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.
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.
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.
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.
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
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.
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.
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.
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.”
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.
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.
Anything that didn’t match a specific category you’ll find here:
Alex Lukey is a registered nurse and researcher. Alex earned her bachelor's and master's degrees in nursing from the University of British Columbia Okanagan. She is now working on a Ph.D. in Public Health as a Killam Scholar at the University of British Columbia. Alex's research has spanned health policy, patient education, and oncology. She is currently working on ovarian cancer prevention using machine learning. Her clinical practice experience includes cardiology, cardiac surgery, and pediatric homecare. Alex is passionate about science communication and education.
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