plans, either formal or informal. The formal nursing care plans are roughly documented or exist in the minds of the nurse. On the other hand, formal nursing care plans are either written on paper or computerized to guide the nursing process. Formal nursing care plans can also be standardized or individualized/patient-centered. While the standardized care plans focus on a specific population or group of patients, say those with cardiac arrest or osteoporosis, the individualized or patient-centered care plans are customized to the unique needs of a specific patient that cannot be addressed through a standardized care plan.

Given the understanding of the typologies of nursing care plans, let's now look at why we write them. Nursing care plans are written, or they exist for different reasons, including:

• To promote the use of evidence-based practices in nursing care to address different healthcare needs of the patients
• Holistically caring for patients in recognition of the nursing metaparadigm (health, people, environment, and nursing)
• Enabling nursing teal collaboration through information sharing and collaborative decision-making
• Measuring the effectiveness of care and documenting the nursing process for care efficiency and compliance
• Offering patient-centered or individualized care to improve outcomes
• Identifying the unique roles of nurses in attending to the needs of the patient without constant consultation with physicians
• Allowing for continuity of care by allowing nurses from different shifts to render quality interventions to patients optimizes care outcomes.
• Guide for delegating duties and assigning specific staff to a patient, especially in cases of specialized care.
• Defining a patient's goals helps involve them in decision-making regarding their care.

The Main Components of a Nursing Care Plan

A well-written nursing care plan must have specific components. The main components of a nursing care plan (NCP) are:

• Expected outcomes
• Interventions
• Evaluations

Let's elaborate on these five main components of a nursing care plan.

• Assessment. Assessments are akin to data collection. It entails a detail of the physical, emotional, sexual, psychosocial, cultural, spiritual/transpersonal, cognitive, functional, age-related, economic, and environmental. Nursing assessments, combined with the results of medical findings and diagnostic studies, are documented in the client database and form the foundation for developing the client's care plan. The assessment is facilitated through observations for objective data and interviews with patients and their significant others or family for subjective data.
• Diagnosis. With a correct assessment, a nursing care plan details the clinical judgment that helps nurses determine the care plan or interventions for the specific patient.
• Expected outcomes. The outcomes entail the specific, measurable actions for a patient to be achieved within a specific time. The outcomes can be short, medium and long-term depending on the patient's condition.
• Interventions. This entails planning for actions to be taken to achieve the set goals of the patients and expected outcomes, including the rationale behind them. The rationale is evidence-based practices drawn from clinical guidelines, standard operating procedures, evidence-based guidelines, and best practices.
• Evaluations. This section of a nursing care plan entails a set of steps to determine the effectiveness of a nursing intervention or nursing interventions to assess whether the expected outcomes have been met.

What makes a good nursing care plan?

A good nursing care plan contains information about the patient's diagnosis, immediate and changing care needs, treatment goals, specific nursing interventions, and an evaluation plan to determine the effectiveness of care. Such a nursing care plan document can only be achieved through observing certain care plan fundamentals.

• The care plan must answer the questions of what, why, and how.
• A successful care plan uses the fundamental aspects of critical thinking to come up with a patient-centered approach to care
• Follows evidence-based practice guidelines when developing interventions or explaining the rationale for actions
• Has SMART goals for the patients
• Allows for effective communication
• Sharable and easily accessible. If written, it should be legible to everyone else. If you are typing it, use a readable font and good formatting.
• Up to date. It entails the latest information about the patient and changes in their conditions.

Steps for Writing a Nursing Care Plan

You will be assigned a patient scenario or case study as a student. These can be actual case studies from real cases happening on hospital floors or cases created to facilitate teaching and learning. As a professional nurse, you will write the case study based on your patient's condition. Given the understanding of the five main components of a nursing care plan, we also say that nursing care plans follow a five-step framework.

1. Assessment

The first step of writing a nursing care plan is to practice critical thinking skills and perform data collection. During this phase, you collect subjective and objective data. The source of subjective data is an interview with the caretakers, family members, or friends of the patient and the patient. The objective data are observed or measured by you, such as weight, height, heart rate, and respiratory rates. In this section of your nursing care plan, you will include the following:

• Verbal statements from the patient and those accompanying them
• Vital signs (heart rate, blood pressure, respiration, temperature, oxygen saturation)
• Physical complaints (headache, vomiting, nausea, pain, swelling)
• Body conditions (head-to-toe assessments)
• Medical history
• Physical features (height and weight)
• Concerns, perceptions, and feelings of the patient
• Lab findings
• Diagnostic tests (EKG, X-ray, echocardiogram, etc.)

2. Diagnosis

The success of this section depends on the accuracy of the data collected from the first part. Next, you need to select a nursing diagnosis that fits the goals and objectives of hospitalization. The diagnosis step entails analyzing the data from the first step or assessment. Writing good nursing diagnoses is a step in the right direction toward choosing nursing strategies targeting specific desired outcomes.

According to NANDA , nursing diagnosis is a clinical judgment about the human response to life processes or conditions. It also refers to vulnerability to that response by an individual, group, community, or family.

When writing a nursing diagnosis, it is essential to formulate it based on Maslow's Hierarchy of Needs Pyramid so that you can prioritize treatments and interventions. For instance, you need to prioritize the basic physiological needs before the higher needs, such as self-actualization and self-esteem. The rationale for first addressing the physiological/safety needs is that they form the foundations for nursing processes (care and intervention planning).

A good diagnosis identifies a problem (current health problem and the nursing interventions required), the risk factors or etiology (reasons for the problem/condition), and the characteristics of the problem (signs and symptoms).

Nursing diagnoses can be categorized into:

• Problem-focused diagnoses . The problems that present during the assessment of the patient. This is the actual diagnosis based on signs and symptoms. It could include shortness of breath, anxiety, acute pain, impaired skin integrity, etc.
• Risk nursing diagnoses . These are clinical judgments that a problem does not exist. However, the presence of risk factors predisposes the patient to the problem unless specific interventions are taken. Examples can include the risk of falls as evidenced by weak bones, the risk of injury as evidenced by altered mobility, the risk of infection as evidenced by immunosuppression, etc.
• Health Promotion or wellness diagnosis is a clinical judgment about the desire and motivation to increase well-being or reach one's health potential.
• Syndrome diagnoses . The clinical judgment concerns and combination of risk nursing diagnoses or problems that can occur due to specific events. Examples include chronic pain syndrome, frail elderly syndrome, etc.

You can read more from Nightingale College concerning nursing diagnosis .

Note that the nursing diagnoses will change as the client progresses through various stages of illness or maladaptation to resolve the problem or to the conclusion of a condition. Therefore, every decision must be time-bound, given that decisions might change as additional information is gathered.

When writing a student nursing care plan, you must provide a rationale for a specific diagnosis. This means including in-text citations from peer-reviewed nursing journal articles.

3. Outcomes

After writing the diagnosis section, you need to develop SMART (specific, measurable, achievable, relevant, and time-bound) goals based on evidence-based practice (EBP) guidelines and client-centered. To do this, you must consider the patient's overall condition, relevant information, and diagnosis.

The goals and desired outcomes describe what you expect to achieve by implementing specific nursing interventions or actions based on the diagnoses. The goals direct the intervention planning process and serve to evaluate the client's progress. When writing the goals, consider the medical diagnosis made by ad advanced healthcare practitioner or physician. It could include COPD, chronic kidney disease, heart failure, diabetes mellitus, diabetes ketoacidosis, obesity, thyroidectomy, hyper/hypothyroidism, cancer, Alzheimer's disease, endocarditis, eating disorders, acid-based balance disorders, fluid/electrolyte imbalance, etc.

The goals of the patient and expected outcomes can be short-term or long-term. Short-term goals immediately focus on the shift in behavior, mainly within a few hours or days. Long-term goals are objectives to be met over a long period, months or weeks.

When writing the goals and desired outcomes, you must include the subject, verb, conditions or modified, and criterion. Usually, they are written in the future tense.

Let's explore the four components:

• Subject. This refers to the client, any part of the client, or some attribute of the client. It could be vitals (temperature, urinary output, blood pressure)
• Verb. This specifies the specific action that the client will perform.
• Conditions or modifiers. These are the "what, where, when, and how?" added to the verb to explain the situations under which behavior is performed.
• Criterion . These are indicators of the standard by which a performance is measured and evaluated or the level at which the patient can comfortably and efficiently perform a given behavior or action.

Examples of goals and outcomes

• The patient will demonstrate adequate cardiac output as evidenced by vital signs within acceptable limits, no symptoms of heart failure, and absence of dysrhythmias.
• The client will identify individual nutritional needs within 36 hours
• The client will ambulate using a cane within 24 hours of surgery

4.  Nursing Interventions

Planning for nursing interventions or strategies is also called the implementation stage. You will be performing various nursing interventions, including following doctor's orders. Every intervention should be developed using evidence-based practice guidelines.

Interventions are classified into seven domains: family, physiological, community, complex physiological, safety, health system, and behavioral interventions. They can be implemented during shifts. Some interventions include pain assessment, listening, preventing falls, administering fluids, etc.

Nursing interventions refer to a set of activities or actions undertaken by a nurse in response to the diagnosis to achieve expected outcomes and meet a patient's goals.

The interventions majorly focus on eliminating or reducing the etiology of the nursing diagnosis. There are different types of nursing interventions:

• Independent nursing interventions . These are activities that the nurses can initiate based on their licensing, clinical judgment, and skills. They include ongoing assessments, emotional support, empathy, providing comfort, patient education, and referrals to other healthcare professionals.
• Dependent nursing interventions . These are activities undertaken through orders from physicians or supervisors. These can be orders to give specific medications, perform diagnostic tests, treatments, diets, or activities.
• Collaborative nursing interventions . Nurses undertake these actions in collaboration with other healthcare team members such as dietitians, physicians, social workers, and therapists.

When selecting a nursing intervention, it should be evidence-based, safe, appropriate for the client's age, health, and condition, and achievable. Every nursing intervention is followed with rationales, which are specific explanations about why a nursing intervention is the most appropriate given the diagnosis and the goals. When giving the rationales, you are expected to refer to your pathophysiological and psychological principles as a student. This means including in-text citations from peer-reviewed journals or clinical practice guidelines to support the choice of a specific intervention.

Nursing interventions are based on your identified needs during data collection or assessment. The timelines for the outcomes should reflect the anticipated length of stay and the individualized nurse-client expectations. You can create a mind map when conceptualizing the needs of the patient/client. The tool helps visualize the link between symptoms and interventions. It is why you will sometimes be asked by an instructor to do a NANDA concept or mind map before writing a nursing care plan assignment.

When writing a nursing strategy or intervention, you should be very specific. You should begin with an action verb that indicates what you are expected to do. You should also include qualifiers expressing how, when, where, time, amount, and frequency of the planned activity. For example:

• "Assist as needed with self-care activities each morning."
• "Record respiratory and pulse rates before, during, and after ambulating."
• "instruct the family in post-discharge care."

5. Evaluation and Documentation

This is the last step of the nursing care plan. As nursing care is provided, you will undertake ongoing assessments to evaluate the client's response to therapy and achieve the expected outcomes.

You should document the response to interventions, which is pretty much what evaluation is about. You can then adjust the care plan based on the information.

Evaluation helps identify the effectiveness of the nursing care plan. It also helps determine if the nursing processes were effective or if there is a need to terminate, continue, or change them.

When evaluating outcomes, you must label them as met, ongoing, or not. You can then decide whether the goals of the intervention need to be altered.

In most cases, all the goals are expected to be met by the time of discharge. However, you must prepare for that transition if a patient is discharged to a long-term care facility, nursing home, or hospice.

If everything is okay, you should document the nursing care plan (NCP) per the hospital's policy or standard operating procedure.

Nursing Care Plan Template for Nursing Students

Your instructor will give you a case study or patient scenario to write a nursing care plan. Some instructors also allow you to develop a nursing case study and write an appropriate nursing care plan. You can also use a real case from your shadowing, internship, or practicum experience. Whichever the case, you can use the template below if none is given. You should organize the nursing care plan into columns for easier entry and organization.

Your introduction should briefly revisit the case study. If requested, expound on the etiology of the medical diagnosis in the background section. The next section is your nursing care plan with columns of assessment, diagnosis, goals and outcomes, interventions, and evaluation, making it 5 columns . Some instructors only want three columns for nursing diagnosis, outcomes and evaluation, and interventions, while others insist on four columns for nursing diagnosis, goals and outcomes, interventions, and evaluation. Below is an example of the nursing care plan section:

The next section can include discharge planning, medication management, rest and activities, diet planning, ongoing care, sleeping, and follow-up.

Finally, write a conclusion that summarizes the entire nursing care plan and include a list of the references you used when writing the nursing care plan.

Sample Nursing Care Plan for Schizophrenia

Nursing Diagnosis : Ineffective coping skills and risk for hematologic side effects of Clozapine

Goals and expected outcomes

• To remain stable on medication and to transition into a less restrictive environment.
• Adequate rest and nutritional intake
• Establish communication and build trust, and encourage patients to participate in the therapeutic community.
• Increase ability to communicate with others.
• Symptom management; decrease in hallucination, delusions, and other psychotic features such as self-talk
• Increase self-esteem
• Subjective and Objective reduction of psychotic symptoms (an irrational behavior)
• Adhere to recommended therapy, including medications, psychotherapy, and lab appointments for hematology.

Nursing Interventions

• Assist the patient in identifying strengths and coping abilities ( nursing interventions) . Strength-based approaches help better recover schizophrenic patients (Xie, 2013). Emphasis on strength is a positive coping mechanism proven to buffer the impact of negative symptoms and promote rehabilitation of patients with schizophrenia (Tian et al., 2019). ( rationale)
• Meet monthly with the clinical team. Interprofessional teams help in the effective management of psychotic disorders such as schizophrenia. Psychiatrists and pharmacists can help improve the patient's status (Farinde, 2013).
• Obtain weekly Vital Signs. Interprofessional teams help in the effective management of psychotic disorders such as schizophrenia. Psychiatrists and pharmacists can help improve the patient's status (Farinde, 2013).
• Encourage all medications as prescribed. Adherence to pharmacological treatment helps alleviate the psychotic symptoms of schizophrenia, v. Non-adherence could lead to deterioration of the symptoms (El-Mallakh & Findlay, 2015).
• Provide opportunities for self-reflection, self-care, positive self-image, and effective communication. Encouraging healthy habits among schizophrenic patients helps optimize functioning, such as drug adherence, maintenance of sleep, reduced stress levels, self-care maintenance, and anxiety (Tian et al., 2019).
• Encourage outings and identify opportunities to reduce anxiety -enjoy music, poetry, and creative writing, and connect with a church spiritual group. Empathy helps the patient perceive the caregivers as caring and makes them feel accepted. It also helps the patients maintain positive coping mechanisms (Peixoto, Mour'o, & Serpa Junior, 2016).
• Monitor lab results (WBC and ANC) and report significant changes per Clozapine guidelines. Patients taking Clozapine must be monitored frequently as they are more predisposed to serious blood dyscrasias. In addition, discontinuing WBC monitoring after 6 months of starting the drug could lead to mortality and accidents (Kar, Barreto & Chandavarkar, 2016).
• Monitor for hematologic side effects: Neutropenia, leukopenia, agranulocytosis, and thrombocytopenia (secondary to bone marrow suppression caused by Clozapine). Clozapine has serious side effects such as seizures, cardiomyopathy, myocarditis, cardiomyopathy, neutropenia, ad agranulocytosis (Dixon & Dada, 2014).
• Instruct patient to report any side effects, illness, s/s of infection, fatigue, or bruising without apparent cause. Constant monitoring of psychotic symptoms helps change treatment (Holder, 2014). For instance, it can help determine if the antipsychotic medication is not working and include evidence-based psychosocial interventions (Stroup & Marder, 2015).
• Monitor anticholinergic effects; dry mouth, difficulty urinating, constipation.
• Monitor for reduction/increase of psychotic symptoms
• Discourage caffeine. Caffeine interacts with Clozapine and can lead to toxicosis. It increases the plasma concentrations of Clozapine (De Berardis et al., 2019). Caffeine inhibits the metabolism of Clozapine through the inhibition of CYP1A2 (Delacr�taz et al., 2018)
• The patient will have reduced symptoms, adhere to medication, and show improvement.
• The patient will control his feelings, perceptions, and thought processes.
• Social increasing ease of communication since starting Clozaril (date). The patient will easily interact with caregivers, family, and other patients.
• The patient will acknowledge the importance of medication in lowering suspicion.
• Self-talk has diminished since admission. The patient will also exhibit high self-esteem levels.
• The patient will have reduced anxiety and violent behavior and have remission.

Brekke, I. J., Puntervoll, L. H., Pedersen, P. B., Kellett, J., & Brabrand, M. (2019). The value of vital sign trends in predicting and monitoring clinical deterioration: A systematic review. PloS one , 14 (1), e0210875. https://doi.org/10.1371/journal.pone.0210875

De Berardis, D., Rapini, G., Olivieri, L., Di Nicola, D., Tomasetti, C., Valchera, A., ... & Serafini, G. (2018). Safety of antipsychotics for the treatment of schizophrenia: a focus on the adverse effects of Clozapine. Therapeutic advances in drug safety, 9(5), 237-256.

Delacr'taz, A., Vandenberghe, F., Glatard, A., Levier, A., Dubath, C., Ansermot, N.,  Eap, C. B. (2018). Association Between Plasma Caffeine and Other Methylxanthines and Metabolic Parameters in a Psychiatric Population Treated with Psychotropic Drugs Inducing Metabolic Disturbances. Frontiers in psychiatry , 9 , 573. https://doi.org/10.3389/fpsyt.2018.00573

Dixon, M., & Dada, C. (2014). How clozapine patients can be monitored safely and effectively.  The Pharmaceutical Journal, 6 (5), 131.

El-Mallakh, P., & Findlay, J. (2015). Strategies to improve medication adherence in patients with schizophrenia: the role of support services. Neuropsychiatric disease and treatment, 11 , 10771090. https://doi.org/10.2147/NDT.S56107

Farinde, A. (2013). Interprofessional Management of Psychotic Disorders and Psychotropic Medication Polypharmacy.  Health and Interprofessional Practice, 1 (4), 4.

Holder, D., S. (2014). Schizophrenia. American Family Physician, 90 (11), 775-782.

Kar, N., Barreto, S., & Chandavarkar, R. (2016). Clozapine Monitoring in Clinical Practice: Beyond the Mandatory Requirement. Clinical psychopharmacology and neuroscience: the official scientific journal of the Korean College of Neuropsychopharmacology, 14 (4), 323�329. https://doi.org/10.9758/cpn.2016.14.4.323

Lantta, T., H�t�nen, H. M., Kontio, R., Zhang, S., & V�lim�ki, M. (2016). Risk assessment for aggressive behavior in schizophrenia.  The Cochrane database of systematic reviews, 2016 (10). https://doi.org/ 10.1002/14651858.CD012397

Peixoto, M. M., Mour�o, A. C. D. N., & Serpa Junior, O. D. D. (2016). Coming to terms with the other's perspective: empathy in the relation between psychiatrists and persons diagnosed with schizophrenia.  Ciencia & saude coletiva, 21 (3), 881-890.

Stroup, T. S., & Marder, S. (2015). Pharmacotherapy for schizophrenia: Acute and maintenance phase treatment.  UpToDate .

Tian, C. H., Feng, X. J., Yue, M., Li, S. L., Jing, S. Y., & Qiu, Z. Y. (2019). Positive Coping and Resilience as Mediators between Negative Symptoms and Disability among Patients with Schizophrenia . Frontiers in psychiatry, 10 , 641.

Xie, H. (2013). Strengths-based approach for mental health recovery. Iranian journal of psychiatry and behavioral sciences, 7 (2), 5�10.

Writing the best nursing care plan can sound easy on paper, but the process is demanding and tiresome. If you are a nursing student who wants to delegate writing nursing care plans to someone who can help you do so accurately, affordably, and reliably, you can trust our care plan writers.

We are a nursing writing service website that offers assistance with completing various nursing assignments. The writers are experienced in research and writing nursing papers online. To date, we have supported the dreams of many nursing students, saving them time and money and maintaining their mental health.

Do not miss a deadline because you are busy with a shift; we can take over and make great things happen. Our nursing care plans are original, 100% plagiarism-free, and submitted to your email within your selected deadline. We also allow you to communicate with your writer to make changes together, share perspectives, and exchange ideas.

We can help you write care plans for type 2 diabetes, risk for injury, acute kidney injury, pressure ulcer, pulmonary embolism, chest pain, hypoglycemia, dementia, PTSD, hyperlipidemia, UTI, asthma, CHF, atrial fibrillation, bipolar disorder, risk for fall, ineffective coping, anemia, seizure, constipation, and any other condition or diagnosis.

Do not hesitate to contact us if you need help.

Important NOTICE!

The information in this article and the 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.

Related Readings:

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Nursing Care Plan (+ Template)

Table of contents, what is a nursing care plan .

A nursing care plan is a written document detailing the nursing interventions that will be done to meet a client’s needs and health goals. It serves as a guide for personalized care of the client and facilitates communication in the healthcare team. 

What is a nursing intervention? 

Nursing interventions are actions in a care plan, such as patient education or treatments. They are formed using patient feedback, evidence-based sources, and the nursing process. 

How to write a nursing care plan 

How to prepare a nursing care plan using the 5-step nursing process (adpie):.

Following the nursing diagnoses that were formed based on a thorough assessment (history, physical assessment, focused assessment), a clear plan of care goals, interventions, and desired outcomes is defined. 

Nursing tip: Gather information in a logical and informed way to provide the best care possible. 

Nursing tip: To address each intervention to assess quality in patient care, goals need to be SMART: 

• M easurable
• A ttainable

Discuss with your client which health goals they would like to achieve. 

Nursing care plan template & examples

Once the client’s goals are established, nursing interventions (NIC) and standard nursing outcomes (NOC) can be used to guide patient care. 

They can, for example, be presented in the nursing care plan in a column-based format: 

Examples of goals could be: 

• Stage 1 pressure ulcer will resolve
• Client demonstrates insulin injection procedure
• Client reports pain level < 4 with ambulation

Examples of fitting nursing interventions could be: 

• Reposition client every 2 hours
• Request diabetes education consult
• Administer pain medication 1 hour before physical therapy

Examples of possible outcomes could be: 

• Reduced redness in lower back area
• Client demonstrates self-injection techniques
• Client ambulates 100 feet twice a day

Nursing intervention examples (practice questions)

Which nursing intervention is placed in the plan of care for a client diagnosed with osteoarthritis.

Answer options:

• Apply a cold compress to the affected joint for 15–20 minutes
• Encourage high-impact exercise like jogging
• Administer IV antibiotics as prescribed
• Start a weight-lifting program for strength

Correct answer:

• Applying a cold compress to the affected joint for 15–20 minutes.

Explanation: 

Cold compresses can help reduce inflammation and relieve pain in osteoarthritis. High-impact exercise and lifting weights can worsen the condition, and antibiotics are not used for osteoarthritis, as it’s not caused by an infection.

A client is diagnosed with hypervolemia. Which is the priority nursing intervention?

• Encourage fluid intake hourly
• Monitor weight and strict I & O
• Administer bronchodilators
• Initiate cardiac monitoring

      2. Monitor weight and intake and output carefully.

In hypervolemia, fluid overload is a concern. Monitoring weight and intake and output allows for accurate assessment and helps guide treatment. More fluid intake would exacerbate the problem, and bronchodilators are not directly related to fluid volume management. Cardiac monitoring is not required as no cardiac problem is identified.

A client has completed a bone marrow biopsy. Which nursing intervention is the priority action post-procedure?

• Elevate the extremity where the biopsy was taken
• Administer a dose of intravenous antibiotics
• Apply pressure to the biopsy site
• Use heating pad at site on low setting

      3. Apply pressure to the biopsy site.

Applying pressure to the biopsy site helps prevent hemorrhage and facilitates clot formation. Elevating the extremity and administering antibiotics are not generally the priority interventions post-bone marrow biopsy. Ice packs, not heat, can be used for short periods of time for tenderness.

Which nursing intervention is essential in caring for a client diagnosed with compartment syndrome?

• Apply ice to the affected extremity.
• Elevate the affected limb above heart level.
• Loosen or remove the tight bandage or cast.
• Alert the Rapid Response Team.

       3. Loosen or remove the tight bandage or cast.

Compartment syndrome is caused by increased pressure within a muscle compartment, which can compromise circulation to the area. If a tight bandage or cast is contributing to the pressure, it should be loosened or removed to alleviate the pressure. The other answers could potentially worsen the condition. The Rapid Response Team is notified for imminent deterioration, which this client is not manifesting

The nurse cares for a client diagnosed with pyelonephritis. Which nursing intervention does the nurse include in the plan of care?

• Encourage fluid restriction.
• Administer prescribed antibiotics.
• Apply a heating pad to the lower back.
• Instruct client to keep blood glucose lower.

      2. Administer prescribed antibiotics.

Pyelonephritis is a bacterial infection of the kidneys that usually requires antibiotic treatment for resolution. Fluid restriction is generally not recommended; in fact, increased fluids may be encouraged. A heating pad may provide temporary relief but doesn’t treat the underlying infection. If the client does have diabetes mellitus, it does increase the risk for pyelonephritis, but no mention of this is given. 

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Nursing Care Plan Template

SimpleNursing’s Nursing Care Plan Template

In the fast-paced world of nursing, time is of the essence, and having a reliable tool can make all the difference.

Enter the nursing care plan (NCP) template — a tool that streamlines the planning process, ensuring that client care is effective and organized. Whether you’re in school or a practicing nurse, nursing care plans are important for positive outcomes. This nursing care plan template provides a clear structure for nursing professionals, enabling them to:

• Outline client needs.
• Set measurable goals.
• Establish a roadmap for care.
• Document the client’s progress and response to nursing interventions .

This article will introduce you to nursing care plan templates, provide tips on using them effectively, and offer downloadable options for your convenience.

How to Use Our Nursing Care Plan Template

To receive your free nursing care plan template, provide your email address.

We’ll send you the template and detailed instructions on how to use it.

The template is available in three formats:

Care Plan Template Sections

The care plan template has several sections, each with a specific purpose.

Here’s a breakdown of what you can expect to find in each section:

Client Information Section

This section contains basic information about the client, such as their name, date of birth, age, gender, primary care provider, and room number.

It also includes a space for important contact information in case of emergencies or follow-up appointments.

• Medical History: Document the client’s past medical conditions and treatments.
• Allergies: Note any known allergies to medications, foods, or other substances.
• Medications: List all the client’s current medications.

You need at least two care plans per client, which we include in the template.

This is the core of nursing care plan templates.

• Assessment: Record the client’s health status, including vital signs and symptoms.
• Diagnosis: Identify the client’s health problems based on the assessment.
• Outcomes: Define the expected results of the care provided.
• Interventions: Outline the specific actions needed to achieve the desired outcomes.
• Rationales: Explain the reasoning behind each intervention. This section is optional and can roll into interventions.
• Evaluation: Assess the effectiveness of the interventions and adjust the care plan as needed.

Benefits of Using a Nursing Care Plan Template

Using an NCP template can provide numerous benefits to nurses and clients.

Here are four examples:

• Organizational Aid: Helps organize client care efficiently
• Customization: Offers flexibility to adapt to individual client needs
• Efficiency: Streamlines communication among health care team members
• Improved Client Care: Enhances client safety and care continuity

Care Plan Template Alternatives

Here are two versions of care plan templates:

3-Column Format:  

A traditional layout with three columns for diagnosis, interventions, and outcomes/evaluations

5-Column Format:

A more detailed layout with added columns for assessment and goals

Choose the template that works best for your needs.

Download your free template today and take the first step towards better client care! 

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Our NCP template is just one example of the many tools we provide to support your growth as a nurse.

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Nursing Care Plans

Download these FREE nursing care plan examples for different conditions. Know their pathophysiology, interventions, goals, and assessment in this database. You can also visit our nursing care plans guide for tips on how to write nursing care plans.

Nursing Care Plans (NCP) Ultimate Guide and List

Introducing our comprehensive guide to crafting your own nursing care plan. It comes with a complimentary collection of nursing diagnosis examples and care plans, perfect for both student nurses and seasoned professionals.

Nursing Diagnosis Guide: All You Need to Know to Master Diagnosing

Know the concepts behind writing nursing diagnosis (NDx) in this ultimate tutorial and list. Learn what is a nursing diagnosis, the nursing process, the different types, and how to write nursing diagnoses correctly.

Hyperthermia (Fever) Nursing Care Plan and Management

This nursing care plan and management guide can assist in providing care for patients with hyperthermia or fever. Get to know the nursing assessment, interventions, goals, and nursing diagnosis to promote safe nursing care for patients with fever.

Risk for Injury & Patient Safety Nursing Care Plan and Management

This nursing care plan and management guide can assist nurses in providing care for patients who are at risk for injury. Get to know the nursing assessment, interventions, goals, and nursing diagnosis to promote patient safety and prevent injury.

Risk for Infection and Infection Control Nursing Care Plan and Management

This nursing care plan and management guide can assist nurses in providing care for patients who are at risk for infection. Get to know the nursing assessment, interventions, goals, and nursing diagnosis for infection prevention and control.

Fall Risk and Fall Prevention Nursing Care Plan

In this nursing care plan and management guide, discover the nursing interventions for fall prevention. Get to know the nursing assessment, nursing diagnosis, and goals for patients at risk for falls.

9 Cesarean Birth Nursing Care Plans

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Acute Pain Nursing Care Plan and Management

Let’s take a closer look at how we can effectively care for patients experiencing acute pain. Use this guide to formulate your nursing care plans and nursing interventions for patients experiencing acute pain.

7 Preeclampsia & Gestational Hypertensive Disorders Nursing Care Plans and Management

Here are six nursing diagnoses for your nursing care plans for pregnant patients with hypertensive disorders with a focus on the management of clients with preeclampsia. 

6 Seizure Disorder Nursing Care Plans

Use this nursing care plan and management guide to help care for patients with seizure disorders. Learn about the nursing assessment, nursing interventions, goals and nursing diagnosis for seizure disorders in this guide.

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How to write a Nursing Care Plan step by step

Why are care plans necessary?

The short answer is: “Proper Preparation Prevents Poor Performance!” The formal answer is: Care plans are an important tool used to plan and provide personalized care to your patients through the implementation of the Nursing Process (ADPIE). They help you be more deliberate in the nursing care you provide.

Click here to follow along with our Free Care Plan Builder!

Our patient is a 54 y/o female with a primary diagnosis of Congestive Heart Failure (CHF). She presented to the emergency room complaining of shortness of breath on exertion.

• In the assessment, we identify the issue we are addressing. In this case, we are concerned by the patient’s cardiac condition due to their CHF diagnosis. So we go ahead and select the “Cardiac” button.

• For the diagnosis, we refine a bit more the type of cardiac issue we are addressing. We know that for patients suffering from congestive heart failure, cardiac output is often affected. We therefore proceed by selecting the “Cardiac Output Alteration” button.

• To complete the nursing diagnosis, we identify the expected outcome of the nursing diagnosis once we have implemented the proper interventions. We want the patient’s condition to improve so they can resume their usual activities of daily living without distress. So we select the “Improve” button to continue.

• After identifying an expected outcome, we have to make a plan on how to reach our goal of improving the patient’s cardiac out alteration. Our plan will comprise of interventions that provide Cardiac Care within our scope of practice. Let’s proceed by selecting the “Cardiac Care” button followed by “Cardiac Rehabilitation.”

• After assessing, diagnosing and planning, we now get to implement our interventions! We will do so by tapping the appropriate buttons and entering examples of actions we are/will take while providing the respective rationales.

• Patients with heart failure can develop cardiac arrhythmias and hemodynamic alterations that impair circulation and oxygenation exchange. Poor circulation and poor oxygenation can lead to organ damage
• Medications such as angiotensin converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), aldosterone antagonists, beta-blockers, calcium channel blockers (CCBs), digitalis drugs, diuretics, inotropic agents, nitrates, and vasodilators are often used in the treatment and management of congestive heart failure
• Congestive heart failure reduces the kidney’s ability to excrete sodium resulting in fluid retention. A low sodium diet such as the DASH diet will help reduce the build up of fluid in the body and help minimize complications
• CHF patients may develop life threatening deteriorations such as myocardial infarctions, ventricular fibrillation and pulmonary edema
• In this last step of the Nursing Process, we evaluate our plan of care to see if it worked or needs some alterations. Fortunately for our patient, we made the appropriate diagnosis, created a personalized plan of care and intervened using evidence based actions. Our patient’s condition improved and she is now ready to be discharged pending final clearance form the provider. We will conclude by selecting the “Improved” button.

The Clinical Care Classification System is an evidence based tool for creating care plans based on the Nursing Process: Assess, Diagnose, Plan, Implement & Evaluate. Using the Nursing Process helps nurses be more deliberate in providing comprehensive care to their patients. You can use the NurseBrain Care Planner tool for free at https://nursebrain.app/careplan . Click here to download this sample patient and care plan.

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How To Write the Perfect Nursing Care Plan with Examples

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Struggling to Write a Nursing Care Plan

I recently met a nursing student named, Sarah who had just started on her journey to become a nurse.  She was struggling with writing nursing care plans.  Sarah struggled with gathering comprehensive patient information, identifying appropriate nursing diagnoses, and formulating effective interventions.

Writing a nursing care plan is an essential skill that every nursing student should master. It serves as a roadmap for providing individualized and effective care to your patients.

In this blog post, you will:

• Know what a nursing care plan is

Purpose of Nursing Care Plans

• Know the 5 Steps to Writing a Nursing Care Plan
• Be provided with 3 Nursing care plan examples

Before we dive into this blog post I know how difficult learning everything in nursing school can be.  That is why I am offering you a free nursing mnemonic cheat sheet.  Just click below to get your copy!

Alright, lets begin!

What is a Nursing Care Plan

A Nursing Care Plan is the way a nurse documents and communicates the Nursing Process. Nursing care plans are one of the most common assignments in nursing school and can be a valuable resource in the clinical setting. They start when a patient is admitted and document all activities and changes in the patient’s condition. Using a care plan will encourage patient-centered care and make your nursing care more consistent. These plans are also a great communication tool among nurses, other healthcare professionals, patients, and their families. Nursing students learn to assess a patient, make a nursing diagnosis, create a plan, implement the plan, and evaluate the plan to ensure best practices and outcomes. This process teaches them to problem-solve and make critical decisions. A nursing care plan helps nurses organize their day, know when things need to be accomplished, and balance their workload.

The nursing care plan serves as a communication tool between healthcare professionals, ensuring a coordinated approach to patient care. It guides nurses in delivering evidence-based, patient-centered care, while also promoting continuity of care among different healthcare providers. Nursing care plans are essential in various healthcare settings, including hospitals, clinics, and long-term care facilities. They facilitate efficient and effective care delivery, enhance patient outcomes, and promote individualized care tailored to each patient's unique needs.

Nursing Care Plans are a written form of The Nursing Process. These plans ensure nurses deliver consistent, patient-centered, and holistic care. Each step in the nursing process is covered in the nursing care plan and helps nurses plan, implement, and evaluate nursing care.

• Assessment - The first step in delivering nursing care. It collects and analyzes physiological, psychological, sociocultural, spiritual, economic, and lifestyle factors data.
• Diagnosis  - Using the data, patient feedback, and clinical judgment to form nursing diagnoses. The diagnosis considers the patient’s signs, symptoms, pain, and the problems their condition has caused, such as anxiety, poor nutrition, conflict with family, and complications that may arise. The nursing diagnosis is the basis for the care plan. 
• Planning - Setting short-term and long-term goals based on the nurse’s assessment and diagnosis.  Ideally, with input from the patient. This is where you determine nursing interventions to meet these goals.
• Implementation  -  Implementing nursing care according to the care plan, based on the patient’s health conditions and the nursing diagnosis. This is where you will document the care the nurse performs. 
• Evaluation  - Monitoring and documenting the patient’s status and progress toward meeting the planned goals. This allows you to modify the care plan as needed. 

5 Steps to Writing a Nursing Care Plan

Writing a nursing care plan can seem overwhelming, but breaking it down into five simple steps can make the process more manageable. Here are five steps to help you write a nursing care plan:

Step 1 – Collect Information (Assess)

Gather relevant data about the patient's health status, medical history, current condition, and other pertinent factors. It involves systematically obtaining and organizing information to inform the development of the care plan.

• Head-to-toe-assessment
• Conversations with your patients and loved ones
• Observations (lab values, vital signs)
• Report (or your report sheet)
• Chart review notes
• Discussions with the healthcare team members

Step 2 – Analyze the Information (Diagnose & Prioritize)

Critically examining and interpreting the collected information and data to identify patterns, relationships, and underlying factors related to the patient's health condition. It involves synthesizing the information to gain a comprehensive understanding of the patient's needs and develop appropriate nursing diagnoses and interventions.

• Look at all information
• What are areas in which this patient has trouble and therefore needs to progress in?
• Think about the ways you could see the patient improving and how you would know they were improving
• Write down the general issues, how you’d help them progress in that area, and how you’d know they were progressing

Step 3 – Think About How (Plan, Implement, & Evaluate)

The process of critical thinking and considering various factors and possibilities when developing the plan. It involves evaluating different options, anticipating potential outcomes, and making informed decisions based on the patient's unique needs and circumstances.

• How did you know he was in pain? Did he tell you? Did you observe it? Was he getting pain medications?
• Write an S or an O next to them
• A recent surgery, trauma, or disease process?
• Write all of your reasons (again in layman's terms) under the problem(s) you’ve identified.
• What would you do to make this better? (Interventions)
• How would you know it got better? (Evaluation)

Step 4 – Translate

The process of converting the collected information, nursing diagnoses, goals, and interventions into clear and actionable language that can be easily understood and implemented by the healthcare team. 

• Take your textbooks (NANDA-I, NIC, NOC, or whatever you may be using)
• Look up the official terms for the problem(s) and write them down
• Look up outcomes and interventions that may align with what you wrote down

Step 5 – Transcribe

The process of accurately documenting the care plan in a written format. It involves transferring the information, including nursing diagnoses, goals, and interventions, into a standardized care plan document or electronic medical record.

• Get your nursing care plan template out
• Put the pieces together (problem + related to factor(s) + defining characteristics/”hows”)
• Use your S’s and O’s to place your subjective and objective data
• Write out your interventions and outcomes/evaluation

3 Nursing Care Plan Examples

Sometimes all you need are a few examples to help you learn how to do a difficult task and to get the brain juices flowing.  Here are 3 care plans that I personally wrote during nursing school.

Nursing Care Plan Example 1

Medical diagnosis: abdominal pain.

Pathophysiology of Abdominal Pain: 

Abdominal pain can be a minor issue that is easy to resolve or a medical emergency. Many different things can cause abdominal pain and their pathophysiology can differ widely. Abdominal pain can is classified as either acute or chronic. When a patient presents to the emergency department or outpatient environment with abdominal pain, it generally constitutes a lengthy workup to determine the cause and its pathophysiology. Additionally, abdominal pain can be referred pain, which can complicate the clinical picture even further.

Etiology of Abdominal Pain

Abdominal pain can be the result of pregnancy, ectopic pregnancy, trauma, a long list of gastric issues (gastroenteritis, constipation, diarrhea, irritable bowel syndrome, GERD, Chron’s disease, appendicitis, to name a few), hernias, allergic response, endometriosis, gallstones, severe menstrual cramps, hepatitis, miscarriage, and many more. Many disease processes result in abdominal pain, and some may present with abdominal pain even though it is not the typical clinical picture.

Desired Outcome

Cease painful stimuli, resolve the underlying cause, and minimize any subsequent damage.

Making an individualized assessment of abdominal pain begins by focusing on the available background information of the patient: health history, current health status, psychological state, and other relevant data.

Subjective Data: Subjective data is information or symptoms reported by the patient. These include feelings, perceptions, and concerns obtained by the patient interview. In the case of abdominal pain, a patient might report feeling:

• Abdominal pain
• Decreased appetite
• Rebound tenderness
• Muscle tension
• Restlessness

Objective Data: Objective data is observable and measurable data, or signs, obtained through observation, physical examination, and laboratory or diagnostic testing. In the case of abdominal pain, a patient may present with:

• Constipation
• Electrolyte imbalances

A nursing diagnosis is a basis for establishing and carrying out a nursing care plan. After performing a proper assessment, formulate a nursing diagnosis based on problems associated with abdominal pain. This will be your clinical judgment about the patient’s health conditions or needs. Select the appropriate nursing diagnostic label from the NANDA-I list of approved nursing diagnostic statements that best identify with the patient’s signs and symptoms. One or more nursing diagnoses may be given.

Planning / Outcomes

Care plan goals form the basis of nursing intervention. Think of these goals as “what the patient will do” and clearly state easy to measure, realistic descriptions of the patient’s expected outcomes. In the case of abdominal pain, a plan may include:

• Return to normal bowel movements
• Taking medications
• Receiving fluids
• Understanding their condition and treatment

Implementation

Implementations are actions and activities you will take to achieve the nursing plan goals. In the case of abdominal pain, an implementation may include:

• Encourage evacuation
• Encourage eating
• Administer medications as prescribed
• Provide fluids
• Educate the patient and family members

The evaluation of our nursing plan involves an organized, ongoing, and intentional assessment of the achievement of set goals and desired outcomes. A good review of our care plan helps determine whether to continue, stop, or change the selected interventions. In our abdominal pain example, an evaluation might include:

• The patient had 2 normal bowel movements
• The patient ate 3 meals
• Patient took medications
• Patient received fluids
• The patient understood information about their care

Nursing Care Plan Example 2

Medical diagnosis: infection.

Pathophysiology of Infection: 

An infection is a disease caused by microorganisms infecting tissues. 

Etiology of Infection

The organisms that can cause disease are very diverse that include viruses, bacteria, fungi, and parasites. You can acquire such infections by contaminated food/water, a bite, cut, or being in contact with someone with an infection.

Patient will remain free from infection and demonstrate proper hand hygiene

Subjective Data: Subjective data is information or symptoms reported by the patient. These include feelings, perceptions, and concerns obtained by the patient interview. In the case of infection, a patient might report feeling:

• Muscle aches
• Sore throat

Objective Data: Objective data is observable and measurable data, or signs, obtained through observation, physical examination, and laboratory or diagnostic testing. In the case of infection, a patient may present with:

• Tachycardia
• Elevated WBC count
• Redness/swelling/heat/drainage from wound

Risk for Infection related to compromised skin integrity and invasive procedures.

Care plan goals form the basis of nursing intervention. Think of these goals as “what the patient will do” and clearly state easy to measure, realistic descriptions of the patient’s expected outcomes. In the case of infection, a plan may include:

• The patient will maintain intact skin and mucous membranes.
• The patient will demonstrate understanding of infection prevention techniques.
• The patient's vital signs will remain within normal limits.
• The patient will report a decrease in signs and symptoms of infection.
• The patient will be free from healthcare-associated infections.

Implementations are actions and activities you will take to achieve the nursing plan goals. In the case of infection, an implementation may include:

• Assess the patient's skin integrity, paying close attention to areas at risk for infection such as surgical wounds, intravenous (IV) sites, and urinary catheter insertion sites.
• Implement proper hand hygiene techniques before and after providing care to the patient.
• Promote adequate hydration and provide a balanced diet to enhance the immune system.
• Educate the patient on proper wound care techniques, including keeping the wound clean, dry, and covered with appropriate dressings.
• Administer prescribed antibiotics and other medications as ordered.
• Monitor the patient's vital signs regularly and report any abnormalities or signs of infection promptly.

The evaluation of our nursing plan involves an organized, ongoing, and intentional assessment of the achievement of set goals and desired outcomes. A good review of our care plan helps determine whether to continue, stop, or change the selected interventions. In infection example, an evaluation might include:

• Assess the patient's skin regularly to ensure integrity and identify any signs of infection.
• Evaluate the patient's understanding and implementation of infection prevention techniques.
• Monitor vital signs and note any abnormalities.
• Assess the patient for any improvement in signs and symptoms of infection.
• Evaluate the patient's risk for healthcare-associated infections and implement appropriate preventive measures.

Nursing Care Plan Example 3

Medical diagnosis: fluid volume deficit.

Pathophysiology of Fluid Volume Deficit: 

Fluid Volume deficit (dehydration) is a state or condition where the fluid output exceeds the fluid intake. The body loses both water and electrolytes from the ECF in similar proportions. Common sources are the gastrointestinal tract, polyuria, and increased perspiration.

Common causes are decreased fluid intake, bleeding, diarrhea, diuresis, abnormal drainage, increased metabolic rate, movement of fluid into third space, and abnormal losses through the skin, GI tract, or kidneys.

Patient has normal vital signs. Demonstrates adequate lifestyle changes to avoid dehydration. Patient has normal urine output

Subjective Data: Subjective data is information or symptoms reported by the patient. These include feelings, perceptions, and concerns obtained by the patient interview. In the case of Fluid Volume Deficit, a patient might report feeling:

• Weakness 
• Extreme thirst 

Objective Data: Objective data is observable and measurable data, or signs, obtained through observation, physical examination, and laboratory or diagnostic testing. In the case of Fluid Volume Deficit, a patient may present with:

• Alterations in mental state
• Weight loss
• Concentrated urine/decreased urine output
• Dry mucous membranes
• Weak pulse/tachycardia
• Decreased skin turgor
• Hypotension
• Postural hypotension
• Sunken eyes/cheeks

Diagnosis for Fluid Volume Deficit

Fluid Volume Deficit related to excessive fluid loss (e.g., vomiting, diarrhea, hemorrhage) as evidenced by decreased urine output, dry mucous membranes, and decreased skin turgor.

Planning / Outcomes for Fluid Volume Deficit

Care plan goals form the basis of nursing intervention. Think of these goals as “what the patient will do” and clearly state easy to measure, realistic descriptions of the patient’s expected outcomes. In the case of Fluid Volume Deficit, a plan may include:

• The patient will maintain adequate fluid balance as evidenced by stable vital signs and improved hydration status.
• The patient will maintain optimal tissue perfusion.
• The patient will demonstrate understanding of fluid management and prevention of fluid volume deficit.

Implementation for Fluid Volume Deficit

Implementations are actions and activities you will take to achieve the nursing plan goals. In the case of Fluid Volume Deficit, an implementation may include:

• Assess and monitor vital signs, including blood pressure, heart rate, respiratory rate, and temperature, to identify signs of hypovolemia.
• Measure and record the patient's intake and output accurately to assess fluid balance.
• Monitor daily weights to track changes in fluid status.
• Encourage and assist the patient with oral fluid intake as tolerated, offering small, frequent sips of water or other fluids.
• Administer IV fluids as prescribed, ensuring accurate infusion rates and monitoring for any adverse reactions.
• Assess the patient's skin turgor, mucous membranes, and capillary refill time regularly to evaluate hydration status.
• Collaborate with the healthcare team to determine the underlying cause of fluid volume deficit and address it accordingly (e.g., treating the underlying infection or stopping excessive fluid losses).
• Monitor laboratory values, including electrolytes and hematocrit levels, and collaborate with the healthcare team to make any necessary adjustments to fluid therapy.

Evaluation for Fluid Volume Deficit

The evaluation of our nursing plan involves an organized, ongoing, and intentional assessment of the achievement of set goals and desired outcomes. A good review of our care plan helps determine whether to continue, stop, or change the selected interventions. In Fluid Volume Deficit example, an evaluation might include:

• Monitor and document the patient's vital signs and fluid intake and output regularly.
• Assess the patient's hydration status, including skin turgor, mucous membranes, and capillary refill time.
• Evaluate the patient's response to fluid therapy, including improvement in vital signs and hydration status.
• Assess the patient's understanding and implementation of fluid management strategies.
• Collaborate with the healthcare team to determine the need for further interventions or adjustments to the care plan.

Mastering the Art of Writing the Perfect Nursing Care Plan

Mastering the art of writing the perfect nursing care plan is crucial for delivering effective and individualized patient care.

By following the five essential steps -

• Collect Information (Assess)
• Analyze the Information (Diagnose & Prioritize)
• Think About How (Plan, Implement, & Evaluate)

You can create comprehensive care plans that address the unique needs of each patient.

Remember to utilize evidence-based practice, collaborate with the healthcare team, and continuously evaluate and modify the care plan as needed. With these strategies in place, you can confidently navigate the complexities of care planning, ensuring optimal patient outcomes and promoting the highest standards of nursing practice.

You Can Do This

Happy Nursing!

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Nursing Care Plans | Free Care Plan Examples for a Registered Nurses (RN) & Students

Nursing care plan overview & introduction: what is a care plan in nursing.

A nursing care plan is a part of the nursing process which outlines the plan of action that will be implemented during a patients’ medical care. LPNs (Licensed Practical Nurses) and Registered Nurses ( RNs) often complete a care plan after a detailed assessment has been performed on the patients’ current medical condition and prior medical history. The nurse can then take action with the patient by fulfilling the care plan’s goals and objectives.

On this page, you will get some free sample care plans that you can use as examples to understand more about how they help nurses treat people. If you want to view our care plan database, make sure to visit our free care plans section.

Search Care Plan Database

When I was in nursing school I bought some books to help me with nursing care plans. Care plans take practice but once you catch on they are a piece of cake. Here are the books I recommend on using to help you with your nursing care plans. I believe they are the best books for nursing care plans. The first one is called “ Nursing Care Planning Made Incredibly Easy! ” It is like one of those “made for dummies” books. Here is a picture of it and you can find it on Amazon.com for less than $25.

Another great book is called “ Nursing Care Plans: Guidelines for Individualizing Client Care Across the Life Span “. This book is excellent because it is universal for all areas in nursing for developing your care plans. This book is awesome for developing your care plans and is used by many nursing students.

*See disclosure at the end of this article.

Care plans are occasionally used by other medical staff, such as doctors, Respiratory therapists, physical therapists, and more. However, they are most often used and associated with the field of nursing.

Thinking about going to Nursing School?

Are you contemplating  going to nursing school, or are you actually in nursing school right now?  Nursing school can be challenging, especially if you do not know what to expect. Here is a great guide by S. L. Page BSN, RN called “ How to Pass Nursing School “. This book gives you detailed information about how to pass nursing school from beginning to end. S.L. Page, the creator of this website, complied all the information students what to know about nursing school into one easy to read guide. She gives in depth information on how to succeed in nursing school.

S.L. Page graduated from nursing school with honors and passed the NCLEX-RN on her first try. In this eBook, she reveals the strategies she used to help her succeed.

Here is what the book looks like:

Why Should Nurses Use Care Plans? Aren’t Care plans a Waste of Time?

In addition, care plans can be easily revised to provide new outcomes or treatment plans if a patient’s condition changes. This flexibility helps the nurse maintain focus during potentially stressful situations. Since the patient’s information will be conveniently located within the care plan, this will save time and reduce the risk of misinformation or mistakes.

Care plans are also helpful during a patient’s discharge process. Nurses can review the care plan to see if the patient met the nursing outcome during their treatment, and can base the patient’s later discharge care based on those outcomes.

Video About Nursing Care Plans

Why Do Nursing Students Use Care Plans?

Nursing school professors often require nursing students to complete many care plans throughout their college career. The reason is simple: Care plans are important. Nursing students should thoroughly learn about care plans for the following reasons:

• It Instills critical thinking and analytical skills related to nursing. This will help future nurses evaluate and treat patients more efficiently.
• By completing care plans, it helps the nursing student successfully pass their board’s test (NCLEX), HESI tests, and acquire their licensing.
• Since care plans are used in the nursing profession and in nursing care, it is vital that all nurses know how to complete them.

What’s the Difference Between Care Plans in Nursing School vs. Care Plans on the Job?

Care Plans In Nursing School:

• Very detailed and comprehensive. This is done so the nurse can become familiar with care plan development, processes, and outcomes, and terminology.
• Often completed on a blank sheet of paper, and each part of the care plan must be completed manually (typed or hand written). This often requires an extensive amount of time and research to complete.
• Often requires a NANDA Nursing Diagnosis book to help guide you when selecting a nursing diagnosis.

Care Plans on the Job:

• Less detailed–Nurses are generally not required to list as many interventions, outcomes, or other values. Instead of having a comprehensive nursing diagnosis statement, it is usually a “focus” that you need to have.
• Care plans are often created on pre-made templates that are “diagnosis-specific” for your patient. These templates often include small boxes or fields you can click or check. This greatly reduces the time it takes to complete.
• Care plans are often completed and stored electronically in many medical settings. However, they are also sometimes printed on templates.

How to Create a Nursing Care Plan: The Process of Developing a Care Plan

If you want to view a video tutorial on how to construct a care plan in nursing school, please view the video below. Otherwise, keep reading to learn the basics of how to complete a care plan in nursing school.

• The first process in completing a care plan is the patient assessment. A nurse should review the patient’s medical history, diagnosis, lab values, medications, and familiarize themselves with the patient. This information is critical to creating an effective and accurate care plan.
• The nurse should then create a main focus for the patient’s treatment. Nurses often use the “A, B, C’s” (airway, breathing, and circulation) during this focus.  Your focus should come from the NANDA Nursing Diagnosis text.
• The nurse should then locate the focus in the NANDA book to help develop the “related to” and “as evidenced by” part of the nursing diagnosis statement.
• The nurse should select some outcomes and interventions based on the nursing diagnosis. At least 3 outcomes should be selected for the patient. Outcomes need to be measurable, patient specific, and have a definite time-frame.
• Intervention should also be measurable, patient-specific, and have parameters. The intervention should correlate with the outcomes. Often times, it is easier to develop the outcomes before the interventions.
• Review the care plan to make sure all of the information is correct.
• Implement the care plan into the nursing actions to provide care for the patient.
• Re-evaluate the care plan as treatment continues. Make any revisions if necessary if the patient’s condition improves or worsens.

What Do Care Plans Look Like in Nursing School?

The care plans given in nursing school are often on a blank sheet of paper with grid-lines for each focus, treatment, and outcome. Nursing students must then manually complete each field using a very comprehensive set of terms and goals. Sometimes, nursing students are intimidated by the care plan process, and often feel overwhelmed when faced with their first care plan. However, they should keep in mind that many nursing students feel this way, and they will become much easier to complete over time.

It is important to note that often times, nursing care plans can have a slightly different appearance. The exact design or appearance of the care plan can vary from school to school. In addition, many hospitals or medical centers adopt their own unique care plan versions. So each basic care plan design can be totally different from another.

An example picture of a basic blank care plan can be found below:

*Disclosure: The items recommended in this article are recommendations based on our own honest personal opinion and experience. We are an affiliate with Amazon.com, and when you buy the products recommended by us, you help support this site.

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How to write a well-written care plan in home health and hospice

Debbie goings.

• June 11, 2024
• Home health :: Hospice ::

How to write a well-written care plan

Staffing shortages in home health and hospice can lead to incomplete or inaccurate care plans due to limited resources and time. With less staff available, crucial aspects of a patient’s condition may be overlooked or under-addressed, which can result in errors or omissions in the patient care plan. Ultimately, this can keep patients from meeting their goals, reduce or delay reimbursements and cause more work for already overburdened staff.

In this blog, we explore the anatomy of a well-written care plan, why it supports  patient-centered care , and how MatrixCare simplifies the process.

What is a care plan?

A well-crafted care plan in home health and hospice is a comprehensive and individualized roadmap that outlines the specific treatments and support services needed to address the patients’ needs while receiving care at home. The patient care plan directly addresses the needs of the patient, family or caregiver and enables staff to provide the best services and environment for patients and families to meet their goals while receiving home health or hospice.

Patient care plans are working documents and need to be flexible based on patient progress or incidences. This approach helps to ensure patient-centered care is a priority.

What are the must-haves of a well-written care plan?

• Guide care and provide a roadmap for the patient.

A well-crafted care plan establishes individualized goals and objectives where staff can measure the effectiveness of care and record evidence that the physician’s orders were followed. Moreover, by outlining specific interventions, treatments, and support services tailored to individual needs, it ensures consistency and continuity of care delivery.

This approach guarantees consistent care and also motivates patients to participate in their own recovery process, which can lead to better outcomes and improved patient satisfaction.

• Show collaboration across disciplines.

Seamless communication between disciplines is critical to patient-centered care. The care plan helps to ensure patients will receive quality care regardless of which staff members provide it. This is important to consider, as agencies often have staff cover for each other during sick days or vacation.

Ultimately, a well-structured care plan promotes synergy among diverse disciplines, enriching the patient’s journey toward comfort, dignity, and wellbeing.

• Justify and support the need for services.

In home health and hospice, a patient care plan is not just a roadmap for treatment; it is justification for the essentiality of services. By documenting the patient’s clinical condition, functional limitations, and care requirements, the plan establishes a clear rationale for the services. It outlines measurable goals and identifies specific interventions tailored to the patient’s needs, emphasizing the necessity of care.

• Identify the skilled interventions needed for the patient.

Clinicians should be able to determine what exactly needs to be done based on the care plan.

• Include patient, caregiver, and family participation.

A comprehensive care plan in home health should prioritize patient, caregiver and family participation to ensure personalized and effective care. By actively involving them in the decision-making process, the plan becomes more patient-centered and responsive to individual needs and preferences.

Patient and family input helps identify goals, preferences, and challenges, fostering a sense of ownership and empowerment in the care journey. Moreover, their insights provide valuable context for caregivers, enhancing understanding and empathy.

Through regular communication and collaboration, the care plan becomes a shared roadmap, promoting trust, cooperation, and ultimately, better health outcomes for the patient within the comfort of their home.

How does MatrixCare support a well-written care plan?

MatrixCare offers a robust library of interventions and goals, as well as the ability to create agency-defined care plans.

Clinicians document in the patient care plan based on their assessment. If the clinician documents in the visit note something that is not part of the care plan, MatrixCare will make suggestions for new interventions.

More benefits of a MatrixCare-supported care plan include:

• Historical information at your fingertips
• Designed to help meet regulatory requirements
• Speech-enabled documentation at the point of care
• Secure, real-time messaging with care teams, partners, patients, and family caregivers
• Ready access to nationwide networks allowing bi-directional clinical information

Ready to take your care plans to the next level? Connect with us today and we’ll show you how.

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With 25 years in nursing and 15 years in post-acute care, Debbie Goings understands the pain points faced by providers and those they employ. From working for a large home health agency as a case manager, coder, OASIS specialist and Director of Compliance, to being a home health and hospice surveyor and legal nurse consultant, Debbie has experienced every angle of this industry. Her experience has fostered her passion for staff to have more time to care and interact with the patient and family — all while maintaining compliance with an EMR that will provide the clinician the ability to maintain requirements.

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Nursing Care Plans: An Introduction

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What is a Nursing Care Plan?

A nursing care plan is a road map for the care of a patient and a necessary tool in following the nursing process. Understanding nursing care plans is an important part of any nursing school curriculum and definitely something you’ll need to know as a nursing student. 

In this guide, you’ll learn how to write and use a nursing care plan and why they’re important for maintaining quality patient care.

Why are Care Plans Important?

Care plans play a vital role in the treatment of a patient. They clearly define guidelines along with the nurse’s role in patient care and help them create and achieve a solid plan of action. This equips nurses to provide focused care—without overlooking important steps.

Nursing care plans also promote:

Collaboration

• A well-documented care plan ensures the patient’s entire care team (doctors, nurses, etc.) can access the same information, give input, and join forces to provide the best care possible.
• Care plans help nurses uphold the nursing code of ethics and provide a record that they did so in case of lawsuits or accusations that they failed to adhere to care standards.
• A care plan is a communication tool for patient care between nurses. When nurses change shifts they’re able to reference the patient’s care plan to ensure the same quality care and interventions are being executed.

Without nursing care plans, nursing staff might have to rely on verbal communication and patient information could become more easily scattered or lost, all of which could result in improper patient care .

How to Write a Nursing Care Plan

Nursing care plans follow a five-step process: assessment, diagnosis, outcomes, implementation, and evaluation.

Assess the patient.

The first step to writing a care plan is performing a patient assessment. This includes reviewing your patient’s medical history, diagnosis, lab values, and medications. This step is critical to creating an effective and accurate care plan for either short term or long term care.

Make a diagnosis.

Nursing diagnoses differs from a medical diagnosis in that it’s based on the patient’s response to an illness, rather than the illness itself. Simply put, a nursing diagnosis is focused on patient care rather than treatment.

According to NANDA (North American Nursing Diagnosis Association), a good nursing care plan should not only list each diagnosis but define it as well. For example, acid reflux should be described as: "Ineffective airway clearance related to gastroesophageal reflux as evidenced by retching, upper airway congestion, and persistent coughing.”

Set goals and outcomes.

Once you’ve completed an assessment and diagnosis, it’s time to write down goals and a desired health care outcomes for your patient. These describe what you hope to achieve in the short- and long-term future, provide direction for planning interventions, and serve as criteria for evaluating progress. Goals are documented in the patient’s care plan so that other nurses and health professionals caring for the patient have access to it.

Determine nursing interventions.

At this point in the care plan, you’ll list all planned nursing interventions and document any that you’ve performed. You’ll write down things such as client responses to care, pain scale responses, medications given and their dosages, vital signs, etc. This communicates what nursing orders were implemented, what still needs to be done, and if the patient is ready to be discharged.

Evaluate the plan.

Evaluation is necessary in a patient care plan to determine whether to continue, adjust, or terminate the plan of care. It measures the degree to which goals and outcomes are achieved and provides evidence for what factors positively or negatively impacted those goals.

How to Use a Nursing Care Plan

Registered nurses and nurse practitioners use these plans in the nursing process as a road map for providing care. They’re also a tool to help nurses think critically and holistically to support the patient’s needs—physically, socially, spiritually, and psychosocially. Only RNs can develop the care plan and make changes, although LPNs can contribute suggestions.

A nursing care plan begins as soon as a patient is admitted and is updated frequently as their condition changes or after an evaluation. It’s an ongoing process that requires detailed, accurate documentation that strictly adheres to the nursing code of ethics , as well as HIPAA rules and regulations .

Knowing how to write and implement a nursing care plan is one essential skill you’ll need as a nurse or nurse practitioner . With a degree in nursing , you’ll gain this valuable experience—and the tools to provide the best patient care possible.

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HEALTH & NURSING

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