Types of Nursing Care Plan

NURSING CARE PLAN (NCP)
-formal process that includes correctly identifying existing needs, as well as recognizing potential
needs or risks.
-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.
-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

1. Informal Nursing Care Plan is a strategy of action that exists in the nurse‘s mind
2. Formal Nursing Care Plan is a written or computerized guide that organizes information about
the client’s care.
A. Standardized care plans specify the nursing care for groups of clients with everyday
needs.
B. 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:
1. Promote evidence-based nursing care and to render pleasant and familiar conditions in
hospitals or health centers.
2. Support holistic care which involves the whole person including physical, psychological, social
and spiritual in relation to management and prevention of the disease.
3. 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.
4. Identify and distinguish goals and expected outcome.
5. Review communication and documentation of the care plan.
6. Measure nursing care.
Purposes of a 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.
 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.
Nursing Care Plan John Paul N. Reganit, RN, MSN, LPT

 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:
 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.
 Nursing Diagnoses.
 Expected client outcomes are outlined. These may be long and short term.
 Nursing interventions are documented in the care plan.
 Rationale for interventions in order to be evidence-based care.
 Evaluation. This documents the outcome of nursing interventions.
 Care Plan Formats

 nursing diagnoses
 desired outcomes and goals
 nursing interventions
 evaluation.
 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.
Writing a Nursing Care Plan
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,
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.
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.

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.
We’ve detailed the steps on how to formulate your nursing diagnoses in this guide: Nursing Diagnosis
(NDx): Complete Guide and List for 2019
TYPES OF NURSING DIAGNOSIS

 Problem-Focused Nursing Diagnosis
-A problem-focused diagnosis (also known as actual diagnosis) is a client problem that is
present at the time of the nursing assessment.
-based on the presence of associated signs and symptoms.
-Actual nursing diagnoses should not be viewed as more important than risk diagnoses. There
are many instances where a risk diagnosis can be the diagnosis with the highest priority for a
patient.
 Risk Nursing Diagnosis

-The second type of nursing diagnosis is called risk nursing diagnosis.
-These are clinical judgment that a problem does not exist, but the presence of risk factors
indicates that a problem is likely to develop unless nurses intervene.
-The individual (or group) is more susceptible to develop the problem than others in the same
or a similar situation because of risk factors.
-For example, an elderly client with diabetes and vertigo has difficulty walking refuses to ask
for assistance during ambulation may be appropriately diagnosed with Risk for Injury.
 Health Promotion Diagnosis

-Health promotion diagnosis (also known as wellness diagnosis) is a clinical judgment about
motivation and desire to increase well-being.
-Health promotion diagnosis is concerned in the individual, family, or community transition
from a specific level of wellness to a higher level of wellness.
-Components of a health promotion diagnosis generally include only the diagnostic label or a
one-part-statement. Examples of health promotion diagnosis:
Readiness for Enhanced Spiritual Well Being
Readiness for Enhanced Family Coping
Readiness for Enhanced Parenting

 Syndrome Diagnosis
-A syndrome diagnosis is a clinical judgment concerning with a cluster of problem or risk
nursing diagnoses that are predicted to present because of a certain situation or event.
-They, too, are written as a one-part statement requiring only the diagnostic label. Examples
of a syndrome nursing diagnosis are:
Chronic Pain Syndrome

Post-trauma Syndrome
Frail Elderly Syndrome
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.
-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.

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.
 Short Term and Long Term Goals
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.
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.

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 in a care plan.

Nursing interventions should be:
o Safe and appropriate for the client’s age, health, and condition.
o Achievable with the resources and time available.
o Inline with the client’s values, culture, and beliefs.
o Inline with other therapies.
o Based on nursing knowledge and experience or knowledge from relevant sciences.
a) 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.
b) 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.
c) 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.

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.
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.
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.

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NURSING CARE PLAN (NCP)

TYPES OF NURSING CARE PLAN

Purposes of a Nursing Care Plan

Nursing Care Plan John Paul N. Reganit, RN, MSN, LPT

 Care Plan Formats

 Student Care Plans

Writing a Nursing Care Plan

1: Data Collection or Assessment

2: Data Analysis and Organization

Nursing Care Plan John Paul N. Reganit, RN, MSN, LPT

TYPES OF NURSING DIAGNOSIS

 Risk Nursing Diagnosis

 Health Promotion Diagnosis

Nursing Care Plan John Paul N. Reganit, RN, MSN, LPT

Chronic Pain Syndrome

Nursing Care Plan John Paul N. Reganit, RN, MSN, LPT

 Short Term and Long Term Goals

Short-term goal – a statement distinguishing a shift in behavior that can be completed

Nursing Care Plan John Paul N. Reganit, RN, MSN, LPT

 Types of nursing interventions in a care plan.

Nursing Care Plan John Paul N. Reganit, RN, MSN, LPT

Nursing Care Plan John Paul N. Reganit, RN, MSN, LPT

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