Nursing Care Plan: Prepared By: Janida Asjada

NURSING CARE
PLAN
P R E PA R E D B Y:
JANIDA ASJADA
WHAT IS NURSING CARE PLAN?
• 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.
TYPES OF NURSING CARE PLAN
1. INFORMAL NURSING CARE PLAN
is a strategy of action that exists in the
nurse‘s mind.
2. FORMAL NURSING CARE PLAN
is a written or computerized guide that
organizes information about the client’s care.
Types of FORMAL NCP:
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:
•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 which 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.
PURPOSES:
• 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.
•Defines client’s goals
It does not only benefit nurses but also
the clients by involving them in their
own treatment and care.
COMPONENTS
1. ASSESSMENT
 This is the first measure in order to be able to
design a care plan.
 can be subjective and objective.
 physical assessment, health history,
interview, medical records review, diagnostic
studies
2. NURSING DIAGNOSIS
identifying, focusing on, and dealing with
specific client needs and responses to actual and
high-risk problems.
3. PLANNING
• This may short or long term.
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.
• describe what the nurse hopes to achieve by
implementing the nursing interventions and are
derived from the client’s nursing diagnoses.
4. NURSING INTERVENTION
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.
TYPES:
Independent nursing interventions
activities that nurses are licensed to initiate based on
their sound judgement and skills.
Eg. ongoing assessment, emotional support, providing
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.
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.
5. EVALUATION
This documents the outcome of nursing
interventions.
is planned, ongoing, purposeful activity in
which client’s progress towards the
achievement of goals, desired outcomes and
effectivenss of ncp.

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NURSING CARE

•Promote evidence-based nursing

Includes orders to direct the nurse to

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