Care plans are a way to strategically approach and streamline the nursing process. They also enable effective communication in a nursing team. This guide will help you understand the fundamentals of nursing care plans and how to create them, step by step. We’ll also outline best practices to keep in mind and provide you with a nursing care plan sample that you can download and print.
Table of Contents
- What Is a Nursing Care Plan?
- What Are the Components of a Care Plan?
- Care Plan Fundamentals
- Sample Nursing Care Plan
What Is a Nursing Care Plan?
A nursing care plan documents the process of identifying a patient’s needs and facilitating holistic care, typically according to a five-step framework. A care plan ensures collaboration among nurses, patients, and other healthcare providers. ((M. Vera., “Nursing Care Plans (NCP): Ultimate Guide and Database”, July 5, 2021: https://nurseslabs.com/nursing-care-plans/)) ((Medical Dictionary for the Health Professions and Nursing, Farlex, “nursing care plan”, 2012: https://medical-dictionary.thefreedictionary.com/nursing+care+plan)) ((Health Navigator, “Care planning”, April 6, 2021: https://www.healthnavigator.org.nz/clinicians/c/care-planning/)) ((Tammy J. Toney-Butler and Jennifer M. Thayer, “Nursing Process,” StatsPearls, July 10, 2020: https://www.ncbi.nlm.nih.gov/books/NBK499937/))
Key Reasons to Have a Care Plan
The purpose of a nursing care plan is to document the patient’s needs and wants, as well as the nursing interventions (or implementations) planned to meet these needs. As part of the patient’s health record, the care plan is used to establish continuity of care. ((C. Björvell et al., “Development of an audit instrument for nursing care plans in the patient record,” Quality in Health Care, March 1, 2000: https://qualitysafety.bmj.com/content/qhc/9/1/6.full.pdf)) These are the main reasons to write a care plan:
- Patient-centered care
A care plan helps nurses and other care team members organize aspects of patient care according to a timeline. It’s also a tool for them to think critically and holistically in a way that supports the patient’s physical, psychological, social, and spiritual care. Sometimes a patient should be assigned to a nurse with specific skills and experience; a care plan makes that process easier. For patients, having clear goals to achieve will make them more involved in their treatment and recovery. ((Health Navigator, “Care planning”, April 6, 2021: https://www.healthnavigator.org.nz/clinicians/c/care-planning/))
- Nursing team collaboration
Writing a care plan allows a team of nurses (as well as physicians, assistants, and other care providers) to access the same information, share opinions, and collaborate to provide the best possible care for the patient.
- Documentation and compliance
A well-written care plan allows nurses to measure the effectiveness of care and to record evidence that the care was given. This is important both to maximize care efficiency and to provide documentation for healthcare providers.
What Are the Components of a Care Plan?
Care plans are structured as a five-step framework: assessment, diagnosis, outcomes and planning, implementation, and evaluation. ((Tammy J. Toney-Butler and Jennifer M. Thayer, “Nursing Process,” StatsPearls, July 10, 2020: https://www.ncbi.nlm.nih.gov/books/NBK499937/))
Step 1: Assessment
The first step of writing a care plan requires critical thinking skills and data collection. Different healthcare organizations use different formats for the assessment phase. In general, the data you will collect here is both subjective (e.g., verbal statements) and objective (e.g., height and weight, intake/output). The source of the subjective data could be the patients or their caretakers, family members, or friends.
Nurses can gather data about the patient’s vital signs, physical complaints, visible body conditions, medical history, and current neurological functioning. Digital health records may help in the assessment process by populating some of this information automatically from previous records.
Step 2: Diagnosis
Using the collected data, you will develop a nursing diagnosis—which the North American Nursing Diagnosis Association (NANDA) defines as “a clinical judgment about the human response to health conditions/life processes, or a vulnerability for that response, by an individual, family, group or community.” ((NANDA, “Glossary of Terms”: https://nanda.org/publications-resources/resources/glossary-of-terms/))
A nursing diagnosis sets the basis for choosing nursing actions to achieve specific outcomes. A nursing diagnosis is based on Maslow’s Hierarchy of Needs pyramid ((Saul McLeod, “Maslow’s Hierarchy of Needs,” Simply Psychology, Dec. 29, 2020: https://www.simplypsychology.org/maslow.html)) (which identifies and ranks human needs) and helps prioritize treatments. For example, physiological needs (such as food, water, and sleep) are more fundamental to survival than love and belonging, self-esteem, and self-actualization, so they have the priority when it comes to nursing actions. ((Chiung-Yu Shih et al, “The association of sociodemographic factors and needs of haemodialysis patients according to Maslow’s hierarchy of needs,” Journal of Clinical Nursing, July 30, 2018: https://pubmed.ncbi.nlm.nih.gov/29777561/))
Based on the diagnosis, you’ll set goals (Step 3) to resolve the patient’s problems through nursing implementations (Step 4).
Step 3: Outcomes and Planning
After the diagnosis is the planning stage. Here, you will prepare SMART goals (more detail on this later) based on evidence-based practice (EBP) guidelines. You will consider the patient’s overall condition, along with their diagnosis and other relevant information, as you set goals for them to achieve desired and realistic health outcomes for the short and long term.
Step 4: Implementation
Once you’ve set goals for the patient, it’s time to implement the actions that will support the patient in achieving these goals. The implementation stage consists of performing the nursing interventions outlined in the care plan. As a nurse, you will either follow doctors’ orders for nursing interventions or develop them yourself using evidence-based practice guidelines.
Interventions are classified into the following seven domains: family, behavioral, physiological, complex physiological, community, safety, and health system interventions. There are several basic interventions that you need to implement during each shift: pain assessment, changing the resting position, listening, cluster care, preventing falls, and fluid consumption.
Step 5: Evaluation
In the final step of a care plan, the health professional (who can be either a doctor or a nurse) will evaluate whether the desired outcome has been met. You will then adjust the care plan based on this information.
Care Plan Fundamentals
In a simple but useful way, Nurse.org explains the core questions your care plan should answer: what, why, and how. ((Mariam Yazdi, “4 Steps to Writing a Nursing Care Plan,” Nurse.org, March 23, 2018: https://nurse.org/articles/nursing-care-plan-how-to/)) A nursing care plan should include:
- The What: What does the patient suffer from? What do they risk suffering from?
- The Why: Why does your patient suffer from this? Why do they risk suffering from this?
- The How: How can you make this better?
Successful care plans use the fundamental principles of critical thinking, client-centered techniques, goal-oriented strategies, evidence-based practice (EBP) recommendations, and nursing intuition. ((Tammy J. Toney-Butler and Jennifer M. Thayer, “Nursing Process,” StatsPearls, July 10, 2020: https://www.ncbi.nlm.nih.gov/books/NBK499937/))
In the planning phase of writing a care plan, it’s important that you use goal-oriented strategies. A SMART goals template can help in this process:
- Specific: Your goals for the patient must be well-defined and unambiguous.
- Measurable: You need to set certain metrics to measure the patient’s progress toward these goals.
- Achievable: Their goal should be possible to achieve.
- Realistic: Their goals must be within reach and relevant to the overall care plan.
- Time-bound: The patient’s goals should have a clear starting time and end date (which can be flexible).
Unless your care plan is communicated effectively to all relevant stakeholders, it will only be a plan. Remember that the purpose of a nursing care plan is not to be a static document, but to guide the entire nursing process and enable teamwork, with the goal of improving care. Writing skills are crucially important for nurses—you’ll need to be as accurate and current as possible in your descriptions. For effective communication, keep in mind the following best practices when writing a care plan:
- Write down everything immediately so you don’t forget the details.
- Write clearly and concisely, using terms that your team will understand.
- Include dates and times.
Although you will learn communication skills in an undergraduate or graduate nursing program, you will also develop them over time and with practical experience. ((TigerConnect, “How to Develop a Nursing Care Plan for Your Hospital”: https://tigerconnect.com/blog/how-to-develop-a-nursing-care-plan-for-your-hospital/))
Shareable and Easy to Access
Care plans also need to be easy to share with the relevant stakeholders—patients, doctors, other members of the nursing team, insurance companies, etc. The documentation format will vary according to hospital policy, but, in general, care plans are created in electronic format and integrated into the electronic health record (EHR) for easy access to everyone. ((TigerConnect, “How to Develop a Nursing Care Plan for Your Hospital”: https://tigerconnect.com/blog/how-to-develop-a-nursing-care-plan-for-your-hospital/))
Up to date
Finally, you will need to update your care plans often with the latest information. That implies checking in with patients frequently and recording data about how the patient is progressing toward their goals, which will be important in the evaluation stage of the care plan. ((TigerConnect, “How to Develop a Nursing Care Plan for Your Hospital”: https://tigerconnect.com/blog/how-to-develop-a-nursing-care-plan-for-your-hospital/))
Sample Nursing Care Plan
Despite the overall general objective, nursing care plans written by students are not the same as those created by registered nurses in clinical settings. The student version is much longer, has a greater level of detail, and is exhaustively thorough. On the other hand, nurses often assume some basic concepts and note some of the steps in the care plan only mentally. ((M. Vera., “Nursing Care Plans (NCP): Ultimate Guide and Database”, July 5, 2021: https://nurseslabs.com/nursing-care-plans/))
For example, in the interventions section, a student would write: “vital signs recorded every four hours: blood pressure, heart rate, three- or five-lead electrocardiograms, functional oxygen saturation, respiratory rate, and skin temperature,” while an experienced registered nurse might just write “Q4 vital signs.”
Why this difference? As a student or recent graduate, including all the information in your care plan will help you solidify your training. While writing care plans in school can be a very time-consuming task, mastering this information in nursing school will improve your competency and confidence. Most of the information that you’ll have to look up while you’re still in school will become second nature in the future. Here’s what a care plan written by a student looks like:
- Assessment: “heart rate 100 bpm, dyspnea, restlessness, guarding behavior.”
- Diagnosis: “impaired gas exchange RT collection of mucus in airway.”
- Outcomes and planning: “patient must maintain optimal gas exchange.”
- Implementations: “assess respiration; encourage breathing and position changes.”
- Rationale: “respiration will indicate the level of lung involvement, as the patient will adjust their breathing to facilitate gas exchange; these will improve ventilation and allow for chest expansion.”
- Evaluation: “the patient maintained good gas exchange, normal respiratory rate.”
Note that student care plans often have an additional column—rationale—where students note the scientific explanation for the implementations they chose. To help you get started with a care plan writing practice, we’ve created a printable nursing care plan, which you can use to practice writing all the steps outlined in this article.
Wrapping Up: Writing an Effective Nursing Care Plan
To be successful, a nursing plan needs effective communication, goal-oriented tasks, accessibility and shareability, and evidence-based practice.
When it meets these qualities and is supported by the nurse’s intuition, critical thinking, and a general focus on the patient, a nursing care plan becomes a go-to resource for nurses to record and access all the information they need. A care plan is your roadmap for effective nursing care, and a collaboration tool that improves the entire healthcare process.
While all nursing programs teach the basics of writing a care plan, your communication, goal setting, and critical thinking skills will be shaped by the program you attend.
For example, one of the benefits of writing care plans is that it will allow you to develop professionalism, along with important values like accountability, respect, and integrity. Key results of professionalism include better overall care, improved team communication, and a more positive work environment. ((Nursco, “Professionalism in Nursing – 5 Tips for Nurses,” July 13, 2018: https://www.nursco.com/professionalism-nursing-5-tips-nurses/))
That’s why it’s important that you choose the right program for your needs—one that will help you develop communication and critical thinking skills, as well as professionalism, to be ready for the day-to-day nursing life.
The University of St. Augustine for Health Sciences (USAHS) offers a Master of Science in Nursing degree (MSN), a Doctor of Nursing Practice degree (DNP), and Post-Graduate Nursing Certificates designed for working nurses. Our degrees are offered online, with optional on-campus immersions.* Role specialties include Family Nurse Practitioner (FNP), Nurse Educator ,** and Nurse Executive. The MSN has several options to accelerate your time to degree completion. Earn your advanced nursing degree while keeping your work and life in balance.
*The FNP role specialty includes two required hands-on clinical intensives as part of the curriculum.
**The Nurse Educator role specialty is not available for the DNP program.
provides an introduction to care and support planning, introduces the 4 steps of the approach and sets out what should happen at each step: prepare, discuss, document, and review.What are the four elements of a care plan? ›
- Problems: The Reason There's a Care Plan. Problems are health issues that range from a specific diagnosis to more general conditions. ...
- Goals: Shaping the Care Plan. ...
- Tasks: Primary Drivers of the Care Plan. ...
- Care Team: Carrying Out the Care Plan.
provides an introduction to care and support planning, introduces the 4 steps of the approach and sets out what should happen at each step: prepare, discuss, document, and review.What is a 5 step nursing care plan? ›
The nursing process functions as a systematic guide to client-centered care with 5 sequential steps. These are assessment, diagnosis, planning, implementation, and evaluation.What are the key elements of an effective care plan? ›
- Emphasize an individual's strengths and abilities.
- Record service user's preferences.
- Utilize a positive narrative.
- Demonstrate the involvement of the service user.
- Contextualize behaviors rather than using labels.
The four primary care (PC) core functions (the '4Cs', ie, first contact, comprehensiveness, coordination and continuity) are essential for good quality primary healthcare and their achievement leads to lower costs, less inequality and better population health.What does a care plan outline? ›
A care plan outlines a person's assessed care needs and how you will meet those needs to help them stay at home.Can nurses write care plans? ›
Only RNs can develop the care plan and make changes, although LPNs can contribute suggestions. A nursing care plan begins as soon as a patient is admitted and is updated frequently as their condition changes or after an evaluation.What are the 5 priorities of nursing care? ›
The five priorities focus on: recognising that someone is dying; communicating sensitively with them and their family; involving them in decisions; supporting them and their family; and creating an individual plan of care that includes adequate nutrition and hydration.What is the goal of the care plan? ›
The Medical Goals of Care Plan ensures that patients unlikely to benefit from medical treatment aimed at cure: receive care appropriate to their condition. are not subjected to futile treatments including cardiopulmonary resuscitation and Medical Emergency Team (MET) calls.
According to Roach (1993), who developed the Five Cs (Compassion, Competence, Confidence, Conscience and Commitment), knowledge, skills and experience make caring unique.What does 5 C's of nursing mean? ›
What Are the Five C's of Caring? Sister Simone Roach came up with the five C's of caring: commitment, conscience, competence, compassion, and confidence. The five C's are considered beneficial to improving coworker and patient relationships and increasing a nurse's chances for career advancement.What are the 6 components of nursing care plan? ›
A care plan includes the following components: assessment, diagnosis, expected outcomes, interventions, rationale and evaluation. According to UK nurse Helen Ballantyne, care plans are a critical aspect of nursing and they are meant to allow standardised, evidence-based holistic care.What are three 3 nursing actions that should be included in the plan of care for the client who has dysphagia? ›
- Assess the ability to swallow by positioning the examiner's thumb and index finger on the patient's laryngeal protuberance. ...
- Evaluate the strength of facial muscles. ...
- Check for coughing or choking during eating and drinking.
Attention will be focused on the four P's: pain, peripheral IV, potty, and positioning. Rounds will also include an introduction of the nurse or PCT to the patient, as well as an environmental assessment.What are the 4 P's of nursing practice? ›
It's structured around four themes – prioritise people, practise effectively, preserve safety and promote professionalism and trust.What is the 4 nursing paradigm? ›
Accordingly, this study aims to analyze nursing students' perceptions of the four basic nursing metaparadigms (person, human factor, health/illness, and environment).Who should be involved in writing a care plan? ›
- The person for whom it is being prepared;
- Any other individual who the person has asked the Local Authority to involve;
- Any carer that the person has; and.
The 6 Cs – care, compassion, courage, communication, commitment, competence - are a central part of 'Compassion in Practice', which was first established by NHS England Chief Nursing Officer, Jane Cummings, in December 2017.What are the ABCs of nursing priorities? ›
ABCD for nurses. Nursing priorities can also be remembered using your ABCs: assessment, basic vitals, charting, and drugs. It is essential that nurses in all settings are able to accurately assess and recognize patients who are at risk of becoming critically ill at an early stage and to effectively manage their care.
Because of the importance of recognizing clinical deterioration in a client, a nurse must always be attuned to the set of physiological needs that are important to maintain life and prevent death. These priorities of care are related to the ABCs – airway, breathing, and circulation – introduced above.What is an example of a goal in a nursing care plan? ›
Goals can be short-term (e.g., resolve acute pain after surgery) or long-term (e.g., lower the patient's A1C with better diabetes management). Then the nurse prioritizes goals based on urgency, importance, and patient feedback. Nurses can also use Maslow's hierarchy of needs to help prioritize patient goals.What is the role of a care plan nursing? ›
Care planning is about the process of negotiation, discussion and decision- making that takes place between the professional and individual (12). The care planning process brings together the concepts and principles of patient involvement, shared decision making, self-care support and patient centred care.What is the difference between goal and objective in nursing care plan? ›
GOAL-is a general statement of condition or state to be brought about by specific courses of action. OBJECTIVE-refers to a more specific statement of the desired results or outcomes of care. They specify the criteria by which the degree of effectiveness of care is to be measured.How do you evaluate care plan effectiveness? ›
- Did anything unanticipated occur?
- Has the patient's condition changed?
- Were the expected outcomes and their time frames realistic?
- Are the nursing diagnoses accurate for this patient at this time?
A nursing diagnosis has typically three components: (1) the problem and its definition, (2) the etiology, and (3) the defining characteristics or risk factors (for risk diagnosis). BUILDING BLOCKS OF A DIAGNOSTIC STATEMENT. Components of an NDx may include problem, etiology, risk factors, and defining characteristics.Which guidelines should the nurse follow when including interventions in a plan of care? ›
Which guideline should the nurse follow when including interventions in a plan of care? Make sure the nursing interventions are unrelated to the original outcomes. Make sure each nursing intervention does not describe the action the nurse should perform.Which guidelines should the nurse follow when writing a nursing diagnosis? ›
- The nurse should identify the nursing intervention, not the patient problem.
- The nurse should identify nursing diagnoses from a cluster of defining characteristics and not just a single symptom.
- The nurse should identify the medical diagnosis rather than the patient's response when creating the statement.
The care plan details why a person is receiving care (their assessed health or care needs), their medical history, personal details, expected and aimed outcomes, and of course what care and support will be delivered to them, how, when and by whom.What is an example of a diagnosis in a nursing care plan? ›
After a thorough assessment, the nurse identifies nursing diagnoses — health problems (or potential health problems) that nurses can handle without physician intervention. For example, acute pain, fever, insomnia, and risk for falls are all nursing diagnoses.
Diagnosis. The nursing diagnosis is the nurse's clinical judgment about the client's response to actual or potential health conditions or needs.What does Nanda stand for? ›
NANDA International (formerly the North American Nursing Diagnosis Association) is a professional organization of nurses interested in standardized nursing terminology, that was officially founded in 1982 and develops, researches, disseminates and refines the nomenclature, criteria, and taxonomy of nursing diagnoses.Which of the following should the nurse include in the plan of care? ›
Nurses have many duties, including caring for patients, communicating with doctors, administering medicine and checking vital signs. Making up for the biggest healthcare job in the U.S., nurses play a vital role in medical facilities and enjoy a large number of job opportunities.What are three 3 nursing interventions that should be included in the plan of care with acute glomerulonephritis? ›
- Activity. Bed rest should be maintained until acute symptoms and gross hematuria disappear.
- Prevent infection. The child must be protected from chilling and contact with people with infections.
- Monitor intake and output. ...
- Monitor BP. ...
- Monitor urine characteristics.
Which guidelines should the nurse follow to reduce errors in the diagnostic statement? Identify medical diagnoses. Identify clinical signs and symptoms. Identify a treatable etiology or risk factor.Which nursing diagnosis should the nurse document in the plan of care for a client diagnosed with Cushing's syndrome? ›
Based on the assessment data, the major nursing diagnoses of the patient with Cushing's syndrome include: Risk for injury related to weakness. Risk for infection related to altered protein metabolism and inflammatory response. Self-care deficit related to weakness, fatigue, muscle wasting, and altered sleep patterns.Why is a nursing care plan important? ›
Why are Care Plans Important? Care plans play a vital role in the treatment of a patient. They clearly define guidelines along with the nurse's role in patient care and help them create and achieve a solid plan of action. This equips nurses to provide focused care—without overlooking important steps.What makes a good care plan? ›
Writing a good care plan
- your assessed needs.
- any risks to you or others.
- personal goals.
- support available.
- your progress towards recovery.