Nursing Care Plan: Guide, Template, & Examples -NurseMyGrade (2024)

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:

1. To promote the use of evidence-based practices in nursing care to address different healthcare needs of the patients
2. Holistically caring for patients in recognition of the nursing metaparadigm (health, people, environment, and nursing)
3. Enabling nursing teal collaboration through information sharing and collaborative decision-making
4. Measuring the effectiveness of care and documenting the nursing process for care efficiency and compliance
5. Offering patient-centered or individualized care to improve outcomes
6. Identifying the unique roles of nurses in attending to the needs of the patient without constant consultation with physicians
7. Allowing for continuity of care by allowing nurses from different shifts to render quality interventions to patients optimizes care outcomes.
8. Guide for delegating duties and assigning specific staff to a patient, especially in cases of specialized care.
9. 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:

• Assessment
• Diagnosis
• Expected outcomes
• Interventions
• Evaluations

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

1. 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.
2. 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.
3. 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.
4. 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.
5. 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.

1. The care plan must answer the questions of what, why, and how.
2. A successful care plan uses the fundamental aspects of critical thinking to come up with a patient-centered approach to care
3. Follows evidence-based practice guidelines when developing interventions or explaining the rationale for actions
4. Has SMART goals for the patients
5. Allows for effective communication
6. 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.
7. 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:

1. 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.
2. 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.
3. Health Promotion or wellness diagnosis is a clinical judgment about the desire and motivation to increase well-being or reach one's health potential.
4. 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)

Evaluation

• 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.

References

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.

Final Note

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.

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