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Northeastern College- College of Nursing

ENRIQUEZ R. CAYABAN, RN, LPT, MAN (Clinical Intructor)

NURSING CARE PLANS: Ultimate Guide and Database

Writing the best nursing care plan requires a step-by-step approach to correctly
complete the parts needed for a care plan.
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 PLAN
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.
PURPOSE OF 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.

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Northeastern College- College of Nursing
ENRIQUEZ R. CAYABAN, RN, LPT, MAN (Clinical Intructor)

 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.

NURSING CARE PROCESS- Developing A Nursing Care Plan

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Northeastern College- College of Nursing
ENRIQUEZ R. CAYABAN, RN, LPT, MAN (Clinical Intructor)

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.

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Northeastern College- College of Nursing
ENRIQUEZ R. CAYABAN, RN, LPT, MAN (Clinical Intructor)

WRITING NURSING CARE PLANS

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, and 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.
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.
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.

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Northeastern College- College of Nursing
ENRIQUEZ R. CAYABAN, RN, LPT, MAN (Clinical Intructor)

Maslow's Hierarchy of Needs for Setting Priorities in NCP

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.

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

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Northeastern College- College of Nursing
ENRIQUEZ R. CAYABAN, RN, LPT, MAN (Clinical Intructor)

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.

 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.

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Northeastern College- College of Nursing
ENRIQUEZ R. CAYABAN, RN, LPT, MAN (Clinical Intructor)

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:

 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.

NURSING CARE PROCESS- Developing A Nursing Care Plan

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Northeastern College- College of Nursing
ENRIQUEZ R. CAYABAN, RN, LPT, MAN (Clinical Intructor)

 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.
Safe and appropriate for the client’s age, health, and condition.
 Achievable with the resources and time available.
 Inline with the client’s values, culture, and beliefs.
 Inline with other therapies.
 Based on nursing knowledge and experience or knowledge from relevant
sciences.
When writing nursing interventions, follow these tips:
1. Write the date and sign the plan. The date the plan is written is essential for evaluation,
review, and future planning. The nurse’s signature demonstrates accountability.
2. Nursing interventions should be specific and clearly stated, beginning with an action
verb indicating what the nurse is expected to do. Action verb starts the intervention
and must be precise. Qualifiers of how, when, where, time, frequency, and amount
provide the content of the planned activity. For example: “Educate parents on how to
take temperature and notify of any changes,” or “Assess urine for color, amount, odor,
and turbidity.”
3. Use only abbreviations accepted by the institution.
Step 7: Providing Rationale
Rationales, also known as scientific explanation, are the underlying reasons for
which the nursing intervention was chosen for the NCP.

Rationales do not appear in regular care plans, they are included to assist nursing
students in associating the pathophysiological and psychological principles with the
selected nursing intervention.

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Northeastern College- College of Nursing
ENRIQUEZ R. CAYABAN, RN, LPT, MAN (Clinical Intructor)

Step 8: Evaluation
Evaluating is a planned, ongoing, purposeful activity in which the client’s progress
towards the achievement of goals or desired outcomes, and the effectiveness of the
nursing care plan (NCP). Evaluation is an important aspect of the nursing process
because conclusions drawn from this step determine whether the nursing intervention
should be terminated, continued, or changed.
Step 9: Putting it on Paper
The client’s NCP is documented according to hospital policy and becomes part of
the client’s permanent medical record which may be reviewed by the oncoming nurse.
Different nursing programs have different care plan formats, most are designed so that
the student systematically proceeds through the interrelated steps of the nursing process,
and many use a five-column format.
REFERENCE
Vera, Matt (2020). Nursing Care Plans (NCP): Ultimate Guide and Database.
Accessed on September 15, 2020. Available at https://nurseslabs.com/nursing-care-
plans/#:~:text=A%20nursing%20care%20plan%20(NCP)%20is%20a%20formal%20pro
cess%20that,to%20achieve%20health%20care%20outcomes.

NURSING CARE PROCESS- Developing A Nursing Care Plan

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