Confused about writing nursing care plans?
Don’t be—we’ve got you covered!
Forget spending hours crafting the perfect plan. With our nifty guide, you can go from care plan novice to master in just a few simple steps.
A nursing care plan (NCP) is more than just admin. It is the cornerstone of clinical excellence, allowing you to treat patients effectively, ensure continuity of care, and maintain legal accountability.
Sounds daunting? It doesn’t need to be.
Writing a good NCP is within your grasp. Read on to find out how.
Let’s break it down: What is a nursing care plan?
An NCP is a formal guide describing the goals, interventions, and actions a nurse uses to treat a patient. Registered nurses (RNs), licensed practical nurses (LPNs), and nursing students all use NCPs.
But wait, what does an NCP include?
Your NCP needs these 5 key elements:
- Assessment
- Nursing diagnosis
- Projected outcomes (goals)
- Nursing interventions
- Observations & evaluations
Below, we’ll cover each element in detail so you can write a rock-solid care plan.
Top tips: How to write a nursing care plan?
Want to craft a comprehensive NCP without all the blood, sweat, and tears? It’s as easy as following these 5 steps:
1. Patient assessment
Without a thorough patient assessment, there can be no care plan. So what data do you need to record during your head-to-toe assessment?
Be objective
Objective data is measurable and observable information, such as vital signs, lab results, physical examination findings, and I&O totals.
Example: "Blood pressure 148/92 mmHg, 2+ pitting edema in bilateral lower extremities."
But let’s not forget the subjective…
Subjective data is shared by the patient or family and reflects their feelings, perceptions, symptoms, and psychosocial and emotional status.
Example: "Patient states, 'My chest feels tight, and I can't catch my breath when I walk to the bathroom.'"
2. Nursing diagnosis
The North American Nursing Diagnosis Association (NANDA) defines a nursing diagnosis as a clinical judgment about an individual, family, or community’s response to actual or potential health problems or life processes.
A nursing diagnosis is not a medical diagnosis (e.g., "pneumonia"); it is a statement about the patient’s response to the condition (e.g., "ineffective airway clearance").
A common format for a nursing diagnosis is the three-part "PES" statement:
- Problem
- Etiology
- Signs and symptoms
Think: Problem related to etiology as evidenced by symptoms.
Example phrase: "Ineffective airway clearance related to increased tracheobronchial secretions as evidenced by diminished breath sounds and a persistent, non-productive cough."
3. Projected outcomes: Make your nursing care plans SMART
You’ve got your diagnosis, so now what?
Is your patient outcome short-term (symptom improvement within a few hours) or long-term (permanent behavioral shift)?
- A short-term SMART goal might be: "The patient will report a pain level of 3 or less on a 0-10 scale within 1 hour of receiving prescribed pain medication."
- A long-term SMART goal would look like: "The patient will report a sustained pain level of 2/10 or less during physical therapy sessions by the day of discharge (approx. 5 days)."
4. Nursing interventions
Interventions are the actions you will take to treat your patient. Your interventions should be evidence-based and directly address the etiology (the "related to" factor) of the nursing diagnosis.
Interventions might be immediate actions or longer-term patient education and advocacy.
- Immediate intervention example: "Administer prescribed oral opioid pain medication (Oxycodone 5mg) every 4 hours PRN for pain > 3/10."
- Long-term intervention example: "Educate patient and family on non-pharmacological pain management techniques, including deep breathing and guided imagery, prior to discharge."
Here is an example of the standardized nursing language used in Nursing Interventions Classification (NIC):
- Pain management: Perform a comprehensive assessment of pain, including location, characteristics, onset/duration, frequency, quality, intensity/severity, and precipitating factors.
5. Observations and evaluations
Did your patient meet their goal?
If they did, great! If not, what are you going to change in your nursing care plan so that they achieve it next time?
Modifications might look like:
- Changing the intervention
- Revising the goal
- Modifying the nursing diagnosis
Making your NCP evaluation clear and detailed is critical to ensure smooth handovers and continuity of care.
- Example evaluation: "Goal met: Patient reported pain as 2/10 at 10:00, 1 hour after medication administration. Plan continues with PRN pain management."
- Example evaluation (revision): "Goal partially met: Patient's pain remains 5/10 after 2 doses of oral pain medication. Notified provider for an order to switch to IV analgesia."
Still confused? Here’s a full example to simplify things
Here is an example of how all 5 components come together for a patient experiencing acute pain after surgery:
What are the different types of nursing care plans?
We’ve got most of our bases covered, but now let’s consider different types of NCPs.
- Informal: An informal plan is a strategy for care that exists only in the nurse’s mind and has not been formally documented.
- Formal: A formal plan is a written or computerized document that systematically organizes and coordinates all information regarding a patient’s care.
- Standardized: A standardized plan is a pre-determined framework that specifies the common care needs for a specific group of patients with similar conditions.
- Individualized: An individualized plan is a personalized document tailored to a single patient’s unique needs, created by modifying a standardized plan or starting from scratch.
Standardized vs. personalized plans
Wondering about the difference between a standardized and personalized plan?
This table will clear it up for you:
A personalized care plan takes a patient-centered approach to treatment planning, taking into account a patient’s:
- Physical symptoms and objective data
- Emotional and psychological status
- Social support systems and home environment
- Cultural values, beliefs, and practices
- Personal lifestyle, preferences, and core values
Practical nursing care plan examples
While every patient is unique, certain common conditions require specific diagnostic and goal-setting skills. Here are a few examples to help you start thinking practically.
Post-operative pain
The diagnosis would be acute pain related to surgical incision as evidenced by a pain score > 6/10.
The goal would be for the patient to report adequate pain control (pain 3/10 or less) with activity by the second post-operative day.
Risk for infection
The diagnosis would be risk for infection related to compromised primary defenses (surgical incision) and invasive lines (IV access).
The goal is for the patient to remain free of signs and symptoms of infection (temperature < 100.4°F, clear wound drainage) throughout the hospital stay.
Heart failure exacerbation
The diagnosis would be excess fluid volume related to compromised regulatory mechanisms (decreased cardiac output) as evidenced by 3+ pitting edema and crackles in the lung bases.
The goal is for the patient to demonstrate a 2lb weight loss per week until edema resolves and for lung sounds to be clear within 72 hours.
Why are nursing care plans important?
NCPs aren’t just an academic test to pass; they are vital for success and patient safety out in the real clinical world!
Nail your NCPs, and you’ll be checking boxes across the board:
- Improved patient outcomes: NCPs provide a systematic, goal-oriented approach to treatment, moving away from reactive, symptom-driven care.
- Continuity of care: As shifts change, the written NCP ensures that every member of the healthcare team is on the same page, providing consistent, effective care regardless of who is at the bedside.
- Legal accountability: The care plan documentation serves as evidence of the nursing process, demonstrating that the nurse used clinical judgment and followed through with appropriate interventions and evaluations.
- Effective communication: The plan clearly communicates the patient's needs, the nursing perspective, and the treatment strategy to other clinicians, ensuring a collaborative approach.
Your role in NCPs as a PRN nurse
In hospitals, NCPs are part of the electronic health record (EHR) and are standardized plans that you, the bedside nurse, must then individualize and implement.
As a practicing nurse, especially in a flexible role like a per diem nurse, your role with the NCP is crucial:
- Documenting interventions: You will document the specific actions you take (e.g., medication administration, patient teaching, repositioning) directly into the plan.
- Evaluating progress: You are responsible for evaluating the patient’s status against the short-term goals during your shift. Did your intervention work? Did the pain medication achieve a 3/10 pain score? This assessment informs the next steps.
- Safe handoffs: Clear NCP documentation and a succinct summary of the patient's progress or lack thereof are essential for safe shift handoffs, particularly when you are coming onto a new unit. The care plan acts as your quick guide to the patient's needs and the existing treatment framework.
NCPs: The key ingredient for clinical success
Building strong nursing care plan skills translates to clinical excellence in your career.
NCPs are so much more than just administration. They are the hallmark of good patient care. In your journey from student to fully-fledged nurse, make mastering NCPs your priority, and you will fly high.
Ready to put your NCP skills to work?
Strong care planning sets you up for safe, independent nursing—whether you’re on your first clinical or picking up flexible PRN shifts through Nursa.
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