A nursing care plan is a road map for the care of a patient and a necessary tool in following the nursing process. Understanding nursing care plans is an important part of any nursing school curriculum and definitely something you’ll need to know as a nursing student.
In this guide, you’ll learn how to write and use a nursing care plan and why they’re important for maintaining quality patient care.
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.
Nursing care plans also promote:
- A well-documented care plan ensures the patient’s entire care team (doctors, nurses, etc.) can access the same information, give input, and join forces to provide the best care possible.
- Care plans help nurses uphold the nursing code of ethics and provide a record that they did so in case of lawsuits or accusations that they failed to adhere to care standards.
- A care plan is a communication tool for patient care between nurses. When nurses change shifts they’re able to reference the patient’s care plan to ensure the same quality care and interventions are being executed.
Without nursing care plans, nursing staff might have to rely on verbal communication and patient information could become more easily scattered or lost, all of which could result in improper patient care.
Nursing care plans follow a five-step process: assessment, diagnosis, outcomes, implementation, and evaluation.
Assess the patient.
The first step to writing a care plan is performing a patient assessment. This includes reviewing your patient’s medical history, diagnosis, lab values, and medications. This step is critical to creating an effective and accurate care plan for either short term or long term care.
Make a diagnosis.
Nursing diagnoses differs from a medical diagnosis in that it’s based on the patient’s response to an illness, rather than the illness itself. Simply put, a nursing diagnosis is focused on patient care rather than treatment.
According to NANDA (North American Nursing Diagnosis Association), a good nursing care plan should not only list each diagnosis but define it as well. For example, acid reflux should be described as: "Ineffective airway clearance related to gastroesophageal reflux as evidenced by retching, upper airway congestion, and persistent coughing.”
Set goals and outcomes.
Once you’ve completed an assessment and diagnosis, it’s time to write down goals and a desired health care outcomes for your patient. These describe what you hope to achieve in the short- and long-term future, provide direction for planning interventions, and serve as criteria for evaluating progress. Goals are documented in the patient’s care plan so that other nurses and health professionals caring for the patient have access to it.
Determine nursing interventions.
At this point in the care plan, you’ll list all planned nursing interventions and document any that you’ve performed. You’ll write down things such as client responses to care, pain scale responses, medications given and their dosages, vital signs, etc. This communicates what nursing orders were implemented, what still needs to be done, and if the patient is ready to be discharged.
Evaluate the plan.
Evaluation is necessary in a patient care plan to determine whether to continue, adjust, or terminate the plan of care. It measures the degree to which goals and outcomes are achieved and provides evidence for what factors positively or negatively impacted those goals.
Registered nurses and nurse practitioners use these plans in the nursing process as a road map for providing care. They’re also a tool to help nurses think critically and holistically to support the patient’s needs—physically, socially, spiritually, and psychosocially. 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. It’s an ongoing process that requires detailed, accurate documentation that strictly adheres to the nursing code of ethics, as well as HIPAA rules and regulations.
Knowing how to write and implement a nursing care plan is one essential skill you’ll need as a nurse or nurse practitioner. With a degree in nursing, you’ll gain this valuable experience—and the tools to provide the best patient care possible.