Guide for Nursing Care Plans | Incredible Health (2024)

New Nurse Graduates / Guide for Nursing Care Plans

Whether you’re enrolled in nursing school or practicing as a nurse, you’ve heard of nursing care plans.

Nursing care plans are a way to communicate the nursing care needs of the patients we serve and help guide the care we give. If the idea of creating a care plan is daunting, don’t worry, we’ll define care plans and discuss why they are essential in the care we provide patients.

This article will cover what a nursing care plan is, describe how to create a care plan, provide helpful resources, and provide the next steps.

• What is a nursing care plan?
• Creating a nursing care plan
• Helpful textbooks and databases
• Next steps

What is a nursing care plan?

Nursing care plans are like the roadmap for helping a patient for a nurse, that ensures patients are receiving safe, consistent, quality nursing care. Additionally, care plans also serve as a way to communicate to clinicians about a patient’s overall care goals.

Hospitals, clinics, hospice facilities, inpatient and outpatient treatment centers, and nursing homes are all places that utilize care plans.

There is a wide assortment of nursing-specific care plans that are used in different clinical areas. Care plans can focus on early ambulation, maintaining skin integrity, reducing the possibility of developing hospital-acquired infections, and so on.

Nurses can also create care plans specific to different body systems, including cardiovascular, musculoskeletal, and respiratory. Since most hospitals use an EHR or electronic health record, care plans are typically embedded in the charting systems.

JCAHO (Joint Commission Accreditation of Hospitals & Healthcare Organizations) defines a care plan as a framework that facilitates communication and results in safe, effective care.

The American Association of Colleges of Nursing also advises on several necessities needed for care planning: appropriate technologies to assess and monitor patients, an ability to plan, deliver, and execute quality care, and creating a holistic care plan.

Creating a nursing care plan

So now that we understand what a nursing care plan is and why it’s essential for day-to-day patient care, let’s look at how to create a care plan.

Remember, a nursing care plan is focused on what we as nurses, can do for our patients. It needs to focus on how we can use our nursing skills to provide care for the patient.

Patient Assessment

To create a thoughtful care plan focused on your patient’s specific needs, you’ll need to familiarize yourself with your patient and their medical history.

Once you receive a handoff report from the previous nurse, take a few moments to conduct a physical assessment of your patient. Listen to heart and lung sounds, assess wounds and surgical drains,

Review the most recent documentation of outputs, including urine, stool, nasogastric drainage, and wound drainage.

If your patient is alert and oriented, assess pain levels, dietary intake, and ability and willingness to ambulate and be active in their care. Having meaningful conversations with your patient even for just a few minutes can allow you to better understand their needs.

For example, post-surgical patients who can are often encouraged to start ambulating early to prevent post-op complications. Having a conversation with your patient and explaining the benefits of early ambulation can not only encourage them to participate in care but serves as a goal in your care planning.

Once you’ve reviewed both your patient and their medical record, start to consider possible nursing issues that you can focus your care plan around.

Identifying the Issue

Identifying the patient issue(s) involves the nurse using their nursing judgment concerning a patient’s real or possible health risks.

For example, a patient may be at risk for falls due to limited mobility, a history of falls, or due to receiving pain medication. Based on the assessment of the patient, their medical history, and in this case, medication record, the nurse can list the risk for falls in the care plan.

Now that the nurse is aware that falls could be a risk for the patient, they can take the necessary steps to reduce the likelihood of a fall.

After assessing your patient and any pertinent medical history and vitals, you may be aware of several nursing issues that can be included in a care plan. Patients having more than one specific focus of care or clinical problem is very common.

Expected Outcome

Once you assess your patient and identify issues for your care plan, you can now list the expected outcomes. These outcomes are based on the actual or potential risks specific to your patient. To be effective, expected outcomes should be attainable and measurable.

For instance, a nursing diagnosis of activity intolerance due to exhaustion can have an expected outcome of the patient having no reports of difficulty breathing with their vital signs remaining in a normal range.

Reviewing the Plan

Make sure to review any existing care plans that are in place for your patient. If the care plan no longer applies to your patient’s condition, remove it from their care plan profile. At the end of your shift, review the plan and address if the care plan was successfully executed and any barriers that prevented you from carrying it out.

Remember that some care plans may be ongoing depending on the patient’s condition.

For example, ventilated patients may have care plans to avoid developing hospital-acquired respiratory infections. This care plan may be necessary while your patient is sedated and on a ventilator but may not be applicable once they are extubated.

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Helpful textbooks and databases

There are multiple resources for nurses centered around care plans. If you’re in nursing school, your professors will have specific care plan books they require.

If you work in a specific specialty of nursing, such as psych, diabetes management, or perioperative areas, there are nursing care plan books created specifically for these areas.

If care plans are listed electronically in your area of care, take a few moments to review the most common plans specific to your nursing area.

NANDA, or the North American Nursing Diagnosis Association, is an excellent resource for providing more information about nursing diagnoses and care plans. Their website also has NANDA Nursing diagnoses books for purchase.

Books specific to nursing care plans are in great abundance. These books will typically list problem care plans and disorder care plans while guiding the planning of patient care. These books can also include digital access to more care plans on their websites.

Next Steps

There you have it! Care plans are meant to serve as an effective, coherent way to communicate the needs and expected outcomes of our patients. Although it’s not the only way we base our patient care, it does allow us to convey the current risks and problems our patients face while providing measurable goals and expected outcomes.

It takes time, practice, and experience to write or select an effective care plan. Both patients and healthcare care are very complex. Patients’ needs may change throughout their care, as will their care plan.

Remember that your patient can have multiple care plans that start, stop, and restart during their care. Having a better understanding of the purpose of care plans will allow you to provide the safest, most focused, and most effective nursing care that will best benefit your patients.

If you’re interested in learning more please visit our Nursing Process page.