Nursing Care Plan

What is a nursing care plan?
A nursing care plan (NCP) is a formal process that includes correctly identifying
existing needs, as well as recognizing potential needs or risks. Care plans also
provide a means of communication among nurses, their patients, and other
healthcare providers to achieve health care outcomes. Without the nursing care
planning process, quality and consistency in patient care would be lost.
Nursing care planning begins when the client is admitted to the agency and is
continuously updated throughout in response to client’s changes in condition
and evaluation of goal achievement. Planning and delivering individualized or
patient-centered care is the basis for excellence in nursing practice.
Types of Nursing Care Plans

Care plans can be informal or formal: Informal nursing care plan is a strategy of action that
exists in the nurse‘s mind. A formal nursing care plan is a written or computerized guide that
organizes information about the client’s care. Formal care plans are further subdivided into
standardized care plan, and individualized care plan: Standardized care plans specify the
nursing care for groups of clients with everyday needs. Individualized care plans are tailored to
meet the unique needs of a specific client or needs that are not addressed by the standardized
care plan.
Objectives
The following are the goals and objectives of writing a nursing care plan:
 Promote evidence-based nursing care and to render pleasant and familiar conditions in hospitals
or health centers.
 Support holistic care which involves the whole person including physical, psychological, social
and spiritual in relation to management and prevention of the disease.
 Establish programs such as care pathways and care bundles. Care pathways involve a team
effort in order to come to a consensus with regards to standards of care and expected outcomes
while care bundles are related to best practice with regards to care given for a specific disease.
 Identify and distinguish goals and expected outcome.
 Review communication and documentation of the care plan.
 Measure nursing care.
Purposes of a Nursing Care Plan
The following are the purposes and importance of writing a nursing care plan:
 Defines nurse’s role. It helps to identify the unique role of nurses in attending the overall health
and well-being of clients without having to rely entirely on a physician’s orders or interventions.
 Provides direction for individualized care of the client. It allows the nurse to think critically
about each client and to develop interventions that are directly tailored to the individual.
 Continuity of care. Nurses from different shifts or different floors can use the data to render the
same quality and type of interventions to care for clients, therefore allowing clients to receive
the most benefit from treatment.
 Documentation. It should accurately outline which observations to make, what nursing actions
to carry out, and what instructions the client or family members require. If nursing care is not
documented correctly in the care plan, there is no evidence the care was provided.
 Serves as guide for assigning a specific staff to a specific client. There are instances when
client’s care needs to be assigned to a staff with particular and precise skills.
 Serves as guide for reimbursement. The medical record is used by the insurance companies to
determine what they will pay in relation to the hospital care received by the client.
 Defines client’s goals. It does not only benefit nurses but also the clients by involving them in
their own treatment and care.
Components
A nursing care plan (NCP) usually includes nursing diagnoses, client problems, expected
outcomes, and nursing interventions and rationales. These components are elaborated below:
1. Client health assessment, medical results, and diagnostic reports. This is the first measure in
order to be able to design a care plan. In particular, client assessment is related to the following
areas and abilities: physical, emotional, sexual, psychosocial, cultural, spiritual/transpersonal,
cognitive, functional, age-related, economic and environmental. Information in this area can be
subjective and objective.
2. Expected client outcomes are outlined. These may be long and short term.
3. Nursing interventions are documented in the care plan.
4. Rationale for interventions in order to be evidence-based care.
5. Evaluation. This documents the outcome of nursing interventions.
Care Plan Formats

Nursing care plan formats are usually categorized or organized into four columns: (1) nursing
diagnoses, (2) desired outcomes and goals, (3) nursing interventions, and (4) evaluation. Some
agencies use a three-column plan wherein goals and evaluation are in the same column. Other
agencies have a five-column plan that includes a column for assessment cues.
3-column care
plan template
A 4-column care plan format

Below is a document containing sample templates for the different nursing care plan formats.
Please feel free to edit, modify, and share the template.
 Download: Nursing Care Plan Templates and Formats

Student Care Plans
Student care plans are more lengthy and detailed than care plans used by working nurses because
they are a learning activity for the students.
Student nursing care plans are more detailed
Care plans by student nurses are usually required to be handwritten and have an additional

column for “Rationale” or “Scientific Explanation” after the nursing interventions column.
Rationales are scientific principles that explains the reasons for selecting a particular nursing
interventions.
Writing a Nursing Care Plan

How do you write a nursing care plan (NCP)? Just follow the steps below to develop a care plan
for your client.
Step 1: Data Collection or Assessment

The first step in writing a nursing care plan is to create a client database using assessment
techniques and data collection methods (physical assessment, health history, interview, medical
records review, diagnostic studies). A client database includes all the health information
gathered. In this step, the nurse can identify the related or risk factors and defining
characteristics that can be used to formulate a nursing diagnosis. Some agencies or nursing
schools have their own assessment formats you can use.
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Step 2: Data Analysis and Organization

Now that you have information about the client’s health, analyze, cluster, and
organize the data to formulate your nursing diagnosis, priorities, and desired
outcomes.
Step 3: Formulating Your Nursing Diagnoses

NANDA nursing diagnoses are a uniform way of identifying, focusing on, and
dealing with specific client needs and responses to actual and high-risk
problems. Actual or potential health problems that can be prevented or resolved
by independent nursing intervention are termed nursing diagnoses. We’ve
detailed the steps on how to formulate your nursing diagnoses in this
guide: Nursing Diagnosis (NDx): Complete Guide and List for 2019
Step 4: Setting Priorities
Setting priorities is the process of establishing a preferential sequence for
address nursing diagnoses and interventions. In this step, the nurse and the client
begin planning which nursing diagnosis requires attention first. Diagnoses can be
ranked and grouped as to having a high, medium, or low priority. Life-
threatening problems should be given high priority.
Maslow’s hierarchy of needs is frequently used

when setting priorities.
Client’s health values and beliefs, client’s own priorities, resources available, and
urgency are some of the factors the nurse must consider when assigning
priorities. Involve the client in the process to enhance cooperation.
Step 5: Establishing Client Goals and Desired

Outcomes
After assigning priorities for your nursing diagnosis, the nurse and the client set
goals for each determined priority. Goals or desired outcomes describe what the
nurse hopes to achieve by implementing the nursing interventions and are
derived from the client’s nursing diagnoses. Goals provide direction for planning
interventions, serve as criteria for evaluating client progress, enable the client and
nurse to determine which problems have been resolved, and help motivate the
client and nurse by providing a sense of achievement.
Example of goals and desired outcomes. Notice how they’re formatted/written.
One overall goal is determined for each nursing diagnosis. The terms goal,
outcome, and expected outcome are oftentimes used interchangeably.
Short Term and Long Term Goals

Goals and expected outcomes must be measurable and client-centered. Goals
are constructed by focusing on problem prevention, resolution, and/or
rehabilitation. Goals can be short term or long term. In an acute care setting,
most goals are short-term since much of the nurse’s time is spent on the client’s
immediate needs. Long-term goals are often used for clients who have chronic
health problems or who live at home, in nursing homes, or extended care
facilities.
 Short-term goal – a statement distinguishing a shift in behavior that can

be completed immediately, usually within a few hours or days.
 Long-term goal – indicates an objective to be completed over a longer
period, usually over weeks or months.
 Discharge planning – involves naming long-term goals, therefore
promoting continued restorative care and problem resolution through
home health, physical therapy, or various other referral sources.
Components of Goals and Desired Outcomes
Goals or desired outcome statements usually have the four components: a
subject, a verb, conditions or modifiers, and criterion of desired performance.
Components of goals and desired outcomes in a nursing care plan.
 Subject. The subject is the client, any part of the client, or some attribute
of the client (i.e., pulse, temperature, urinary output). That subject is often
omitted in writing goals because it is assumed that the subject is the client
unless indicated otherwise (family, significant other).
 Verb. The verb specifies an action the client is to perform, for example,
what the client is to do, learn, or experience.
 Conditions or modifiers. These are the “what, when, where, or how” that
are added to the verb to explain the circumstances under which the
behavior is to be performed.
 Criterion of desired performance. The criterion indicates the standard by
which a performance is evaluated or the level at which the client will
perform the specified behavior. These are optional.
When writing goals and desired outcomes, the nurse should follow these
tips:
1. Write goals and outcomes in terms of client responses and not as activities
of the nurse. Begin each goal with “Client will […]” help focus the goal on
client behavior and responses.
2. Avoid writing goals on what the nurse hopes to accomplish, and focus on
what the client will do.
3. Use observable, measurable terms for outcomes. Avoid using vague words
that require interpretation or judgment of the observer.
4. Desired outcomes should be realistic for the client’s resources, capabilities,
limitations, and on the designated time span of care.
5. Ensure that goals are compatible with the therapies of other professionals.
6. Ensure that each goal is derived from only one nursing diagnosis. Keeping
it this way facilitates evaluation of care by ensuring that planned nursing
interventions are clearly related to the diagnosis set.
7. Lastly, make sure that the client considers the goals important and values
them to ensure cooperation.
Step 6: Selecting Nursing Interventions

Nursing interventions are activities or actions that a nurse performs to achieve
client goals. Interventions chosen should focus on eliminating or reducing the
etiology of the nursing diagnosis. As for risk nursing diagnoses, interventions
should focus on reducing the client’s risk factors. In this step, nursing
interventions are identified and written during the planning step of the nursing
process; however, they are actually performed during the implementation step.
Types of Nursing Interventions

Nursing interventions can be independent, dependent, or collaborative:
Types of nursing interventions in a care plan.
 Independent nursing interventions are activities that nurses are licensed

to initiate based on their sound judgement and skills. Includes: ongoing
assessment, emotional support, providing comfort, teaching, physical care,
and making referrals to other health care professionals.
 Dependent nursing interventions are activities carried out under the
physician’s orders or supervision. Includes orders to direct the nurse to
provide medications, intravenous therapy, diagnostic tests, treatments,
diet, and activity or rest. Assessment and providing explanation while
administering medical orders are also part of the dependent nursing
interventions.
 Collaborative interventions are actions that the nurse carries out in
collaboration with other health team members, such as physicians, social
workers, dietitians, and therapists. These actions are developed in
consultation with other health care professionals to gain their professional
viewpoint.
Nursing interventions should be:
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Nursing Care Plan

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What is a nursing care plan?

Types of Nursing Care Plans

Care Plan Formats

A 4-column care plan format

 Download: Nursing Care Plan Templates and Formats

Care plans by student nurses are usually required to be handwritten and have an additional

Writing a Nursing Care Plan

Step 1: Data Collection or Assessment

Step 2: Data Analysis and Organization

Step 3: Formulating Your Nursing Diagnoses

Maslow’s hierarchy of needs is frequently used

Step 5: Establishing Client Goals and Desired

Short Term and Long Term Goals

 Short-term goal – a statement distinguishing a shift in behavior that can

Components of goals and desired outcomes in a nursing care plan.

Step 6: Selecting Nursing Interventions

Types of Nursing Interventions

 Independent nursing interventions are activities that nurses are licensed

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