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.
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.
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:
A well-written nursing care plan must have specific components. The main components of a nursing care plan (NCP) are:
Let's elaborate on these five main components of a 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.
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.
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:
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:
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.
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:
Examples of goals and outcomes
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:
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:
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.
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:
|Nursing Diagnosis||Goal/Expected Measurable Outcomes||Nursing Interventions||Underlying Scientific Principles of Nursing (Rationale)||Evaluation|
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.
Nursing Diagnosis: Ineffective coping skills and risk for hematologic side effects of Clozapine
Goals and expected outcomes
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.
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