What are the steps of a nursing care plan?

If you aspire to become a nurse, you'll want to familiarize yourself with what nursing care plans (NCPs) are all about. Nursing care plans provide a means of communication among nurses, their patients, and other healthcare providers to achieve healthcare outcomes.

What is a Nursing Care Plan?

A nursing care plan contains relevant information about a patient’s diagnosis, the goals of treatment, the specific nursing orders (including what observations are needed and what actions must be performed), and an evaluation plan. 

Over the course of the patient’s stay, the plan is updated with any changes and new information as it presents itself. In fact, most hospitals require nurses to update the care plan during and after each shift. 

What is the Purpose of a Nursing Care Plan?

Nursing care plans help define nursing guidelines and some treatment guidelines (as ordered) for a specific patient.

Essentially, it is a plan of action. It helps guide nurses throughout their shift in caring for the patient. It also allows nurses to provide attentive and focused care. 

Show Me RN-to-BSN Programs

Types of Nursing Care Plans

There are four main types of nursing care plans. 

1. Informal - A care plan that exists in the nurse’s mind and is actions the nurse wishes to accomplish during their shift.
2. Formal - This is a written or computerized plan that organizes and coordinates the patient’s care information and plan. 
3. Standardized - Nursing care for groups of patients with everyday needs.
4. Individualized - A care plan tailored to the specific needs of the patient. 

What are the Components of a Nursing Care Plan?

Nursing care plans follow a five-step process: 

• Assessment
• Diagnosis
• Expected outcomes
• Interventions
• Rationale and Evaluation

>> Related: The Nursing Process Explained

How to Write a Nursing Care Plan

When writing a nursing care plan, you first have to determine what type of care plan you are interested in. If it is for your own use throughout the shift, then an informal one may be beneficial; however, if it is for the patient’s chart and required during your shift then an individualized care plan is the way to go. 

Step 1: Assessment

The first step in writing an organized care plan includes gathering subjective and objective data. This information can come from, 

• Verbal statements from patient and family
• Vital signs
• Physical complaints
• Body conditions
• Medical history
• Height and weight
• Intake and output

Step 2: Diagnosis

Using the information and data collected in Step 1, a nursing diagnosis is chosen that best fits the patient, the goals, and objectives for the patient’s hospitalization. 

According to North American Nursing Diagnosis Association (NANDA), defines a nursing diagnosis 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.”

A nursing diagnosis is based on Maslow’s Hierarchy of Needs pyramid and helps prioritize treatments. Based on the nursing diagnosis chosen, the goals to resolve the patient’s problems through nursing implementations are determined in the next step. 

Step 3: Outcomes and Planning

After determining the nursing diagnosis, it is time to create a SMART goal based on evidence-based practices. SMART goals stands for Specific, Measurable, Achievable, Relevant, and Time-Bound. It is important to consider the patient’s medical diagnosis, overall condition, and all of the data collected. 

It is also during this time you will consider goals for the patient and outcomes for the short and long term. These goals must be realistic and desired by the patient. For example, if a goal is for the patient to seek counseling for alcohol dependency during the hospitalization but the patient is currently detoxing and having mental distress - this might not be a realistic goal. 

Step 4: Implementation

Now that the goals have been set, you must put the actions into effect to help the patient achieve the goals. While some of the actions will show immediate results (ex. giving a patient with constipation a suppository to elicit a bowel movement) others might not be seen until later on in the hospitalization. 

The implementation phase means performing the nursing interventions outlined in the care plan. Interventions are classified into seven categories: 

• Family
• Behavioral
• Physiological
• Complex physiological
• Community
• Safety
• Health system interventions

Some interventions will be patient or diagnosis-specific, but there are several that are completed each shift for every patient:

• Pain assessment
• Position changes
• Fall prevention
• Providing cluster care
• Infection control

Step 5: Evaluation 

The fifth and final step of the nursing care plan is the evaluation phase. This is when you evaluate if the desired outcome has been met during the shift. There are three possible outcomes, 

Based on the evaluation, it can determine if the goals and interventions need to be altered. 

Show Me RN-to-BSN Programs

Sample Nursing Care Plans

Nursing Diagnosis:  Ineffective breathing pattern related to right pulmonary agenesis as evidenced by high carbon dioxide levels and absent breath sounds on right side of the chest. 

Assessment: 

• Vital signs: Monitor the patient’s heart rate, respiratory rate and SpO2 levels. Signs of respiratory distress include tachypnea, dyspnea and an SpO2 <95%. 
• Breathing patterns: If the patient shows signs of respiratory distress, it should alarm the nurse, and interventions should take place. Signs of respiratory distress include nasal flaring, accessory muscles, grunting, shortness of breath, and retractions.
• CO2 lab values: When the body has an ineffective breathing pattern, inadequate gas exchange will take place. During this, the body retains CO2 and can enter into a stage of respiratory acidosis. Monitor for respiratory acidosis with blood gas lab values.
• Skin assessment: A person experiencing respiratory distress may experience pallor, cyanotic, and/or mottled skin.

SMART Goal: The patient will maintain a SpO2 level of >95%, RR of 30 to 55 breaths per minute, and heart rate of 80 to 140 beats per minute until the end of the shift. 

Interventions: 

• Check manual heart rate and respiratory rate every four hours. 
• Check patient is on continuous SpO2 monitor with pulse oximetry on the same extremity throughout shift. 
• Obtain blood gases as ordered.
• Monitor for signs and symptoms of increased work of breathing and respiratory distress. 

Evaluate:

• The patient is observed and/or documented to have SpO2, HR, and RR all within normal limits by end of the shift.
• The patient is documented to have received blood gas results that contain a CO2 value that is within the normal range.
• The patient is observed and documented to not experience any symptoms of respiratory distress throughout the shift. 

Nursing Care Plan FAQs:

• How do you write a nursing care plan?
  • Writing a nursing care plan takes time and practice. It is something you will learn during nursing school and will continue to use throughout your nursing career. First, you must complete an assessment of your patient to determine the nursing diagnosis and include relevant patient information. Next, utilize a NANDA-approved diagnosis and determine expected and projected outcomes for the patient. Finally, implement the interventions and determine if the outcome was met. 
• What is the purpose of the nursing care plan?
  • Nursing care plans provide a means of communication among nurses, their patients, and other healthcare providers to achieve healthcare outcomes.
• What are the 5 main components of a care plan? 
  • There are five main components to a nursing care plan including; assessment, diagnosis, expected outcomes, interventions, and rationale/evaluation. 
• What is included in a nursing care plan?
  • Nursing care plans include relevant information about the patient’s assessment, goals of treatment, interventions that need to occur, and observations. These observations may include subjective and objective data.

*This 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.

Care plans are part of the core curriculum in most nursing schools. Yet, new hospital nurses often complain that despite all the hype and time spent learning how to make a nursing care plan, they never do it again after graduation. As a nursing leader, you might not have written one for a while, either. Why should you start now?

Care plans help nurses focus on patients in a holistic, big-picture way so they can deliver evidence-based, patient-centered care. Care plans also help hospitals ensure continuity of care across nursing shifts, promote inter-professional collaboration by getting everyone on the same page, and meet documentation requirements for insurers and governing bodies.

Even if your hospital requires care plans, unless it’s a strict requirement, there’s a good chance your nurses aren’t preparing one for every single patient because they’re too busy. Depending on the unit, they might only treat people for a couple of days before they’re overwhelmed with redundant paperwork. Considering that most of the information in a nursing care plan is already required in multiple sections of each patient’s electronic health record (EHR), nurses might not see the point in drafting an official plan of care.

Unless care plans are required, nurses probably won’t make them. And unless care plans are useful, writing them will be perceived as more “busywork” — the bane of every nurse’s existence.

What are the benefits of a nursing care plan for hospitals? How can you ensure that care plans are a useful tool that nurses will want to have at their disposal?

Discover the value of upgrading to a clinical collaboration platform.

Why Your Hospital Needs a Nursing Care Plan

Care plans are used to teach nursing students how to individualize patient care, think critically about what’s needed to achieve the desired outcomes, and work towards those outcomes through the nursing process. Experienced nurses already know how to do that, without documenting it and often without even realizing they’re doing it. Still, a formal nursing care plan can be a valuable tool for effective communication in nursing.

Long-term care providers such as nursing homes, mental health facilities, and home health nurses typically use formal care plans, and they are often required to do so by governing bodies like the Joint Commission. Yet, in hospitals, care plans often fall by the wayside.

For hospitals that successfully implement care plans, there are many benefits, including:

• Continuity of care: Nursing care plans ensure that nurses from different shifts or floors have the same patient data, are aware of the patient’s nursing diagnoses, share their observations with one another, and collaborate towards the same goals.
• Inter-professional collaboration: Nurses are the heart of the care team, but they’re not the only members. Physicians, social workers, nursing assistants, physical therapists, and other care providers also need to understand the patient’s health problems, goals, and progress. A nursing care plan puts all this information in one place, providing a clear roadmap to the desired outcomes.
• Patient-centered care: Care plans help to ensure that patients receive evidence-based, holistic care. Nursing diagnoses are standardized to ensure quality care, but nursing interventions are tailored to meet the physical, psychological, and social needs of the individual patient.
• Engaged patients: Setting achievable goals for and with patients helps to guide and measure nursing care. Goals also help motivate patients to become more involved in their recovery, because they can understand exactly what they need to do to achieve the desired outcomes.
• Compliance: The care plan serves as proof of receipt and helps payers determine how much they should reimburse for care.

What Is a Nursing Care Plan?

A nursing care plan is the written manifestation of the nursing process, which the American Nurses Association defines as “the common thread uniting different types of nurses who work in varied areas … the essential core of practice for the registered nurse to deliver holistic, patient-focused care.”

The nursing process includes five key steps:

1. Assessment: Collecting and analyzing data to gain a holistic understanding of the patient’s needs and risk factors.
2. Diagnosis: Using data, patient feedback, and clinical judgment to form the nursing diagnoses.
3. Outcomes/Planning: Setting short-term and long-term goals based on the nurse’s assessment and diagnosis, ideally with input from the patient. Determining nursing interventions to meet those goals.
4. Implementation: Implementing nursing care according to the care plan, based on the patient’s health conditions and the nursing diagnosis. Documenting care the nurse performs.
5. Evaluation: Monitoring (and documenting) the patient’s status and progress towards goals, and modifying the care plan as needed.

A nursing care plan is formal documentation of this process, and most care plans are organized into four columns that closely mirror the steps of the nursing process. Care plans include:

1. Nursing diagnoses
2. Desired outcomes/goals
3. Nursing interventions
4. Evaluation

NurseLabs notes that some healthcare providers use only three columns, combining “desired outcomes/goals” and “evaluation” into the same column, whereas other providers use five columns, including one for “assessment cues.” Care plans for nursing students typically include another column for “rationale/scientific explanation,” where they are asked to explain the reasoning behind their proposed nursing interventions.

In case you haven’t seen one in a while, here’s what a nursing care plan looks like:

To create a plan of care, nurses should follow the nursing process:

1. Assessment
2. Diagnosis
3. Outcomes/Planning
4. Implementation
5. Evaluation

1. Assess the patient.

The nurse starts by reviewing all relevant data, including (but certainly not limited to): medical history, lab results, vital signs, head-to-toe assessment data, conversations with the patient and their loved ones, observations from other care team members, and demographic information. The nurse uses this data to assess the patients:

• Physical, emotional, psychosocial, and spiritual needs
• Areas for improvement
• Risk factors

2. Identify and list nursing diagnoses.

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. The North American Nursing Diagnosis Association (NANDA) curates an official nursing diagnosis list, which includes definitions, features, and commonly applied interventions for each diagnosis.

3. Set goals for (and ideally with) the patient.

What are the desired outcomes, and how will the patient get there? The nurse answers these questions based on the assessment, nursing diagnosis, and feedback from the patient. Together, the nurse and patient set reasonable goals that can be achieved with nursing interventions and (in some cases) effort by the patient. 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.

4. Implement nursing interventions.

Nursing interventions are actions taken by the nurse to achieve patient goals and get desired outcomes — for example, giving medications, educating the patient, checking vital signs every couple hours, initiating fall precautions, or assessing the patient’s pain levels at certain intervals. This is also where the nurse documents care as they perform interventions, including dependent nursing interventions ordered by physicians.

5. Evaluate progress and change the care plan as needed.

Finally, the nurse monitors and evaluates the patient and the nursing care plan on a regular basis to answer the question: Are the nursing interventions helping the patient reach their goals and desired outcomes, and should those interventions be changed, terminated, or continued?

How to Implement Nursing Care Plans in Your Hospital

For care plans to be useful, they need to promote effective communication in nursing. They need to be shareable, easy to access, and always up to date. That means they need to be electronic, and preferably integrated into the EHR for cloud access and real-time inter-professional collaboration.

Leading EHR providers have care plan functionality built into their systems, with lists of nursing diagnoses and interventions. Finding these resources is not always intuitive, but with a little help from IT, you can build custom care plan forms that are part of each patient’s record and each nurse’s workflow. With the right integrations, you can even automate parts of the care plan so certain fields get automatically populated with information. That means fewer fields for nurses to fill out and regularly update.

Nurses are also more likely to comply with care plan requirements if they don’t have to track down an available computer first. If they can access the care plan from secure mobile devices, they can review and update care plans at the patient bedside, refer to them regularly to help guide patient care, and even use them as a patient education tool.

Smartphone-wielding nurses can do more than manage care plans on the go. They can also use HIPAA-compliant clinical workflow solutions that let them securely talk, text, or have a group conference about the plan of care.

Supported by technology and a secure communication platform, a patient care plan becomes a resource for nurses to get all the information they need in one place, a roadmap for recovery, and a collaboration tool that helps ensure continuity of care.

Learn more about smartphone-based clinical communications with EHR integration.

Tags: Nursing Diagnosis, Registered Nurse, Nursing Students, Nursing Care, Nursing Care Plan, Nurse Educator, Acute Pain, Nursing Schools, Nursing Process, Plan Of Care, Care Plans Include, American Nursing, Nursing Diagnoses, Health Problems, Nursing Interventions, Desired Outcomes, Nurse Performs, evidence based, long term, Continuity of care, Patient Care