A Complete Student’s Guide on How to Write a Nursing Care Plan
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What is a Nursing Care Plan?
A nursing care plan also known as NCP is a formal document that is used to record the needs of patients, the interventions used,
the goals of the intervention, and the evaluation of the expected outcomes for the patient. Nursing care plans provide the main
form of communication among nurses and other interdisciplinary professionals to enable the best health outcomes for patients.
Care plans are crucial to nursing as they document the nursing process. The nursing care plan is updated over the course of the
patient’s stay within the healthcare facility.
Types of Nursing Care Plans
NCPs can be either formal or informal, standardized or individualized.
1. Informal Nursing Care Plan
An informal NCP is just a strategy plan in the mind of the nurse.
2. Formal Nursing Care Plan
A formal NCP is a written or computerized nursing care plan guide that healthcare organizations use to document
patients’ information.
3. Standardized nursing care plans
These are pre-designed care plan guides issued for specific patient groups by the nurses and healthcare providers.
Standardized NCPs serves to ensure that the specific patient group who have a particular condition receives consistent
care. Therefore, these care plans ensure the efficiency of care for nurses.
4. Individualized nursing care plans
These are designed specifically to meet the needs and treatment goals of an individual patient. Individualized NCPs
are just patient-tailored standardized nursing care plans. These care plans promote personalized and holistic care in the nursing
process.
Guidelines for Writing Nursing Care Plans
Nursing care plans are very crucial in the nursing field. Therefore, understanding how to correctly write them is equally as
important. Here is a guideline on how to write a nursing care plan as a nursing student.
The 5 Steps in Writing a Nursing Care Plan
- Nursing care plan assessment. This section contains all the patient health assessments on the physical, emotional, cognitive, sexual, psychosocial, age-related, economic, and environmental information,
- Nursing diagnosis NANDA list. A nursing diagnosis is a clinical judgment made by the nurse describing the patient’s health concern after assessment. Nursing diagnoses are guided by the North American Nursing Diagnosis Association (NANDA) principles. According to NANDA, there are four types of nursing diagnosis: problem-focus, risk-focused, health promotion, and syndrome.
- Nursing expected outcomes. These are specifically set goals to be attained through the nursing intervention. These outcomes or goals have to be SMART for both the nurse and the patient and may be short or long-term.
- Nursing care plans interventions and rationales. Nursing interventions are specific actions that the nurse to ensure that the expected nursing outcomes are achieved. These actions should always be guided by evidence-based practices as the rationales behind the intervention.
- How to write an evaluation in the nursing care plan. This section covers the progress of the patient after the intervention and the changes the patient’s condition has undergone. This progress is measured against the expected nursing outcomes to find out if it was a success or not.
Long-Term Goals for Nursing Care Plans
NCPs should contain goals, whether short-term or long-term. However, these goals have to be measurable. Most NCPs have
short-term goals as patients are in acute care settings. However, patients with chronic illnesses or who are in home-based care or
nursing homes require long-term goals. These patients require long-term objectives to promote restorative care and hope for better
results. These long-term goals should be SMART.
- SMART goals nursing care plans: Goals set for any nursing care plan have to be Specific Measurable Attainable Realistic and Time-framed for both the patient and the nurse. They also have to be client-centered above all else.
Nursing Care Plan Sample Format
| ASSESSMENT | DIAGNOSIS | GOALS AND OUTCOMES | INTERVENTION | EVALUATION |
| DoB- May 24th, 1996 3256 Almond St. Miami, FL | 444=555=3215 Experiencing severe itching and having red bumps on their arms. History of migraines. No known allergies. Normal vitals. Mentally competent. Currently prescribed () | List all the symptoms the patient exhibits. Make a simple diagnosis such as an Allergic reaction to mosquito bites | Reduced swelling. The itching will reduce after two to three days of consistent use of medicated ointment. Bumps must go away after three days. | Medicated ointments. Antihistamines | No anaphylaxis. Responded well to ointments. Bumps, itchiness, swelling, and reddening reduced after four days. The patient is to use Orajel until the symptoms completely subside. |
11 Popular Care Plan Ideas for Nursing Students
Here’s a list of popular examples of nursing care plans that a nursing student might come across in the course of their nursing
education. They include general nursing care plans as well as specific nursing care plans.
- care plan for depression
- care plans for nursing homes
- care plan for hypertension
- care plan for the elderly
- care plan for mental health
- care plan for diabetes
- care plan for pneumonia
- care plan for burns
- care plan for anemia
- care plan for diarrhea
- care plan for fever
FAQ
1. Do nurses still write care plans?
Nurses still do write care plans as it is an essential part of the process of delivering quality patient-centered care.
2. What should be written in a care plan?
The contents of a care plan include an assessment of the patient (physical, emotional, sexual, psychosocial, cognitive, and other demographic information), a nursing diagnosis, nursing expected outcomes or goals, a description of the nursing intervention, an evidence-based rationale for the nursing intervention, and an evaluation of the patient’s progress against the expected goals. An alternative intervention is offered in the evaluation section if the patient’s expected outcome were not achieved.
3. What is the nurse’s role in care planning?
The role of the nurse in care planning is to inform the patient of their condition and the impact it has on their quality of life. The nurse also has the role of coming up with an intervention that best meets the needs of the patient clinically and individually. The nurse further has the role of expressing and protecting the wishes and preferences of the patient throughout the whole care plan.
